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Emergency Medicine > hand and wrist > Flashcards

hand and wrist Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

At the wrist, the ______ gives off a superficial palmar branch which completes the superficial palmar arterial arch.

A

At the wrist, the RADIAL ARTERY gives off a superficial palmar branch which completes the superficial palmar arterial arch.

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2
Q

the ULNAR ARTERY enters the hand anterior to the _____ just lateral to the pisiform

A

The ULNAR ARTERY enters the hand anterior to the flexor retinaculum, just lateral to the pisiform bone. It gives off the deep palmar branch and continues onto the palm as the superficial palmar arterial arch.

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3
Q

ulnar nerve passes between

A

passing between hook of hamate

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4
Q

radial nerve superficial branch travels above

A

Superficial branch above radial styloid

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5
Q

median nerve travels through the

A

Median nerve: through carpal tunnel

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6
Q

Superficial radial nerve supplies

A

Superficial radial nerve supplies skin on the lateral side of the dorsum of the hand, and a small portion of the thenar eminence

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7
Q

the recurrent branch of the median n. supplies

A

the recurrent branch of the median n. supplies the muscles of the thenar eminence

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8
Q

cutaneous branch of the median nerve is responsible for

A

b. cutaneous branches to the skin on the palmar surfaces of the of the first 3½ digits

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9
Q

The ulnar nerve enters the palm of the hand through the ___-

A
  1. The ulnar nerve enters the palm of the hand through the ulnar canal
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10
Q

Prior to entering the ulnar canal, ulnar n gives off:

A

a palmar cutaneous branch
(ulnar aspect of the palm)

A dorsal cutaneous branch

(the ulnar aspect of the dorsum of the hand)

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11
Q

what is the most frequent injury of the hand and commonly fractured

what is the most common finger

A

Lacerations most frequent injury

Distal phalanx most commonly fractured

Little finger most common in US

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12
Q

how do you document hand injury

A

i. Dominant hand
ii. Occupation
iii. Tetanus status
iv. Traumatized or non traumatized documentation

always think in terms of anatomy (ulnar or radial aspect of the hand)

volar or dorsal (flexor or extensor)

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13
Q

this nerve is responsible fo

A

the ulnar nerve innervates all the intrinsic muscles of the hand not innervated by the median nerve.

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14
Q

how to document trauma

A
  1. Ascertain hx of trauma
  2. Time elapsed since injury (golden window = 6 hours)
  3. Environment of injury
  4. Mechanism of injury
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15
Q

how to document non-trauma

A

v. Nontraumatized
1. When did sx begin
2. What functional impairment
3. What activities worsen sx

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16
Q

what are the NEVER rules with excessive bleeding

A

i. Elevation
ii. Apply a sterile wet-compression dressing.

NEVER LEAVE BP CUFF FOR MROE THAN 30

never ligate a hand vessel without directly visualizing the bleeding vessel and all surrounding structures

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17
Q

dorsum of first web space.

A

radial

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18
Q

how do you test strength of R/U/M nerve

A
  1. Radial: extension at wrist and MP joint
  2. Ulnar: forcible spread of fingers
  3. Median: flexion of wrist and PIP of thumb and index against resistance
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19
Q

5th finger sensory what N

A

ulnar

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20
Q

flexor aspect of index and middle

A

medial

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21
Q

document ROM in

A

degrees

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22
Q

this PE finding is common with tendon injury

A

Patients unable to flex one finger together with the others often found to have associated tendon injury.

pain with flexion is indicative of a partial tear

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23
Q

testing flexor digitorum profundus and Flexor Pollicis Longus

A

hold down all other fingers in extension and have pt just test finger needed

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24
Q

Test by holding all other fingers in extension and have the pt flex the finger to be tested

A

Flexor Digitorum Superficialis

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25
Q

how to test extension

A

: hand palm-down on a table and extend the fingers off the table one at a time.

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26
Q

If you suspect an extensor tendon laceration but cannot visualize in the wound,

A

try putting the hand in the position it was in when the injury occurred.

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27
Q

whenever there is glass involved

A

get an xray

XRAYS sensitive for glass > 2mm

ULS is also sensitive for glass
Sensitive 95-100% < 1-4mm

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28
Q

best imaging for organic FB

A

uls

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29
Q

Consideration for the management of FB

A

anbx

might need OR removal

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30
Q

why are hands a scary place for infx?

A

infections extend QUICKLY across the fascial planes of the hand without resistance.

many structures and a lil meat

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31
Q

finger infections can ended mid-palmar space through

A

Proceed through the flexor tendon sheath and enter the mid-palmar space.

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32
Q

Infections in the mid-palmar space

A

i. Extend rapidly into the thenar space.

ii. Devastating effects: may resist aggressive treatment with IV antibiotics.

