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Emergency Med Final > Hand & Wrist Injuries > Flashcards

Hand & Wrist Injuries Flashcards

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1
Q

where do the tendons of the lumbricals & interossei muscles insert?

A

on the lateral bands of the extensor expansions of the medial 4 digits

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2
Q

the line of pull of the tendons of the lumbricals & interossei muscles are:

A

ventral to the MP joints, but dorasal to the PIP & DIP joints

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3
Q

the lubricals & interossei muscles can assist in flexion of the?

A

MP joints & extension of the DIP & PIP joints

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4
Q

what do you want to remember to do before you inject anesthesia into hand?

A

pt’s sensation

lacerated nerves are common!

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5
Q

what tunnel does the median nerve run thru?

A

carpal tunnel

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6
Q

what does the ulnar nerve pass between?

A

hook of hamate

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7
Q

the superficial branch of the radial nerve lies above what?

A

radial styloid

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8
Q

does the radial nerve supply muscles in the hand?

A

NO

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9
Q

what does the radial n, supply?

A

skin on the lateral side of the dorsum of the hand, and a small portion of the thenar eminence

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10
Q

what branches does the median nerve give off in the palm?

A

recurrent branch of the median n.
branches of the first 2 lumbricals
cutaneous branches to the skin on the palmar surfaces of the 1t 3.5 digits

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11
Q

what does the recurrent branch of the median n. supply?

A

supplies the muscles of the thenar eminence

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12
Q

the ulnar n. enters the palm of the hand through what?

A

the ulnar canal (just lateral to the pisiform bone)

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13
Q

prior to the ulnar n. entering the ulnar canal, it gives off what branches?

A

palmar cutaneous branch

dorsal cutaneous branc

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14
Q

palmar cutaneous branch provides cutaneous innervation to what?

A

skin of the medial side of the palm

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15
Q

the dorsal cutaneous branch provides cutaneous innervation to the skin of what?

A

the medial side of the dorsum of the hand

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16
Q

what n. innervates all the intrinsic muscles of the hand not innervated by the median n.?

A

ulnar nerve

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17
Q

what is the most frequent hand injury?

A

lacerations

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18
Q

which part of hand is most commonly fractured?

A

distal phalanx

little finger MC in U.S.

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19
Q

documenting hand injury

A 
dominant hand
occupation
tetanus status
traumatized
nontraumatized
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20
Q

traumatized documentation

A

ascertain hx of trauma
time elapsed since injury
environment of injury
mechanism of injury

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21
Q

nontraumatized documentation

A

when did sx begin
what functional impairment
what activities worsen tx

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22
Q

initial assessment of hand injury

A

remove rings, watches, jewelry

compare hands for symmetry

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23
Q

examination of hand injury

A
  • cyanosis, pallor, edema, erythema, ecchymosis, blistering
  • radial, ulnar, volar, dorsal, flexor, extensor surfaces
  • capillary refill, skin color (do bilaterally)
  • radial & ulnar pulses
  • if swelling of dorsum of the hand, but otherwise nml, turn hand over; r/o palmar puncture wound or other injury
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24
Q

what to do with excessive bleeding

A

elevation & sterile wet-compression dressing (a BP cuff can be inflated to about 100 mmHg above pt’s SBP, never leave on >30 min)
NEVER ligate a hand vessel w/o directly visualizing the bleeding vessel & all surrounding structures
-never blindly clamp bleeding vessel- trauma to n., tendon, or assoc. vessels

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25
Q

how do you check for sensory nerve injury

A

radial: dorsum of 1st web space
ulnar: 5th finger
median: flexor aspect of index & middle finger

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26
Q

how do you check for motor nerve injury

A

radial: extension at wrist & MP joint
Ulnar: forcible spread of fingers
median: flexion of wrist & PIP of thumb & index against resistance

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27
Q

range of motion

A

documentation of presenting motor exam!
pts unable to flex one finger together w/ the others often found to have associated tendon injury
weak mvnt of the joint may signal an incomplete tendon injury
note that pain may also limit functional exam (false +)

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28
Q

how do you test flexor digitorum profundus & flexor pollicis longus?

