Hand and Wrist Flashcards
1
Q
the ulnar nerve in the hand
A
- -The ulnar nerve enters the palm of the hand through the ulnar canal
- -Prior to entering the ulnar canal, it gives off:
- a palmar cutaneous branch which provides cutaneous innervation to the skin of the ulnar aspect of the palm
- -A dorsal cutaneous branch which provides cutaneous innervation to the skin of the ulnar aspect of the dorsum of the hand
- -In the palm of the hand, the ulnar nerve innervates all the intrinsic muscles of the hand not innervated by the median nerve.
2
Q
epidemiology: hand and finger injuries
A
- nMore than 30% of industrial accidents and three-fourths of industrial injuries
- n5-10% of ED visits
- nMost frequent body parts injured at work
- nLacerations most frequent injury
- nDistal phalanx most commonly fractured
- nLittle finger most common in US
3
Q
documentation
A
- Dominant hand
- Occupation
- Tetanus status
- Traumatized
- Ascertain hx of trauma
- Time elapsed since injury
- Environment of injury
- Mechanism of injury
- Nontraumatized
- When did sx begin
- What functional impairment
- What activities worsen sx
4
Q
initial assessment
A
- First, remove any rings, watches, or other jewelry with a ring cutter if necessary.
- if the finger swells, the metal ring will compromise circulation.
-
Compare both hands for symmetry.
- Swelling
- Deformity
- color changes
- Sensory deficits
5
Q
examination
A
- location of the injury should be described as radial or ulnar side and on the volar or dorsal (flexor or extensor) surface.
- skin color; check for capillary refill.
- Repeat the test on an uninjured digit for comparison.
- radial and ulnar pulses
- If swelling of the dorsum of the hand, but otherwise normal, examine volar
- r/o palmar puncture wound or other injury
6
Q
excessive bleeding
A
- elevation
- apply a sterile wet-compression dressing.
- a blood pressure cuff can be inflated to about 100 mmHg above the patient’s systolic blood pressure. Never leave this cuff on for more than 30 minutes.
- Since the nerves follow vessels, never ligate a hand vessel without directly visualizing the bleeding vessel and all surrounding structures.
- Never blindly clamp a bleeding vessel:
- trauma to nerve, tendon, or associated vessels.
7
Q
nerve injury testing
A
- Sensory:
- Radial: dorsum of first web space.
- Ulnar: 5th finger
- Median: flexor aspect of index and middle fingers.
- Motor:
- Radial: extension at wrist and MP joint
- Ulnar: forcible spread of fingers against resistance
- Median: flexion of wrist and PIP of thumb and index against resistance
8
Q
range of motion
A
- Documentation of presenting motor exam
- Patients unable to flex one finger together with the others often found to have associated tendon injury.
- Weak movement of the joint may signal an incomplete tendon injury
- Note that pain may also limit functional exam (false positive)
9
Q
Flexor examination
A
- Flexor Digitorum Profundus and Flexor Pollicis Longus
- Have pt flex DIP while proximal joints are held in extension
10
Q
test of flexor tendon function
A
- Flexor Digitorum Superficialis
- Test by holding all other fingers in extension and have the pt flex the finger to be tested
11
Q
testing extension
A
- Patient position: hand palm-down on a table and extend the fingers off the table one at a time.
- Test against resistance for partial lacerations
- 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.
- Ranging finger increases the chances of seeing a tendon injury in the wound.
12
Q
foreign bodies
A
- Glass, metal, wood—most common
- Glass, metal detected on xray / ULS
- Large f.b.’s tend to cause a fibrous rx and become symptomatic
13
Q
missed foreign bodies
A
- 1/3 of legal claims: retained FB
- Retained glass = most commonly reported in hand
- XRAYS sensitive for glass > 2mm
- Rarely plastic, wood, organic
- Xray neg but suspicion high = closer examination
14
Q
foreign bodies identification
A
- Ultrasound
- sensitive 95-100% < 1-4mm
- CT most sensitive
15
Q
foreign body management
A
- mechanical and inflammatory effects
- Remove based on size, composition, and location
- Small FB deeply imbedded – do not attempt
- Infection common complication
- Antibiotics? –depends on object and mechanism
- Ortho Consult ?
