hand and wrist Flashcards
At the wrist, the ______ gives off a superficial palmar branch which completes the superficial palmar arterial arch.
At the wrist, the RADIAL ARTERY gives off a superficial palmar branch which completes the superficial palmar arterial arch.
the ULNAR ARTERY enters the hand anterior to the _____ just lateral to the pisiform
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.
ulnar nerve passes between
passing between hook of hamate
radial nerve superficial branch travels above
Superficial branch above radial styloid
median nerve travels through the
Median nerve: through carpal tunnel
Superficial radial nerve supplies
Superficial radial nerve supplies skin on the lateral side of the dorsum of the hand, and a small portion of the thenar eminence
the recurrent branch of the median n. supplies
the recurrent branch of the median n. supplies the muscles of the thenar eminence
cutaneous branch of the median nerve is responsible for
b. cutaneous branches to the skin on the palmar surfaces of the of the first 3½ digits
The ulnar nerve enters the palm of the hand through the ___-
- The ulnar nerve enters the palm of the hand through the ulnar canal
Prior to entering the ulnar canal, ulnar n gives off:
a palmar cutaneous branch
(ulnar aspect of the palm)
A dorsal cutaneous branch
(the ulnar aspect of the dorsum of the hand)
what is the most frequent injury of the hand and commonly fractured
what is the most common finger
Lacerations most frequent injury
Distal phalanx most commonly fractured
Little finger most common in US
how do you document hand injury
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)
this nerve is responsible fo
the ulnar nerve innervates all the intrinsic muscles of the hand not innervated by the median nerve.
how to document trauma
- Ascertain hx of trauma
- Time elapsed since injury (golden window = 6 hours)
- Environment of injury
- Mechanism of injury
how to document non-trauma
v. Nontraumatized
1. When did sx begin
2. What functional impairment
3. What activities worsen sx
what are the NEVER rules with excessive bleeding
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
dorsum of first web space.
radial
how do you test strength of R/U/M nerve
- Radial: extension at wrist and MP joint
- Ulnar: forcible spread of fingers
- Median: flexion of wrist and PIP of thumb and index against resistance
5th finger sensory what N
ulnar
flexor aspect of index and middle
medial
document ROM in
degrees
this PE finding is common with tendon injury
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
testing flexor digitorum profundus and Flexor Pollicis Longus
hold down all other fingers in extension and have pt just test finger needed
Test by holding all other fingers in extension and have the pt flex the finger to be tested
Flexor Digitorum Superficialis
how to test extension
: hand palm-down on a table and extend the fingers off the table one at a time.
If you suspect an extensor tendon laceration but cannot visualize in the wound,
try putting the hand in the position it was in when the injury occurred.
whenever there is glass involved
get an xray
XRAYS sensitive for glass > 2mm
ULS is also sensitive for glass
Sensitive 95-100% < 1-4mm
best imaging for organic FB
uls
Consideration for the management of FB
anbx
might need OR removal
why are hands a scary place for infx?
infections extend QUICKLY across the fascial planes of the hand without resistance.
many structures and a lil meat
finger infections can ended mid-palmar space through
Proceed through the flexor tendon sheath and enter the mid-palmar space.
Infections in the mid-palmar space
i. Extend rapidly into the thenar space.
ii. Devastating effects: may resist aggressive treatment with IV antibiotics.
what is a felon
Subcutaneous pyogenic infection of the pulp space of the finger tip (tuft)
Paronychia but just of the tip of the finger
felons can present like this
severe throbbing pain
1. Can be hx of trauma or finger nail biters
what is the most common management and approach to felons
iii. Most common org = staph aureus
I&D
midline incision and draw packing strp in
most common complication of felon
Avoid neurovascular bundle
Most serious complication is acute tenosynovitis
what is a paronychia
Inflammation involving the lateral and posterior fingernail folds.
predisposing factors for paronychia
- Overzealous manicuring
- Nail biting
- Thumb sucking
- Diabetes mellitus
- Occupations in which the hands are frequently immersed in water
tx of paronychia
TX=I&D: separate the nail plate from the lateral nail fold
- Iodoform Packing vs warm soaks
- If doing I&D, don’t usually need to put them on abx
is packing bring back in two days recheck
four cardinal signs of flexor tenosynovitis
- Tenderness over the flexor tendon,
- Swelling of the finger
- Pain on PASSIVE extension,
- Flexed posture of the digit.
what are we worried about with flexor tenosynovitis
ii. Tendons have scant blood supply; blood flow easily interrupted by relatively little edema and may cause destruction of underlying tendon.