A

have pt flex DIP while proximal joints are held in extension

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29
Q

test for flexor digitorum superficialis

A

test by holding all other fingers in extension & have the pt flex the finger to be tested

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30
Q

pt position when testing extension

A

hand palm-down on a table & extend the fingers off the table one at a time

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31
Q

testing extension general info

A

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; moving the associated finger also increases the chances of seeing a tendon injury in the wound

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32
Q

MC foreign bodies in hand injuries

A

glass
metal
wood

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33
Q

glass & metal detected on what?

A

x-ray

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34
Q

large foreign bodies tend to cause?

A

fibrous rx & become symptomatic

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35
Q

x-rays sensitive for glass when it is larger than?

A

2mm

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36
Q

most commonly missed FB?

A

retained glass

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37
Q

missed FB’s rarely include what?

A

plastic, wood, organic

x-ray neg but suspicion high= closer examination

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38
Q

if pt comes into the ER with a feeling of something stuck in their hand, be sure to what?

A

tell them x-rays don’t pick up certain things and that they need to return to the ED if it worsens d/t possible retained FB!! document this & that pt understands

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39
Q

FB identification

A

ULS
sensitive 95-100% <1-4mm
CT most sensitive

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40
Q

FB mgnt

A 
mechanical & inflammatory effects
remove based on size, composition & location
small FB deeply imbedded best left
Abx- depends on object & mech
ortho consult
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41
Q

what is the MC complication of FB?

A

infection

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42
Q

anatomy of hand infxns

A

infxns extend across the various planes of the hand w/o resistance

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43
Q

infections that start in the fingers do what?

A

proceed thru the flexor tendon sheath & enter the mid-palmar space

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44
Q

infxns in the mid-palmar space do what?

A

extend rapidly into the thenar space

devestating effects: may resist aggressive tx w/ IV abx

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45
Q

hadn infxns often require what?

A

I & D in OR

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46
Q

what is a felon?

A

subcutaneous pyogenic infxn of the finger tip (tuft)

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47
Q

how does a felon present?

A

severe throbbing pain

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48
Q

MC organism causing felon?

A

S. aureus

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49
Q

tx of felon

A 
I&D
incision 5mm distal to the digital crease & extend to the pulp space
midline incision
avoid neurovascularl bundle 
consult ortho if complex
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50
Q

what is the most serious complication of felon?

A

acute tenosynovitis

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51
Q

what is paronychia

A

inflammation involving the lateral & posterior fingernail folds

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52
Q

predisposing factors for paronychia

A

overzealous manicuring
nail biting
thumbsucking
DM
occupations in which the hands are frequently immersed in water
also reported in assoc. w/ antiretroviral therapy for HIV infxn

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53
Q

tx of paronychia

A

I&D
separate the nail plate from the lateral nail fold
packing vs. warm soaks

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54
Q

the 4 cardinal signs of flexor tenosynovitis

A

tenderness over flexor tendon
swelling of the finger
pain on passive extension
flexed posture of the digit

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55
Q

tendons have____________blood supply & blood flow is easily interrrupted by relatively little__________& may cause destruction of underlying tendon

A

scant

edema

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56
Q

peri-tendonous scarring leads to what?

A

subsequent loss of function of the hand

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57
Q

tx of flexor tenosynovitis

A

prompt drainage in the OR & admit w/ appropriate IV abx

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58
Q

pyogenic flexor tenosynovitis

A 
often begin as benign puncture wound
PE: slight digital flexion
uniform volar swelling
flexor tendon sheath tenderness
pain on passive extension
Admit: surgical drainage & IV abx
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59
Q

what to think about with wounds

A 
control bleeding
thru irrigation w/ high pressure NS
consider delayed closure of "dirty" wounds
debridement
FB removal
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60
Q

incisional wound

A

caused by sharp object

usually may be closed primarily

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61
Q

avulsion wound

A

full thickness require skin grafting

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62
Q

blast/crush

A

considered “dirty” d/t maceration of tissue & microvasculatrue
often require debridement

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63
Q

degloving injuries

A

require skin grafting

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64
Q

puncture wounds

A

may require “coring”
greater risk of infxn
elevate extremity
low threshold for abx tx

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65
Q

what often complicates crush injuries?

A

open wounds
massive levels of contamination
thermal injuries

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66
Q

what may result from damage to local microcirculation from the crush, from damage to major blood vessels, or a combo of these?