16
Q
hand infections
A
- Anatomy : infections extend quickly across the fascial planes of the hand without resistance.
- Finger infections
- proceed through the flexor tendon sheath and enter the mid-palmar space.
- Infections in the mid-palmar space
- extend rapidly into the thenar space.
- devastating effects: may resist aggressive treatment with IV antibiotics
- often require incision and drainage in the operating room.
17
Q
Felon
A
- Subcutaneous pyogenic infection of the pulp space of the finger tip (tuft)
- Presents with severe throbbing pain
- Most common org = staph aureus
- Requires I&D
- incision 5mm distal to the digital crease and extend to the pulp space
- tx:
- Midline incision
- Avoid neurovascular bundle
- Consult Ortho if complex
- Most serious complication is acute tenosynovitis
18
Q
paronychia
A
- Inflammation involving the lateral and posterior fingernail folds.
- Predisposing factors:
- overzealous manicuring
- nail biting
- thumb sucking
- diabetes mellitus
- occupations in which the hands are frequently immersed in water
- also reported in association with antiretroviral therapy for HIV infection
- TX=I&D: separate the nail plate from the lateral nail fold
- Packing vs warm soaks
19
Q
anatomical snuff box
A
- The anatomical snuff box:
- Boundaries:
- Anterior: Extensor pollicis longus and extensor pollicis brevis
20
Q
compartments of the palm
A
21
Q
blood supply to the hand
A
- Blood supply to the palm of the hand is provided by both the radial and ulnar arteries.
- 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.
- At the wrist, the RADIAL ARTERY gives off a superficial palmar branch which completes the superficial palmar arterial arch. The radial artery then courses posteriorly, traveling in the floor of the anatomical snuffbox. It pierces the first dorsal interosseus muscle to enter the palm. When in the palm, the radial artery is the primary source of blood to the deep palmar arterial arch (completed by the the deep palmar branch of the ulnar artery).
22
Q
allen test
A
- collateral circulation between the two vessels through the palmar arch.
- forcefully open and close the fist 10-20 times. compress the radial and ulnar arteries
- When the ulnar artery is released, the patient’s skin pallor should rapidly resolve.
23
Q
neurologic evaluation
A
- examine the patient’s sensation prior to instilling anesthesia.
- Lacerated nerves are common
- Median nerve: through carpal tunnel
- Ulnar nerve: passing between hook of hamate
- Radial nerve:
- Superficial branch above radial styloid
24
Q
radial nerve in the hand
A
-Superficial radial nerve supplies skin on the lateral side of the dorsum of the hand, and a small portion of the thenar eminence
35
Q
finger tip amputation zones/treatment
A
- Zone I = secondary intention
- Irrigate/Debridement
- Antibx dressing
- Protective splint
- Zone II = flap reconstruction
- Zone III = amputation
36
Q
extrinsic muscle and tendon injuries
A
- Extrinsic
- Tendons responsible for the gross movements of the hand and digits
- Most commonly involved in hand injuries
- Abductor pollicis longus and extensor pollicis brevis: ask pt to forcefully spread their fingers
- Extensor pollicis longus: ulnar border of the snuff box; ask pt to hyperextend distal phalanx of thumb against resistance
41
Q
swan neck deformity
A
- Untreated Mallet
- Overactive pull of extensor on middle phalanx
- PIP hyperextension
- Flexion of DIP
- Compensatory Swan neck
42
Q
Boutonniere deformity
A
- Disruption of the tendon at the PIP
- Flexion of PIP with hyperextension of DIP
- results from jamming or forced flexion injury that disrupts the extensor tendon insertion into the dorsal base of the middle phalanx
- Tx: Extension splint to immobilize PIP x 4-6 wks