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33
Q

what is a felon

A

Subcutaneous pyogenic infection of the pulp space of the finger tip (tuft)

Paronychia but just of the tip of the finger

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34
Q

felons can present like this

A

severe throbbing pain

1. Can be hx of trauma or finger nail biters

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35
Q

what is the most common management and approach to felons

A

iii. Most common org = staph aureus

I&D

midline incision and draw packing strp in

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36
Q

most common complication of felon

A

Avoid neurovascular bundle

Most serious complication is acute tenosynovitis

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37
Q

what is a paronychia

A

Inflammation involving the lateral and posterior fingernail folds.

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38
Q

predisposing factors for paronychia

A
  1. Overzealous manicuring
  2. Nail biting
  3. Thumb sucking
  4. Diabetes mellitus
  5. Occupations in which the hands are frequently immersed in water
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39
Q

tx of paronychia

A

TX=I&D: separate the nail plate from the lateral nail fold

  1. Iodoform Packing vs warm soaks
  2. If doing I&D, don’t usually need to put them on abx

is packing bring back in two days recheck

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40
Q

four cardinal signs of flexor tenosynovitis

A
  1. Tenderness over the flexor tendon,
  2. Swelling of the finger
  3. Pain on PASSIVE extension,
  4. Flexed posture of the digit.
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41
Q

what are we worried about with flexor tenosynovitis

A

ii. Tendons have scant blood supply; blood flow easily interrupted by relatively little edema and may cause destruction of underlying tendon.

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42
Q

Peri-tendonous scarring results in

A

iii. Peri-tendonous scarring = subsequent loss of function of the hand.

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43
Q

tx of flexor tenosynovitis

A

tx the operating room and admit with appropriate intravenous antibiotic therapy.

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44
Q

Pyogenic Flexor Tenosynovitis

A

Uniform volar swelling

Flexor tendon sheath tenderness

Pain on passive extension

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45
Q

Pyogenic Flexor Tenosynovitis tx

A

Admit: surgical drainage and IV antibiotics

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46
Q

Pyogenic Flexor Tenosynovitis often beings with

A

i. Often begins as benign puncture wound

ii. Slight digital flexion

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47
Q

wound management and consideration

A

Control bleeding

Copious irrigation with high pressure NS (1 liter of irrigation)

Consider delayed closure of “dirty” wounds
Debridement

Foreign body removal

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48
Q

Incisional mngmt

A
  1. Caused by a sharp object

2. Usually may be closed primarily

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49
Q

avulsion mngmt

A
  1. Full thickness require skin grafting
50
Q

Considered this wound MOA “dirty”

what is the mangement

A

Blast/Crush injuries

Considered “dirty” due to maceration of tissue and microvasculature

Often require debridement

51
Q

Degloving injuries require

A

i. Require skin grafting

52
Q

special considerations for puncture wounds

A

May require “coring”

Greater risk of infection

iii. Elevate extremity
iv. Low threshold for antibiotic tx

53
Q

Crush injuries–> tx and complications

A

Tx: antibiotics, supportive care, watch for compartment syndrome

Ischemia may result from damage to local microcirculation/damage to major blood vessels

54
Q

Subungal hematoma

mngmt

A

> 50% = remove nail plate to evaluate for nail bed laceration

Repair nail bed w/ absorbable suture

Removed nail may be used as splint

Decrease possibility of post traumatic ridged nail or cosmetic deformities

55
Q

recommended reimplantation with these types of amputations (4)

A

Recommend reimplantation of

thumb
the index finger proximal to the PIP joint
multiple digits
and single amputated digits in children.

56
Q

mngmt of patient with amputation

A
  1. If stable do not delay evaluation for transplant
  2. Minimally manipulate/Avoid extensive cleaning
  3. Do NOT inject with local anesthesia –>you will cause ischemia to the part
  4. Saline gauze, bulky dressing, splint, elevate
  5. Ancef 1 gm IV
  6. Update Tetanus and NPO

Save all parts and rinse with normal saline remove gross contamination only

  1. Xray stump and part
57
Q

management of amputated part and time window

A

Wrap in DRY gauze

Place in DRY zip lock bag and place bag ON ice

Do not use dry ice, do not bury in bag

Cooling part to 40° F enhances survival

1 hr of warm ischemia = 6 hrs cold ischemia

of hanging on a thread wrap in saline gauze and keep it cool

58
Q

management of a zone I amputation

A

before the bone

secondary intention

Irrigate/Debridement
Antibx dressing
Protective splint

Lorraine does dissect out tissue and cover with this for fun rather than let an open wound grannualte in