A

ischemia

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67
Q

tx of crush injuries

A

Abx
supportive care
watch for compartment syndrome

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68
Q

nail bed injuries

A

subungal hematoma
>50%= remove nail plate to eval 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

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69
Q

survival & function of amputations depend on what?

A

type of injury
ischemia of the injured part (particularly if warm)
general condition & comorbidities

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70
Q

what is recommended for reimplantation?

A

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

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71
Q

mgnt of the amputation pt

A

if stable do NOT delay eval for transplant
minimal manipulation
AVOID extensive cleaning
DO NOT INJECT W/ LOCAL ANESTHESIA
saline gauze, bulky dressing, splint, elevate
update tetanus & NPO

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72
Q

what Abx do you want to give to amputation pt

A

Ancef 1 gm IV

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73
Q

mgnt of amputated part

A

save ALL parts & rinse w/ NS- remove gross contamination only
xray stump & part
wrap in DRY gauze
place in DRY zip lock bag & place bag ON ice (do not use dry ice, do not bury in ice)
cooling part to 40F enhances survival
1 hr of warm ischemia= 6 hrs cold ischemia

74
Q

amputations & reimplantation absolute indications

A

ANY amputation in CH
clean amputations of hand, wrist, distal forearm
multiple digit amputations
amputated thumbs

75
Q

Zone I for finger amputation zones

A

secondary intention: irrigate/debride, Abx dressing, protective splint

76
Q

zone II

A

flap reconstruction

77
Q

zone III

A

amputation

78
Q

2 ways to remove fish hooks?

A

advance & cut

yank technique

79
Q

extrinsic muscles of hand

A

tendons responsible for the gross movements of the hand & digits
commonly involved in hand injuries

80
Q

abductor pollicis longus & extensor pollicis brevis check

A

ask pt to forcefully spread their fingers

81
Q

extensor pollicis longus check

A

ulnar border of the snuff box

ask pt to hyperextend distal phalanx of thumb against resistance

82
Q

intrinsic muscles of hand responsible for what?

A

fine detailed mvnt

83
Q

dorsal interossei check

A

tested by spreading the hand forcibly against resistance

84
Q

volar interossei check

A

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

85
Q

thenar & hypothenar muscles check

A

pinch & opposition

86
Q

lumbrical tendons check

A

extend wrist & fingers while examinar presses down on finger tips

87
Q

MC site of injury is the__________of the hand where____________tendons are superficial & more exposed to injury

A

dorsum

extensor

88
Q

tendon injuries may be partial or_________?

A

complete

70-90% of tendon lacerated & still function

89
Q

it is important to determine the_________of the hand at time of injury

A

position

90
Q

DO NOT close….

A

bites
crush injury
contaminated wound

91
Q

DO start what if dirty wound?

A

Abx

92
Q

DO consult who in ED for timing of repair

A

ortho

93
Q

open flexor tendon injuries

A 
lacerations
NEVER repair in ED
assess for vascular injury
surgical consult for timing of repair
irrigate, close skin & flexion splint
consider Abx
94
Q

open extensor tendon injury

A

most dorsal wounds effect extensor tendons

repair based on: >50% lacerated, zone of injury (consider ED repair if zone VI), severity & contamination

95
Q

timing of primary tendon repair

A

w/in 72 hrs of injury

96
Q

timing of delayed tendon repair

A

1st wk after injury

97
Q

secondary tendon repair

A

after all edema has subsided & the scar has softened (4-6 wks)

98
Q

splint tendon injury in what position?

A

neutral

99
Q

swan neck deformity

A 
untreated mallet
overactive pull of extensor on middle phalanx
PIP hyperextension
flexion of DIP
compensatory swan neck
100
Q

in Swan neck deformity the PIP is ___________ & the DIP is?

A

PIP hyperextension

Flexion of DIP

101
Q

Boutonniere deformity

A

disruption of the tendon at the PIP
flexion of PIP w/ hyperextension of DIP
results from jamming/forced flexion injury that disrups the extensor tendon insertion into the dorsal base of the middle phalanx

102
Q

tx of Boutonniere deformity

A

extension splint to immobilize PIP x 4-6 wks

103
Q

flexion of PIP w/ hyperextion of DIP is what type of deformity?

A

Boutonniere deformity

104
Q

types of fractures

A 
comminuted
transverse
spiral
oblique
torus
avulsion
105
Q

a finger forced upward may cause?

