Hand Injury

Question 1

Approach to hand lacerations?

Answer 1

TIN AX
Tetanus prophylaxis
Irrigate with normal saline
NPO
ABx prophylaxis
X rays

Question 2

Key history questions in hand injury assessment?

Answer 2

• ABC
• AMPLE
• Hand dominance
• Occupation
• Time and place of accident
• Mechanism of injury
• Tetanus status
• Pain Mx

Question 3

PEx features on observation of hand injury assessment?

Answer 3

Look and draw/photograph

• Position of finger
• Deformity
• Bruising or swelling
• Sweating pattern
• Anatomical structures beneath: blood supply, tendons, nerves, bone and joint

Question 4

How is vascular status assessed in hand injury?

Answer 4

• Radial and ulnary arteries = Allen’s test (release either artery to assess collateral)
• Digital arteries = capillary refill

Question 5

Tendons for assessment in hand injury?

Answer 5

FDP and FDS

Question 6

How is FDP assessed?

Answer 6

Stabilise fingers in extension at PIP and ask pt to flex at DIP

Question 7

Speed of peripheral nerve regeneration?

Answer 7

1mm/day

Question 8

What is Tinnel’s sign?

Answer 8

Cutaneous percussion over repaired nerve produces parasthesis and defines level of nerve regeneration.

Question 9

Why is there no TInnel’s sign until 2weeks post repair?

Answer 9

Wallerian degeneration occurs in the first 2wk

Question 10

Why does Tinnel’s sign occur?

Answer 10

Parasthesias felt in area of percussion because regrowth of myelin (Schwann cells) is slower than axonal re growth –> percussion on exposed free end on generates paresthesia

Question 11

Post op management of hand injury with vascular laceration?

Answer 11

• Dress, immobilise and splint hand with finger tips visible

- Monitor colour, capillary refill, skin turgor, fingertip temperature post revascularisation

Question 12

Where may different tendon repairs be performed?

Answer 12

• Extensor = ED

- Flexor = OT

Question 13

Mx of nailbed injury?

Answer 13

• Removal nail to examine nailbed under digital block anaesthesia
• Irrigate
• Suture repair of nailbed
• Replace cleaned nail (acts as splint, prevents adhesion formation between nail fold and nailbed)

Question 14

Organisms causing hand infection?

Answer 14

90% by G+VEs

• S aureus
• S. viridans
• Grp A strep

Question 15

What is flexor tendon posture referred to as?

Answer 15

Cascade

Question 16

Describe extensor tendon anatomy

Answer 16

Terminal tendon extends DIP joint, central slip extends PIP

Question 17

What extends the MP joints of the fingers?

Answer 17

Extensor digitorum communis

Question 18

How is Median Nerve examined?

Answer 18

• Abductor pollicis brevis
• FDS, FPL, radial FDP, FCR
• Sensation

Question 19

How is Ulnar Nerve examined?

Answer 19

• Adductor pollicis (Froment’s test)
• Interossei (abduction)
• Ulnar FDP, FCU
• Sensation

Question 20

How is radial nerve examined?

Answer 20

Long extensors

-sensation

Question 21

What are the mechanisms of hand injury?

Answer 21

• Cut
• Crush
• Shear
• Puncture

Question 22

Workup/Mx of paediatric finger tip injury?

Answer 22

Usually crush (e.g. door)
Anatomy: distal phalanx
Ix: XR
Rx: clean wounds, compression, rest (splint in position of function), elevate, ABx, tetanus status, analgesia
Refferal: plastics re nail bed repair, suture finger tip

Question 23

Workup/management of dorsal laceration injury?

Answer 23

• Mechanism: e.g. circular saw, knife
• Ix: +/- XR (saw/FB/glass)
• Rx: clean wounds, compression, rest i.e. splint in position of function, elevation, ABx, tetanus status, analgesia
• Refer plastics if suspect deeper than skin

Question 24

Which structures are endangered in dorsal laceration injury?

Answer 24

-Anatomy: extensor tendon, bone, cutaneous, nerves, joint

Question 25

Which structures are endangered in volar laceration injuries?

Answer 25

• Flexor tendon
• Digital nerve and arteries
• Bone
• Joint

Question 26

Assessment/Mx volar laceration injury?

Answer 26

-Ix: +/- XR if force enough to cause #, FB e.g. glass
Rx: clean wounds, compression, rest i.e. splint in position of function and to stop movement (separation of tendon ends), elevation, ABx, tetanus status, analgesia
-Refer plastics if deeper than skin

Question 27

Considerations in wounds overlying joints?

Answer 27

Should be presumed to involve joint until proven otherwise; if underrated may cause septic arthritis with permanent loss of cartilage and joint destruction

Question 28

What should never be done to human bite wound?

Answer 28

Never suture!!

Question 29

Structures injured in closed punch injury?

Answer 29

Metacarpals generally

Question 30

Management/assessment of punch injury with open wound?

Answer 30

Risk of SA: tooth knuckle injury WORSE than animal bite, extensor tendon usually injury, joint usually breached.

• Tetanus
• ABx (inc anaerobes e.g. Aug DF)
• XR (tooth fragment/#)
• Rest, splint, elevation
• Refer plastics

Question 31

Assessment of limb amputation?

Answer 31

• Ix: XR limb and part
• Rx: rest (splint), elevation, compression, clean wounds, ABx, tetanus status, analgesia
• Urgent refferal!
• NBM

Question 32

Care of amputated part?

Answer 32

Saline gauze into plastic bag next to ice (not in ice!)

Question 33

What is tenosynovitis? CFx?

Answer 33

Infection within tendon sheath;

• presents as fusiform swelling of digit with partially flexed posture.
• Tender along sheath.
• Pain with passive extension.

Question 34

Ix and Mx tenosynovitis?

Answer 34

Ix: clinical dx, +/- US, wound swab if any
Rx: rest (splint), elevation, compression, clean wound if present, IV ABx, tetanus, analgesia
Urgent referral