Plastic Surgery: Hand Injuries Flashcards

1
Q

How to describe #

A

Open vs closed.
Location: metaphysis (connects epiphysis to diaphysis), diaphysis (mid-part long bone), articular.
Displaced or non-displaced: translation, angulation, shortening, rotation.
Comminution (reduced to multiple fragments)

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2
Q

Mgmt of # based on displacement, etc.

A

If not displaced –> splint.

Displaced: then reduce then splint. If not reducible or unstable –> OR.

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3
Q

Tx of distal phalanx #

A

Note that soft tissue injuries associated with crush injuries. Treat with 3 weeks of digital splinting.

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4
Q

Tx proximal and middle phalanx #

A

Check for rotation, scissoring (overlap of fingers with fist), shortening of digit.
If undisplaced or minimally displaced, closed reduction with buddy tape, splint for 2-3 weeks.
Displaced, unstable, rotational/scissor deformity, etc require perQ pins or ORIF then splint.

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5
Q

Assessment of ulnar collateral ligament injury

A

Secondary to forced thumb abduction.
Radially deviate joint in full extension. Compare bilaterally.
With UCL rupture, injured side will have no end point. If torn or avulsed from insertion, look for # at base of phalanx of thumb.

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6
Q

What is a boxer’s #?

A
Extra-articular # of the 5th metacarpal, just proximal to the MCP. (essentially under the pinky below, the joint). 
Acute angulation of neck of metacarpal of little finger into palm. Often due to blow on the distal-dorsal aspect of closed fist. Lose prominence of metacarpal head. 
Get volar (palmar) displacement of head. 
Check for scissoring with fist.
Closed reduction, ulnar guttar splint for 2-3 weeks.
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7
Q

What is a Bennett’s #?

A
# at base of thumb metacarpal. 
Requires percutaneous pinning, thumb spica x6 wks.
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8
Q

What is a Rolando’s #?

A

Intra-articular # of the thumb metacarpal.
T or Y shaped #.
Requires ORIF with K wire.

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9
Q

Position required for safe hand splinting

A

Wrist extended at 45, MCP’s flexed at 60, fingers straight, thumb abducted/in opposition.
Hand # require cast/splint.
Need to prevent late deformity by keeping hand/wrist immobilized with ligaments in stretched position.

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10
Q

Hx taking Q’s for hand injuries

A

Age, hand dominance, occupation, time/place of accident, mxn of injury, tetanus status.

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11
Q

PEx for hand injuries: what to observe, vascular exam, sensory exam and motor exam (including specific muscles tested), flexor digitorum exam.

A

Observe: normal cadence, scissoring, bony deformities (mallet, swan neck, boutonniere), bruising/swelling, anatomical structures.

Vascular status: look at radial/ulnar arteries, assess for nerve injuries. Vascular assessment to include Allen’s test, cap refill, temp/skin turgor. If digit devascularlized, repair within 6 hrs.

Sensory nerve assessment:
Median nerve: innervates digits 1 - 3.5 on palmar surface. Test sensation at tip of index (next to thumb) on volar (palmar) side of hand.
Ulnar nerve: innervates digits medial 1.5 fingers on ulnar side. Test sensation at tip of pinky.

Radial nerve: test at dorsal webspace of thumb. Distribution = dorsal side of hand.
Digit nerves: check 2 pt discrimination on each finger. Normally 2-3 mm difference should be detected.

Motor nerve assessment:
Median nerve: flexion of thumb, index and middle finger. Get pt to give OK sign. Push against thumb while it is abducted (have pt place back of hand on flat table, then test the ABDUCTOR POLLICIS BREVIS but having pt lift thumb straight up toward ceiling).

Ulnar nerve: intrinsic hand muscles. ‘Tata.’ Abduction/adduction of fingers. Can get pt to flex DIP or give peace sign. Move index finger in radial direction, tests 1st DORSAL INTEROSSEUS.

Radial nerve: extension of fingers, wrist
Check passive/active ROM wrist, fingers, thumbs. Have pt place palm flat on table and lift thumb (EXTENSOR POLLICIS LONGUS)

Check tendons: flexor digitorum profundus and superficialis. For FDP, single common muscle belly so it pulls on everything. FDS has independent control of each finger with individual muscle bellies. To test, extend out DIP (of finger tested AND all other fingers since since FDP belly!), then test PIPs.

Palpate over bones and look for instability of joints.

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12
Q

Common extensor tendon deformities

A

Divided into zones; distal have less favorable prognosis compared to proximal.
Mallet finger: DIP flexed with loss of active extension. Rupture of extensor tendon at DIP.
Boutonniere deformity: PIP flexed, DIP hyperextended due to injury to extensor tendon insertion into middle phalanx.
Swan neck deformity: PIP hyperextended, DIP flexed.

Treatment: repair in ER with primary suture repair, 2-3 wks splinting.

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13
Q

Common flexor tendon deformities.