A

volar plate rupture or dorsal dislocation

106
Q

a finger that has been compressed is more likely to have?

A

fx or mallet finger injury

107
Q

a joint that is stressed sideways should raise suspicion of a?

A

collateral ligament injury

108
Q

anterior dislocations

A

combo of varus/valgus force

anteriorly directed force

109
Q

combo of varus/valgus force in anterior dislocations may cause?

A

rupture of the collateral ligament & volar plate

110
Q

anteriorly directed force in anterior dislocations displace what?

A

the base of the middle phalanx forward & rupturing the central slip of the extensor mechanism

111
Q

posterior dislocations

A

d/t hyperextension of PIP

assoc. w/ rupture of volar plate or collateral ligaments

112
Q

lateral dislocations

A

abduction or adduction stresses while in extension

commonly assoc. w/ radial collateral ligament rupture

113
Q

volar plate collateral ligaments are the main stabilizers of?

A

PIP

114
Q

hyperextension of volar plate collateral ligaments avulses?

A

volar plate

115
Q

what are the MC dislocations of volar plate collateral ligaments

A

dorsal

116
Q

ligaments of ________most commonly injured in hand

A

PIP

117
Q

PIP joint injuries general

A

often dismissed as a simple sprain & left untreated

may have occult fxs, dislocations, or ligament injury

118
Q

mgnt of dislocations

A 
digital block
closed relocation
mandatory x-rays
active ROM & PROM assess after reduction
splinting; ortho f/u
119
Q

unable to reduce=

A

entrapment= volar plate, collateral ligament, or fx

120
Q

ulnar collateral ligament rupture is also known as a?

A

gamekeeper’s/skier’s thumb

121
Q

gamekeeper’s/skier’s thumb general info

A

weakened pinch
cannot resist an adduction stress
examine thumb in extension; if > 20 degrees of instability= surgical repair

122
Q

mgnt of skier’s thumb

A

xray for underlying avulsion fx
w/ or w/o fx full tear= surgical fixation
partial tear= splint & refer

123
Q

any pain in distribution of UCL or inability to oppose thumbe=

A

UCL injury until proven otherwisw

124
Q

types of distal phalanx fx’s

A

tuft
comminuted
transverse
mallet

125
Q

transverse fx of distal phalanx is often assoc. w/?

A

nail bed laceration

126
Q

mallet fx of distal phalanx assoc. w/?

A

avulsion injury at the attachment of the extensor tendon

127
Q

mallet finger

A

flexion deformity at the DIP w/ complete passive but incomplete active extension of the DIP joint

128
Q

a mallet finger is usually sustained from a?

A

sudden flexion force to the tip of the extended finger

129
Q

mallet fingers can also be d/t

A
  • avulsion of the extensor tendon at the site of insertion

- avulsion fx of the distal phalanx w/ tendon attached

130
Q

mgnt of middle & proximal phalanx extra-articular fx’s

A

ulnar or radial gutter splint

131
Q

mgnt of middle & proximal phalanx fx’s that are oblique, spiral, displaced, or unstable

A

refer for reduction or surgical fixation

132
Q

mgnt of middle & proximal phalanx intra-articular fx’s

A

reduced anatomically; often require surgical intervention

133
Q

metacarpal fx’s occur most commonly at the

A

metacarpal neck

134
Q

metacarpal fx involving the 4th or 5th digit is called a

A

boxer’s fx

it is a clenched fist injury

135
Q

index or middle finger anulation > 15 degrees & 4th/5th digit angulation >30 degrees requires what?

A

reduction

136
Q

metacarpal fx’s can be?

A

transverse
oblique
spiral
comminuted

137
Q

check for rotational malalignment by doing what?

A

complete flexion of 2nd-4th digits
nml flexion of fingers pointing toward region of schaphoid- if any fingers point in different direction they are malrotated

138
Q

what do you call a fx at the base of the thumb metacarpal involving the joint?

A

Bennett’s fx

139
Q

a Bennett’s fx is sustained from?

A

axial load w/ closed hand

140
Q

mgnt of Bennett’s fx

A

must be reduced

requires surgical intervention

141
Q

what is the MC carpal fx?

A

scaphoid fx

142
Q

with a scaphoid fx, you’ll have tenderness where?

A

snuff box

143
Q

the more proximal the schaphoid fx, the more common is?