59
Q

Zone II mnmgt

A

= flap reconstruction

60
Q

zone III mngmt

A

Zone III = amputation

does not help to attach distal pahlaynx

61
Q

fish hook removal

A

 advance them a little bit and then cut off the bar

1. Can use the yank technique as well

62
Q
  1. Tendons responsible for the gross movements of the hand and digits
A

extrinsic tendons

63
Q

ask pt to forcefully spread their fingers helps test which tendons

A

Abductor pollicis longus and extensor pollicis brevis: ask pt to forcefully spread their fingers

64
Q
  1. Most commonly involved in hand injuries
A

extrinsic tendons

65
Q

how to test extensor pollicis longus:

A

ulnar border of the snuff box; ask pt to hyperextend distal phalanx of thumb against resistance

66
Q

Intrinsics are responsible for

A

Responsible for fine detailed movement

67
Q

Volar interossei test by

A

tested by placing paper between extended fingers and asking pt to resist its removal.

68
Q

Dorsal interossei test by

A

tested by spreading the hand forcibly against resistance

69
Q

Thenar and hypothenar muscles

A

pinch and opposition

70
Q

Lumbrical tendons

A

extend wrist and fingers while examiner presses down on fingertips

71
Q

most common site of injuries to tendons

A

Most common site of injury is dorsum of hand where extensor tendons are superficial and more exposed to injury.

Tendon injuries may be partial or complete
1. 70-90% of tendon lacerated and still function

72
Q

mngmt of tendon injuries

dos and do NOT (1)

DO (2)

A

Determine the position of the hand at the time of injury

DO NOT close bites, crush injury, contaminated wounds

DO Start prophylactic antibiotics if dirty

DO Consult Ortho in the ED for timing of repair

73
Q

Extensor tendons need to be repaired in

A

Extensor tendons need to be repaired in about 72 hours

74
Q

mnmgt of open Flexor Tendon Injuries

A

i. Lacerations
ii. Never repair in ED
iii. Assess for vascular injury

Surgical consult for timing of repair
Irrigate, close skin and flexion splint

Consider antibiotics

75
Q

primary timing of tendon repair

A

Primary repair: within 72 hours of injury

Delayed repair: first week after injury

Splint in a neutral position

76
Q

why would secondary repair be indicated for tendon injury and when would it occur

A

after all edema has subsided and the scar has softened
1. (4-6 weeks)

Splint in a neutral position

77
Q

Swan Neck Deformity occurs after

A

Untreated Mallet

Overactive pull of extensor tendon on middle phalanx

78
Q

why is the classic swan neck

A

PIP Hyperextension

Flexion of DIP

79
Q

boutonniere deformity -what is it

A

Extensor Tendon Injury: Boutonniere Deformity

Flexion of PIP with hyperextension of DIP

80
Q

boutonniere deformity occurs after

A

Disruption of the tendon at the PIP

Results from jamming or forced flexion injury that disrupts the extensor tendon insertion into the dorsal base of the middle phalanx

81
Q

tx of extensor tendon injury

A

Tx: Extension splint to immobilize PIP x 4-6 wks

82
Q

tendonitis is usually caused by

A

Usually etiology =repetitive stress
1. Active and passive movement accentuates pain with well localized tenderness

Tx with NSAIDS and/or local steroid injection

83
Q

Tenosynovitis:

A

hx of excessive stress on the affected tendon

-friction between tendon and sheath causes synovial thickening

84
Q

what is trigger finger

A

Painful blocking of flexion and extension at the involved joint

Hypertrophy of the tendon and pulley as a result of excess repetitive strain

85
Q

sxs of trigger finger

A

iii. Localized tenderness over the proximal flexor pulley

86
Q

mc tirgger finger and tx

A

Ring and middle fingers most common

Tx: steriod injection / surgical release

87
Q

main stabilizer that is disrupted in dislocations (hyperextension_

A

Volar Plate Collateral Ligaments

88
Q

MC dislocation dorsal or ventral?

DIP or PIP

A

dorsal

PIP most commonly injured

89
Q

treatment of volar plate avulsion

A

splinting and early ROM after reduction

always XRAY before and after

90
Q

general mngmt of finger dislocations

A

i. Digital block
ii. Closed relocation
iii. Post reduction Xrays
iv. Access Active ROM and PROM after reduction
v. Unable to reduce = entrapment: volar plate, collateral ligament, or fracture
vi. Splinting & Ortho f/u

91
Q

Gamekeeper’s/Skier’s Thumb what ligament is injure in this and what purpose does it serve

