plastic surgery - hand surgery Flashcards
hand examination
- Accurate diagnosis of hand problems depends on a systematic, careful physical examination
- assessment of unaffected hand first
- inspection, palpation, measurement of range of motion, stability assessment, musculotendinous assessment, nerve assessment and vascular assessment should be included in the examination procedure
- Repeated physical examinations reveal how symptoms change over time, which is important for assessing the effectiveness of the treatment.
assessment of history
- Age
- Hand dominance
- Occupation
- Hobbies
- Chief complain
- Previous operation
- Previousinjuries
inspection assessment
- Discoularation
- Deformity
- Muscular atrophy
- Trophic changes
- Swelling
- Skincreases
palpation assessment
Useful in identifying
* Abnormal skin temperature
* Areas of tenderness
* Crepitance
* Clicking or snapping sounds
* Effusion
* Masses
De Quervain tenosynovitis (DQTS) tests
+ tenderness in soft tissue palpation of 1st extensor compartment (abductor pollicis longus & extensor pollicis brevis)
+ Finkeilsteings test (thumb in palm, move wrist in ulnar position, pain)
intersection syndrome
- similar to DQTS
- Related to bursal inflammation at the junction of the 1st & 2nd compartments
- Proximal to De Quarvian, 4-6cm from radiocarpal joint
- Crepitations or squeaking can be heard with ROM (Squeaker wrist)
- However 6th compartment tenosynovitis second most common following DQTS
trigger finger / stenosing flexor tenosynovitis
- painful snap / lock
- palpable nodule (trapped in pulley)
flexor tenosynovitis
- tendon sheath infection
- due to puncture wound
- Kanavels cardinal signs
- 4 signs:
intense pain on passively extending there finger,
a flexion position of finger,
uniform swelling of finger,
tenderness
range of motion assessment
- Both passive and active ranges of motion should be documented.
- The contralateral healthy limb and the affected limb should be measured and compared.
- A limited range of passive motion is associated with joint stiffness and soft tissue contracture
- The active range of motion is affected by tendon excursion, the posture of the hand and fingers, nerve function and muscular strength.
stability assessment
- The tightness of the ligaments around a joint, morphology of the surface of a joint and musculotendinous balance around a joint are useful indices of joint stability.
- The stability of ligaments is tested by holding the portions distal and proximal to the joint and gently moving the joint passively to stress the ligaments that stabilize the joint.
- The opening angle of the affected joint under stress should be assessed using X-rays and compared to the opposite side
musculotendinous assessment
- The integrity of the tendon and the strength of the muscle should be considered when conducting a musculotendinous assessment.
- Assess posture, motion and power of both intrinsic and extrinsic muscles.
- MRC power grading scale
flexor zones of hand
zone 1- FDA sensation
zone 2- btw FDA sensation & A1 pulley
zone 3- proximal to A1 but distal to carpal tunnel
zone 4- capacitance
zone 5- proximal to carpal tunnel
flexor profundus test
- examine flexor digitorum profundus
- blocking the pt digits at the distal phalangeal joint & ask pt to flex distal phalanges
flexor sublimes test
- examine flexor digitorum superficialis
- hold down fingers not being examined & pt to flex finger that is being questioned
flexor pollicis longus (FPL) test
- to test thumb distal phalange
- same as flexor profundus test to hold at distal phalangeal joint & pt to flex
extensor zones
zone 1 - distal interphalangeal joint
zone 2 - btw distal & proximal interphalangeal joint
zone 3 - proximal interphalangeal joint
zone 4 - btw proximal interphalangeal and metacarpal phalangeal joint
zone 5 - metacarpal phalangeal joint
zone 6 - proximal to metacarpal phalangeal joint but distal to wrist joint
zone 7 - wrist joint
zone 8 - proximal to wrist
extensor compartment of hand
- 6 compartments (thumb to pinky)
1st - extensor pollicis brevis & abductor pollicis longus
2nd - extensor carpi radialis longus & brevis
3rd - extensor pollicis longus
4th - extensor indicis & digitorum
5th - extensor digiti minimi
6th - extensor carpi ulnaris
extensor exam
- pt to place hand on table & extend fingers
intrinsic muscles of hand
- thenar
- hypothenar
- interosseous & lumbral muscles
intrinsic muscle exam
- Thenar muscles are evaluated by asking the patient to place the dorsum of the hand flat on a table and to raise the thumb until it is perpendicular to the palm. The patient is then asked to resist a downward force by the examiner on the thumb.
- The hypothenar muscles abduct the small finger, moving it away from the other fingers.
- The interosseous and lumbrical muscles flex the MP joints and extend the PIP and DIP joints of the fingers.
nerve assessment of hand
- Evaluation of peripheral nerves should include both motor and sensory function.
- To evaluate the motor function of the hand, it is necessary to understand the anatomy, biomechanics and peripheral innervation of the muscle.
- Comprehensive sensibility evaluation includes static and dynamic two-point discrimination testing, Semmes– Weinstein monofilament testing, vibrotactile threshold testing, and cold-heat testing.
nerves of hand
(thumb to pinky)
- superficial branch of radial n.
- median n.
- ulnar n.
tunnel of guyon
- ulnar n. passes through guyon’s tunnel
& divided into 3 zones
zone 1 (proximal)- mixed motor & sensory zone
zone 2 (middle)- motor
zone 3 (distal)- sensory
ulnar n. fallout test
- froment’s test
- pt to hold piece of paper btw index and thumb (ok hand sign)
- paper pulled & pt to resist pull
+ if flexion of thumb/distal phalange
+ Jeanne’s sign (hyperextension of thumb at basal carpometacarpal)
waternberg sign
- hands placed palm down on table
+ pinky abducted
claw deformity
carpal tunnel
phallen’s test
ape hand deformity
hand of benediction
- median n. injury characteristic
radial n. palsy
- wrist drop
tinel’s sign
nerve regeneration
vascular assessment
- There are two types of vascular problems: arterial and venous insufficiency.
- Vascular problems are assessed according to the color, capillary refill, pressure (turgor) and temperature of the affected part.
- The Allen’s test is helpful for determining if there is an intact circulatory connection between the radial and ulnar arteries in the hand.
allen’s test
- depress/press radial & ulnar arteries ( pt opens and closes fist)
- normal if blood returns via ulnar artery