A

avascular necrosis

144
Q

what type of xray do you want in a schaphoid fx?

A

scaphoid views

they often demonstrate a fx not seen on a plain wrist film

145
Q

mgnt of scaphoid fx

A

immobilize in thumb spica splint

146
Q

fx of distal radius w/ volar displacement is what type of fx?

A

Smith’s fx

check for assoc. median n. or flexor tendon injury

147
Q

fx of distal radius w/ dorsal displacement is what type of fx?

A

Colles fx

reduce after traction & hematoma block

148
Q

usual etiology of tendonitis?

A

repetitive stress

149
Q

active & passive mvnt accentuates pain with well localized tenderness in what?

A

tendonitis

150
Q

tenosynovitis

A

hx of excessive stress on the affected tendon

friction between tendon & sheath causes synovial thickening

151
Q

tx for tendonitis

A

NSAIDs &/or local steroid injection

152
Q

what do you have when you have painful blocking of flexion & extension at the involved joint?

A

trigger finger

153
Q

what causes trigger finger

A

hypertrophy of the tendon & pulley as a result of excess repetitive strain

154
Q

sx’s of trigger finger

A

localized tenderness over the proximal flexor pulley

155
Q

what fingers are most commonly affected in trigger finger?

A

ring & middle fingers

156
Q

tx for trigger finger

A

steroid injection/ surgical release

157
Q

DeQuervain’s is also known as?

A

stenosing tenosynovitis

158
Q

DeQuervain’s involves the?

A

abductor pollicis longus &

extensor pollicis brevis

159
Q

with DeQuervain’s pt’s complain of what?

A

pain at the radial aspect of wrist localized to the radial syloid

160
Q

what test can be used to determine if it is DeQuervain’s or not?

A

Finkelstein’s test

161
Q

Finkelstein’s test will illicit what?

A

sharp pain w/ ulnar deviation of wrist

162
Q

carpal tunnel syndrome is caused by compression of what?

A

median nerve in the carpal canal most often d/t repetitive motion
pain awakens pt from sleep

163
Q

etiology of carpal tunnel syndrome

A

any condition which produces chronic swelling

164
Q

you will have paresthesias over what nerve distribution in carpal tunnel syndrome?

A

median nerve

165
Q

what tests can you do to check for carpal tunnel syndrome?

A

Tinels & Phalen’s sign

166
Q

the MC tumor of the hand is a?

A

ganglion cyst

167
Q

a ganglion cyst is a synovial cyst from?

A

joint or synovial lining of a tendon that has herniated

168
Q

ganglion cysts contain what?

A

gel-like fluid that forms a cyst or connects w/ the synovial cavity

169
Q

what is the MC site for ganglion cysts?

A

dorsum of the wrist

170
Q

tx of ganglion cyst

A

surgical excision is TOC

171
Q

grease guns, paint sprayers, or compressed air devices can cause?

A

serious penetrating injuries that require wide debridement
true extent of injury hidden behind tiny puncture wound
***high incidence of amputation
ACT AGGRESSIVELY!!!!

172
Q

high pressure injection devices generate pressures that range from 1500-7000 psi and can deposit toxins into?

A

tendon & synovial sheaths

173
Q

MC site of high pressure injection injury?

A

index finger followed by palm & long finger (3rd digit)

174
Q

complications of high pressure injection injuries

A

intense throbbing & pain shortly after injury leading to compartment syndrome

175
Q

mgnt of high pressure injury

A 
xrays
pain ctrl
NO digital blocks= worse outcome
NPO & tetanus
early extensive surgical debridement & decompression of the wound/fasciotomy
prophylactic broad spectrum Abx
corticosteroids often used
176
Q

prognosis of high pressure injury

A

time since injection critical
pt requiring amputation presented bet. 6-48 hrs after injury
chemical properties of agent contribute to severity

177
Q

what is the most irritating to tissue in high pressure injury?

A

paint & paint solvents

178
Q

in a high pressure injury, what may rapidly compromise circulation to the digits?

A

swelling d/t injury
substance induced irritation
material deposited w/in sheath

179
Q

what makes up the highest # of medicolegal actions against ED docs?

A

complications of hand wounds

180
Q

what do you want to consider in all open wounds?

A

retained FBs or deep tissue injury

Emergency Med Final (9 decks)

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