A

Loss of natural cascade of resting hand (normal = flexion of fingers at rest).
Flexor tendon zones: important for prognosis of tendon lacerations.
No-man’s land: between distal palmar crease and mid-middle phalanx. Recovery of glide between superficialis and profundus ligaments very difficult.
Tx: repear in OR within 2 weeks and avoid excessive immobilization.

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14
Q

Describe Dupuytren’s contracture.

A

Contraction of the longitudinal palmar fascia resulting in painless nodules and fibrous cords.
Eventually causes flexion contractures at MCP and interphalangeal joints. Does NOT involve flexor tensons.
Affects 4th digit > 5th > 3rd > 1st > 2nd.
Treatment with surgical fasciectomy. Indicated when there is a lack of extension at MCP/PIP. Not indicated if there is palmar pit/nodules/palpable cord but no limitation.

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15
Q

Describe the timing of nerve repairs and expected time for return of function.

A

Test nerve function before anesthesia given.
Within 14 days of clean injury and without concurrent major issues, do direct repair. If not satisfying these requirements, secondary repair.

Direct: epineural repair of nerves with minimal tension.

Peripheral nerves regenerate at 1 mm/day.

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16
Q

What is Tinel’s sign?

A

Paresthesias with cutaneous percussion over a repaired nerve 2 weeks post-injury. Determines the level of nerve regeneration. Parasthesias are felt due to regrowth of myelin being slower than axonal regrowth. Percussion over exposed free-end axon causes paresthesias.

Note that due to Wallerian degeneration, don’t get Tinel’s sign over first 2 weeks.

17
Q

Describe Carpal Tunnel Syndrome: presentation + Dx

A

Median nerve compression at the flexor retinaculum –> entrapment neuropathy.

Presents with:
Sensory loss in median nerve distribution (radial 3.5 digits). Discrimination of touch is first sign. May awaken at night with numb/painful hand relieved by shaking, rubbing or dangling hand. Decreased light touch and 2 pt discimination especially in fingertips.

Look for thenar wasting/weakness. TInel’s sign (tingling sensation with percussion of median nerve). Phalen’s sign (wrist flexion induces symptoms).

Is a clinical Dx but can use nerve conduction studies/EMG to confirm.

18
Q

Tx for carpal tunnel syndrome + potential complications of Sx.

A

Conservative: avoid repetitive wrist and hand motion, splint overnight.
Medical: NSAIDs, local steroid injection or oral steroids.
Surgical decompression: transverse carpal ligament incision to decompress median nerve. Indicated for numbness/tingling +/- sensory loss, weakness +/- atrophy, conservative mgmt failure.

Complications: injury to median motor branch, palmar cutaneous branch damage, superficial transverse vascular arch damage, local pain, scar.

19
Q

What is a ‘felon’ infection?

A

subcutaneous abscess of the fingertip. Often occurs after puncture wound into pad of digit.
Associated with OM and may cause compartment syndrome or skin necrosis.
Tx with cloxacillin 500 mg PO q6 hrs.
If abscess present, do I+D and C+S.

20
Q

Describe acute purulent tenosynovitis.

A

Infection of the flexor tendon sheath. Caused by penetrating injury.
Staph > strep > gram neg rods.
Kanavel’s 4 signs: 1) point tenderness along flexor tendon sheath, 2) pain on passive extension of DIP, 3) fusiform swelling of entire digit, 4) flexed posture.

Take to OR for I+D with irrigation, IV abx.

21
Q

Describe paronychia

A

Infection of soft tissue around the fingernail.

Acute infection caused by hangnail, artificial nail, nail biting. Staph infxn. Tx with keflex 500 mg PO q6 hrs.
Drain abscess with blade from under the paronychial fold.

If chronic infection: more likely to be fungal/candidal. Associated with chronic moisture (e.g. dishwashers). Tx with drainage if needed + anti-fungal.

22
Q

Describe lymphangitis

A

infection of lymph vessels as complication of bacterial infection. Acute strep infection of skin, associated with mammalian bites.
Cellulitis –> red streaks –> high fever, sepsis.
Give IV cefazolin.

23
Q

Describe septic arthritis

A

Infection of the joint space.
Commonly staph, strep, gonorrhea.
Empiric therapy with vanco + CTX

24
Q

Summarize acute care of traumatic amuptation or avulsion of a hand digit

A

Injured pt and amputated limb both require care.
pt: ABC, XR, NPO, clean wound/irrigate with NS, dress the stump with non-adherent dressing and cover with dry sterile dressing.
Give tetanus shot and abx (cephalosporin/erythromycin) prophylaxis.

Limb mgmt: do CR, gently irrigate with RL, wrap in NS/RL soaked sterile gauze, place inside waterproof plastic bag then place in a container on ice.

Indications for reimplantation:
Age: kids have better results than adults.
Level of injury: proximal, thumb and multiple digit amputations are higher priority.
Nature: clean cut injury more likely to have successful reimplant. Avulsion and crush injuries are relative contraindications.

If not reimplanting, manage stump with revision amputation.