A

i. Ulnar collateral ligament rupture

1. Ulnar collateral ligament – keeps the thumb from opening too much

92
Q

gamekeeper thumb exam

A

Weakened “pinch”

iii. Cannot resist an adduction stress

93
Q

gamekeeper thumb mngmt

A
  1. Xray for underlying avulsion fx
  2. Any pain in distribution of UCL or inability to oppose thumb = UCL injury until proven otherwise
  3. With/without fracture full tear = surgical fixation
  4. Partial tear = splint and refer

thumb spika

94
Q

fx of distal phalanx that you do nothing about

A

Tuft –> does not affect functionality; painful, not intraarticular

95
Q

Transverse fx is often associated with

A

often associated with nail bed laceration

96
Q

avulsion injury at the attachment of the extensor tendon

A

Mallet

soft ball vs. finger

bam jam jam

97
Q

deformity associated with mallet finger

A

a. Flexion deformity at DIP with complete passive but incomplete active extension of DIP joint

98
Q

Extra-articular fractures of k. Middle and Proximal Phalanx Fractures

A

ulnar or radial gutter splint

early ROM is necessary

Oblique, spiral, displaced, or unstable
1. refer for reduction or surgical fixation

99
Q

Avulsion fx of distal phalanx with tendon attached.

A

mallet

100
Q

Metacarpal Fractures MC occur at

A

i. Most commonly at the metacarpal neck

think 4th or 5th digit = boxer’s fx
clenched fist injury

101
Q

when would reduction be required with metacarpal fx

A

Index or middle finger:

angulation > 15 degrees;

4th or 5th digit angulation > 30 degrees

102
Q

check for rotational alignment with metacarpal fx by

A

flexing fingers and looking for alignment

Make sure all fingernails are pointing to the same place

103
Q

what is a bennet’s

A

i. Fracture at the base of the thumb metacarpal involving the joint

104
Q

MOA of bennet’s

A

ii. Sustained from an axial load with a closed hand

105
Q

tx of bennet’s

A

iii. Must be reduced and requires surgical intervention

106
Q

Most common of all carpal fractures

what is the sxs

A

scaphoid

  1. Anatomic snuff box tenderness (if present, place thumb spica splint)
107
Q

dx and tx of scaphoid fx

A
  1. Scaphoid views will often demonstrate a fx not seen on plain wrist films.
  2. Immobilize in thumb spica splint.
108
Q

smith’s fx-what is it

need to check for

A

fx of distal radius with volar displacement

  1. Check for associated median nerve or flexor tendon injury.
109
Q

Colles fx what is it and managemet

A

fx of distal radius with dorsal displacement; more commonly seen

Reduce after traction and hematoma block

110
Q

DeQuervain’s also known as… what is it

A

Stenosing tenosynovitis

Involves the abductor pollicis longus and extensor pollicis brevis

111
Q

need to document this with DeQuervain’s

A

Finkelstein’s test

a. Sharp pain with ulnar deviation of wrist
5. Splint

112
Q

Carpal tunnel caused by

A

Compression of the median nerve in the carpel canal

Etiology = any condition which produces chronic swelling

Repetitive motion

anything causing flexion or extension

113
Q

documentation and tx of carpal tunnel

A

Tinels and Phalen’s sign

Splint them and tell them to wear it to bed

114
Q

Most common tumor of the hand

A

Ganglion Cyst

115
Q

physiology ganglion Cyst

A

Synovial cyst from joint or synovial lining of a tendon that has herniated

116
Q

Grease gun, paint sprayers, or compressed air devices cause

what are the complications of this

A

high pressure injuries

deposit toxins into tendon and synovial sheaths.

117
Q

MC site of high pressure injection injury

what are the sxs

A

Most common site of injection = index finger followed by the palm and long finger.

The patient may develop intense throbbing and pain shortly after the injury leading to compartment syndrome.

118
Q

complications of high pressure injection injury

A

True extent injury hidden behind tiny puncture wound

Even with early dx high incidence of amputation

Act aggressively!

119
Q

mngmt of high pressure injury

A

Xrays

b. Pain control
c. No digital blocks = worse outcomes d. NPO and Tetanus

Early extensive surgical debridement and decompression of the wound / fasciotomy.

Prophylactic broad-spectrum antibiotics

Corticosteroids?

120
Q

prognoses of high pressure injury

A

Time since injection critical

Patients requiring amputation presented 6-48 hours after injury

Chemical properties contribute to the severity of the injury.

Paint and paint solvents = most irritating to tissue.

Rapid compromise of circulation to digits.

121
Q

Hand wound complications = highest # medicolegal actions against ED

how do you avoid these

A

Consider retained foreign bodies or deep tissue injury in all open wounds

Inform all patients of possibility of complications: pain, limitation of mobility

Carefully document initial neuro exam, procedures and follow-up for all patients

When in doubt , refer to ORTHO

Emergency Medicine (28 decks)

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