Peri-tendonous scarring results in
iii. Peri-tendonous scarring = subsequent loss of function of the hand.
tx of flexor tenosynovitis
tx the operating room and admit with appropriate intravenous antibiotic therapy.
Pyogenic Flexor Tenosynovitis
Uniform volar swelling
Flexor tendon sheath tenderness
Pain on passive extension
Pyogenic Flexor Tenosynovitis tx
Admit: surgical drainage and IV antibiotics
Pyogenic Flexor Tenosynovitis often beings with
i. Often begins as benign puncture wound
ii. Slight digital flexion
wound management and consideration
Control bleeding
Copious irrigation with high pressure NS (1 liter of irrigation)
Consider delayed closure of “dirty” wounds
Debridement
Foreign body removal
Incisional mngmt
- Caused by a sharp object
2. Usually may be closed primarily
avulsion mngmt
- Full thickness require skin grafting
Considered this wound MOA “dirty”
what is the mangement
Blast/Crush injuries
Considered “dirty” due to maceration of tissue and microvasculature
Often require debridement
Degloving injuries require
i. Require skin grafting
special considerations for puncture wounds
May require “coring”
Greater risk of infection
iii. Elevate extremity
iv. Low threshold for antibiotic tx
Crush injuries–> tx and complications
Tx: antibiotics, supportive care, watch for compartment syndrome
Ischemia may result from damage to local microcirculation/damage to major blood vessels
Subungal hematoma
mngmt
> 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
recommended reimplantation with these types of amputations (4)
Recommend reimplantation of
thumb
the index finger proximal to the PIP joint
multiple digits
and single amputated digits in children.
mngmt of patient with amputation
- If stable do not delay evaluation for transplant
- Minimally manipulate/Avoid extensive cleaning
- Do NOT inject with local anesthesia –>you will cause ischemia to the part
- Saline gauze, bulky dressing, splint, elevate
- Ancef 1 gm IV
- Update Tetanus and NPO
Save all parts and rinse with normal saline remove gross contamination only
- Xray stump and part
management of amputated part and time window
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
management of a zone I amputation
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
Zone II mnmgt
= flap reconstruction
zone III mngmt
Zone III = amputation
does not help to attach distal pahlaynx
fish hook removal
advance them a little bit and then cut off the bar
1. Can use the yank technique as well
- Tendons responsible for the gross movements of the hand and digits
extrinsic tendons
ask pt to forcefully spread their fingers helps test which tendons
Abductor pollicis longus and extensor pollicis brevis: ask pt to forcefully spread their fingers
- Most commonly involved in hand injuries
extrinsic tendons
how to test extensor pollicis longus:
ulnar border of the snuff box; ask pt to hyperextend distal phalanx of thumb against resistance
Intrinsics are responsible for
Responsible for fine detailed movement
Volar interossei test by
tested by placing paper between extended fingers and asking pt to resist its removal.
Dorsal interossei test by
tested by spreading the hand forcibly against resistance
Thenar and hypothenar muscles
pinch and opposition
Lumbrical tendons
extend wrist and fingers while examiner presses down on fingertips
most common site of injuries to tendons
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
mngmt of tendon injuries
dos and do NOT (1)
DO (2)
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
Extensor tendons need to be repaired in
Extensor tendons need to be repaired in about 72 hours
mnmgt of open Flexor Tendon Injuries
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
primary timing of tendon repair
Primary repair: within 72 hours of injury
Delayed repair: first week after injury
Splint in a neutral position
why would secondary repair be indicated for tendon injury and when would it occur
after all edema has subsided and the scar has softened
1. (4-6 weeks)
Splint in a neutral position
Swan Neck Deformity occurs after
Untreated Mallet
Overactive pull of extensor tendon on middle phalanx
why is the classic swan neck
PIP Hyperextension
Flexion of DIP
boutonniere deformity -what is it
Extensor Tendon Injury: Boutonniere Deformity
Flexion of PIP with hyperextension of DIP
boutonniere deformity occurs after
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
tx of extensor tendon injury
Tx: Extension splint to immobilize PIP x 4-6 wks
tendonitis is usually caused by
Usually etiology =repetitive stress
1. Active and passive movement accentuates pain with well localized tenderness
Tx with NSAIDS and/or local steroid injection
Tenosynovitis:
hx of excessive stress on the affected tendon
-friction between tendon and sheath causes synovial thickening
what is trigger finger
Painful blocking of flexion and extension at the involved joint
Hypertrophy of the tendon and pulley as a result of excess repetitive strain
sxs of trigger finger
iii. Localized tenderness over the proximal flexor pulley
mc tirgger finger and tx
Ring and middle fingers most common
Tx: steriod injection / surgical release
main stabilizer that is disrupted in dislocations (hyperextension_
Volar Plate Collateral Ligaments
MC dislocation dorsal or ventral?
