Hand injuries

Question 1

What is the cause of a tendon laceration?

Answer 1

Sharp injury

Question 2

How would you manage a tendon laceration?

Answer 2

Restore anatomy usually with sutures (non dissolving)

Needles can be put through pulley (thick annulars) to keep tendons in place

Any incisions made should be performed at cruciate pulleys between the annulars

Question 3

What is Mallet’s finger?

Answer 3

Deformity of finger where tendon that straightens the finger (extensor tendon) is damaged at the fingertip

Question 4

What causes Mallet’s finger?

Answer 4

commonly happens when an object (like a ball) strikes the tip of the finger of thumb or when forceful bending of the fingertip occurs

Can be avulsion or evulsion

Question 5

How would you manage Mallet’s finger?

Answer 5

(A)Tendon: treated non operatively using a splint

(B)Bone: Fixed surgically usually with pins, takes 4-6 weeks

Question 6

In order of how common it is, what are the causes of hand injuries?

Answer 6

Trauma > Post operative care > Foreign body > Animal bites > spontaneous > IV drug abuse > Human bites

Question 7

What is paronchyia?

Answer 7

A skin infection around the fingernails or toenails. It usually affects the skin at the base (cuticle) or up the sides of the nail

Question 8

What are common organisms causing hand injuries?

Answer 8

Staphylococcus aureus (44%, by far most common) > Mixed (staphylococci, streptococci) > Anaerobes

Question 9

What is felon finger?

Answer 9

A felon finger infection, commonly referred to as felon finger, is a painful infection affecting the soft tissue located on the pad of the finger, also known as the fingertip pulp

Question 10

What causes felon finger?

Answer 10

Bacteria (Staph. A)

Treat with ABx
In the case of abscess formation, incision and drainage will often be required

Question 11

How does a felon finger present?

Answer 11

The primary signs and symptoms of felon finger are a swollen, red finger pad with intense, throbbing pain that is tender to the touch

Can lead to abscess formation

Question 12

What is a common cause of finger tip injuries?

Answer 12

Can occur commonly in children when door hinge is shut on fingertip

Question 13

If a finger tip was amputated due to trauma, how would you store it for surgery?

Answer 13

Amputated part: in wet gauze, sealed in plastic bag, bag immersed in ice/water 50% ratio

Muscle has to be re-attached immediately due to necrosis, only finger/finer tips can be preserved for longer periods

Question 14

What is a closed fracture?

Answer 14

Bone is broken but skin is intact

Question 15

What is an open fracture?

Answer 15

Bone pokes through skin and can be seen/deep wound exposes bone through skin

Question 16

How would you classify open fractures?

Answer 16

Gustilo and Anderson classification:

1. Low energy <1cm
2. > 1cm with moderate soft tissue damage
3. > 1cm with extensive soft tissue damage

Question 17

How would you manage open fractures?

Answer 17

Manage infection including tetanus prophylaxis
IV broad-spectrum ABX for open injuries
All open fractures should be thoroughly debrided

Surgery

Question 18

What are the indications to manage a fracture operatively?

Answer 18

Displaced irreducible fractures and fracture dislocations Unstable fractures
Open fractures

Question 19

What are the indications to manage a fracture non-operatively?

Answer 19

Undisplaced or minimally displaced, stable
Patient at high operative risk/unfit for surgery
Paediatric fractures (green stick, buckle/torus)

Question 20

What is a irreducible dislocation?

Answer 20

Dislocation that cannot be re-aligned

Usually follows dislocation and relocation

PIP/MCPJ most commonly affected

Requires open reduction in theatre

Question 21

What are volar plate injuries often caused by?

Answer 21

Hyperextension

Early mobilisation is vital

Question 22

What are common wrist fractures?

Answer 22

Colles’ fracture (distal radius with dorsal displacement of fragments).

Smith’s fracture (distal radius with volar displacement of fragments).

Scaphoid fracture.

Barton’s fracture (fracture dislocation of the radiocarpal joint).
Chauffeur’s fracture (fracture of the radial styloid).

Question 23

What causes scaphoid fractures?

Answer 23

Fall on an outstretched hand

Can also be the result of injury sustained from the steering wheel during a road traffic accident

Question 24

What are the signs and symptoms of scaphoid fractures?

Answer 24

Pain along radial aspect of wrist, at base of thumb -Loss of grip/pinch strength

1. Point of maximum tenderness over the anatomical snuffbox (high sensitivity low specificity)
2. Wrist joint effusion (accumulation of fluid) Note: Hyperacute injuries <4 hours old + delayed presentation >4 days may not present with joint effusions 3.Pain elicited by telescoping of thumb (pain on longitudinal compression)
3. Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
4. Pain on ulnar deviation of the wrist

Question 25

How would you manage scaphoid fractures?