DIP or PIP
dorsal
PIP most commonly injured
treatment of volar plate avulsion
splinting and early ROM after reduction
always XRAY before and after
general mngmt of finger dislocations
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
Gamekeeper’s/Skier’s Thumb what ligament is injure in this and what purpose does it serve
i. Ulnar collateral ligament rupture
1. Ulnar collateral ligament – keeps the thumb from opening too much
gamekeeper thumb exam
Weakened “pinch”
iii. Cannot resist an adduction stress
gamekeeper thumb mngmt
- Xray for underlying avulsion fx
- Any pain in distribution of UCL or inability to oppose thumb = UCL injury until proven otherwise
- With/without fracture full tear = surgical fixation
- Partial tear = splint and refer
thumb spika
fx of distal phalanx that you do nothing about
Tuft –> does not affect functionality; painful, not intraarticular
Transverse fx is often associated with
often associated with nail bed laceration
avulsion injury at the attachment of the extensor tendon
Mallet
soft ball vs. finger
bam jam jam
deformity associated with mallet finger
a. Flexion deformity at DIP with complete passive but incomplete active extension of DIP joint
Extra-articular fractures of k. Middle and Proximal Phalanx Fractures
ulnar or radial gutter splint
early ROM is necessary
Oblique, spiral, displaced, or unstable
1. refer for reduction or surgical fixation
Avulsion fx of distal phalanx with tendon attached.
mallet
Metacarpal Fractures MC occur at
i. Most commonly at the metacarpal neck
think 4th or 5th digit = boxer’s fx
clenched fist injury
when would reduction be required with metacarpal fx
Index or middle finger:
angulation > 15 degrees;
4th or 5th digit angulation > 30 degrees
check for rotational alignment with metacarpal fx by
flexing fingers and looking for alignment
Make sure all fingernails are pointing to the same place
what is a bennet’s
i. Fracture at the base of the thumb metacarpal involving the joint
MOA of bennet’s
ii. Sustained from an axial load with a closed hand
tx of bennet’s
iii. Must be reduced and requires surgical intervention
Most common of all carpal fractures
what is the sxs
scaphoid
- Anatomic snuff box tenderness (if present, place thumb spica splint)
dx and tx of scaphoid fx
- Scaphoid views will often demonstrate a fx not seen on plain wrist films.
- Immobilize in thumb spica splint.
smith’s fx-what is it
need to check for
fx of distal radius with volar displacement
- Check for associated median nerve or flexor tendon injury.
Colles fx what is it and managemet
fx of distal radius with dorsal displacement; more commonly seen
Reduce after traction and hematoma block
DeQuervain’s also known as… what is it
Stenosing tenosynovitis
Involves the abductor pollicis longus and extensor pollicis brevis
need to document this with DeQuervain’s
Finkelstein’s test
a. Sharp pain with ulnar deviation of wrist
5. Splint
Carpal tunnel caused by
Compression of the median nerve in the carpel canal
Etiology = any condition which produces chronic swelling
Repetitive motion
anything causing flexion or extension
documentation and tx of carpal tunnel
Tinels and Phalen’s sign
Splint them and tell them to wear it to bed
Most common tumor of the hand
Ganglion Cyst
physiology ganglion Cyst
Synovial cyst from joint or synovial lining of a tendon that has herniated
Grease gun, paint sprayers, or compressed air devices cause
what are the complications of this
high pressure injuries
deposit toxins into tendon and synovial sheaths.
MC site of high pressure injection injury
what are the sxs
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.
complications of high pressure injection injury
True extent injury hidden behind tiny puncture wound
Even with early dx high incidence of amputation
Act aggressively!
mngmt of high pressure injury
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?
prognoses of high pressure injury
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.
Hand wound complications = highest # medicolegal actions against ED
how do you avoid these
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