Answer 25

Undisplaced fractures of the scaphoid: Cast for 6-8 weeks

Displaced scaphoid fractures: Requires surgical fixation
Proximal scaphoid pole fractures: Require surgical fixation

Question 26

What are the complications of scaphoid fractures?

Answer 26

Avascular necrosis: the blood supply enters the scaphoid near its waist. Fractures in this area can potentially interrupt the blood supply to the proximal part of the scaphoid, leading to avascular necrosis, non-union and arthritis.

Scaphoid non-union/delayed union; non-union occurs in approximately 5-10% of undisplaced scaphoid fractures

Question 27

What is Colles’ fracture?

Answer 27

The classical definition is a fracture through the distal metaphysis of the radius, within 2-3 cm of the articular surface.

The term is now more loosely used for any fracture of the distal radius, with or without involvement of the ulna, with dorsal (backward) displacement of the fracture fragments

Question 28

What causes Colles’ fractuers?

Answer 28

It is common in older people who fall and have osteoporosis

It can also occur in younger people with normal bones, when it is more likely to have an intra-articular component and follow high-energy trauma.

Question 29

What features dod classic Colles’ fractures have?

Answer 29

Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation

Question 30

What are the complications for Colles’ fractures?

Answer 30

Median and/or ulnar nerve damage can occur acutely. There can be an acute carpal tunnel syndrome.

Compartment syndrome

Question 31

What is Smith’s fracture?

Answer 31

The definition is a fracture of the distal radius, with or without ulnar involvement, that has volar (anterior) displacement of the distal fragments.

It is usually caused by falling backwards - a fall on to the palm of the outstretched hand with the arm above it pronating as the body falls.

The characteristic appearance is called a ‘garden spade deformity’.

The X-ray of a Smith’s fracture is very similar to a Colles’ fracture except with the displacement anteriorly instead of posteriorly.

Question 32

What are causes of Dupuytren’s contracture?

Answer 32

Manuel labour
Phenytoin treatment
Alcoholic liver disease
DM
Trauma to hand

Question 33

What is the presentation of Dupuytren’s contracture?

Answer 33

Flexed:

1. Wrist
2. Pinky
3. Ring finger

Question 34

How would you manage Dupuytren’s contracture?

Answer 34

Consider surgical treatment when metacarpophalangeal joints cannot be straightened

Question 35

What is compartment syndrome?

Answer 35

Compartment syndrome is caused by an increased pressure within a closed anatomical space, which compromises the circulation and function of the tissues within that space

Question 36

How would you manage compartment syndrome?

Answer 36

The mainstay of treatment is prompt diagnosis and early surgery. Patients with a swollen limb and no clear underlying cause should be considered for urgent orthopaedic opinion

Question 37

What injuries can damage the axillary nerve?

Answer 37

Fracture of surgical neck of humerus
Stab wounds to posterior shoulder
Anterior shoulder dislocation
Pressure of crutches on armpits (“crutch palsy”)

Question 38

How does axillary nerve palsy present?

Answer 38

Sensory loss: numbness over “sergeant’s patch”

Motor deficit: paralysis of deltoid leading to very weak shoulder abduction from 15-90°; weak shoulder flexion and extension. Paralysis of teres minor leading to weak shoulder external rotation.

Deformity: wasting of deltoid muscle, making the bones of the shoulder joint very prominent and obvious. The shoulder may appear adducted and internally rotated.

Question 39

What injuries can damage the radial nerve?

Answer 39

Fractures of proximal humerus, shaft of humerus or radius

Stab wounds to antecubital fossa, forearm or wrist (this includes blood tests and cannulation)

Question 40

How does radial nerve palsy present?

Answer 40

Sensory loss: numbness of skin over posterior arm, posterior forearm and radial distribution of dorsum of hand

Wrist drop

Question 41

What injuries can damage the median nerve?

Answer 41

Supracondylar fractures of humerus

Stab wounds to antecubital fossa, forearm of wrist (this includes blood tests and cannulation!)

Deep wrist lacerations inflicted during deliberate self-harm

Question 42

How does median nerve palsy present?

Answer 42

Sensory loss: numbness of skin over thenar eminence and median distribution of hand. However, in carpal tunnel syndrome, sensation to the palm is usually preserved due to an intact palmar cutaneous branch.

“Hand of benediction” deformity on attempted finger flexion, the patient cannot flex their index or middle fingers, resulting in unopposed extension of those two fingers. They cannot make a fist with all of their fingers. Wasting of anterior compartment of forearm and thenar eminence

Question 43

What injuries can damage the ulnar nerve?

Answer 43

Supracondylar fractures of humerus
Fractures or soft tissue injuries to medial epicondyle of humerus
Stab wounds to forearm or wrist (this include blood tests and cannulation!)

Question 44

How does ulnar nerve palsy present?

Answer 44

Claw hand