Wrist and Hand Injuries

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					Injuries to the Hand and
        Chapter 268
Hand/Digit Anatomy
► Extensor   tendons (9)
   Dorsal side of forearm, wrist and hand
   Pass under extensor retinaculum
   Connected by junctura  complete tendon lac my still
    result in normal extensor function
► Flexor   tendons (9)
     Volar side of forearm, wrist and hand
     Pass under flexor retinaculum
     4 flexor digitorum superficialis (FDS)  middle phalanx
     4 (FDP) profundus  distal phalanx
                 Blood Supply
► Dual
   Radial artery  deep arch
    ►Supply   palm, thumb, and part of index finger
   Ulnar artery  superficial arch
    ►Giverise to common digital arteries
    ►Supply palm, 2nd through 5th digits
                  Ulnar Nerve

► Runs deep to the carpi ulnaris tendon.
► Sensation:
   palm and dorsal aspects of the ulnar side of hand, 5th
    digit and ulnar half of the 4th digit.
► Motor:
   Dorsal interosseous, hypothenar muscles, ulnar
► Test
   abduction of fingers against resistance
                 Median nerve
► Runs through carpal tunnel
► Sensory:
   Thumb, palm on the radial side of the hand, the palmar
    aspect of the radial 2 ½ fingers, the dorsal aspect of
    the tips of the index and middle fingers and radial half
    of the ring finger.
► Motor:
   Thenar muscles, radial lumbricals
► Test:
   opposition of the thumb to each finger vs resistance -
    watch for thenar muscles contractions
                  Radial nerve
► Sensory
   dorsum of radial aspect of the hand, dorsum of thumb,
    dorsal aspect of the 2nd and 3rd fingers, dorsal radial
    half of the 4th finger.
► Motor
   Extensors of wrist, no intrinsic muscles in hand
► Test
   extension of the wrist and fingers against resistance
► Loss   of function: wrist drop
► History
   Time and cause of injury
   Occupation, prior hand injury, handedness
► PE
   Posture, status of skin, devascularization,
    deformity, active bleeding, grip strength
   Compare to other hand
   Clenched fist: observe orientation if
    middle/distal phalanxes (should be parallel)
► Sensory     Testing
   Two point discrimination
       ► >6mm   fingertips abnormal
       ► Sensory deficit implies digital artery lac (close prox)

► Tendon     Testing
     Full ROM vs resistance compared to uninjured side
     Pain along course of tendon suggests partial lac
     FDP: flex DIP while PIP/MP held extended
     FDS: flex PIP while fingers held extended
► Radiographs
   PA, lateral, oblique
    Hand Surgery Consultation
► Immediate:
   vascular injury, irreducible dislocations,
    contaminated wounds, crush, compartment
    syndrome, high pressure injection, hand or
    finger amputation
► Delayed:
   Extensor/flexor tendon laceration, FDP rupture,
    nerve injury, fractures, dislocations, unstable
    ligament injury
► Regional   nerve blocks-useful with finger/hand
► Finger injuries-digital block better than local
► Sensation is by the palmar and dorsal digital
  nerves along the lateral aspect of each finger.
► Digital block
   Dorsal approach
   Palmar approach
   Web space approach
           Flexor Tendon Injuries
► Most  common:
► Zone I – Zone V

► Flexor tendon injuries-
  repaired by hand
  surgeon in 12 hours
            Extensor Tendon Injury
►   Most common site of
    tendon injury: superficial
    on dorsum of hand
►   Mallet Finger: common injury in
     MOI: blunt trauma, sudden
      forced flexion
     Unable to extend DIP
     Swan-neck deformity develops
      in chronic/untreated
     Tx
        ► No fx: Splint in slight
        ► Fx: ortho for pinning
         Extensor Tendon Injury
► Boutonniere   Deformity
   Complete disruption of
    central tendon
   Flexion of PIP and
    hyperextension of DIP
► MOI   direct blow
► Tx
   splint the PIP in
    extension refer to ortho
 Ligament and Dislocation Injury
► DIP   (uncommon)
   Longitudinal traction and hyperextension, direct dorsal
    pressure base of distal phalanx
► PIP   (most common)
   Reduce as above plus splint 30 degree flexion
► MP
   Wrist flexed with pressure applied over dorsum of the
    proximal phalanx in a distal and volar direction
► Thumb   MP Collateral Ligament Rupture
   Game keepers/Skiers Thumb: radial deviation of MP
   Hand surgery referral recommended with weak pincer
► Distal   Phalanx (15-30% of hand fx)
   Splint
► Proximal   and Middle Phalanx
   Buddy taping
► Metacarpal:         MOI - punch clenched fist
►   Head
     Direct blow, crush, missile
     Laceration- assume human bite
►   Neck
     Direct impaction of force
     Reduce if:
        ► >15   degree angulation 2nd and 3rd
        ► >20   degree angulation 4th
        ► >40   degree in 5th (Boxer’s fx)
►   Shaft
     Direct blow
     Rotational deformity/shortening likely
     Tx: operative
       Compartment Syndrome
► Crush injury
► Involved compartments:
   Thenar, hypothenar, adductor pollicis, 4 interossei
► Edema/hemorrhage      increased pressure 
  tissue necrosis  loss of hand fxn/contracture
► Pain (disproportionate and on passive stretch),
  paresthesia, paralysis, pulselessness
► Tx: Hand consult for fasciotomy
     High pressure injection injury
►   Initially appear benign: HISTORY important
►   Injection into soft tissue (2000-10,000) psi
       Industrial/operator
       Grease, paint, hydraulic fluid, diesel fuel, etc.
       Causes inflammatory response, tissue edema/ischemia
       Compartment syndrome
►   Xray:
     radio-opaque substance, subQ air
►   Tx:
     Hand consult, immobilize, elevate, tetanus, atb, analgesics
     Surgical decompression/debridement
High Pressure Injection
    DeQuervain’s tenosynovitis
► Inflammed   extensor tendons of the thumb-
  pain on radial aspect of wrist-worse with
► Finkelstein test-pain on ulnar deviation of
  the wrist while thumb is flexed and held in
  the palm by the other finger
► Treatment-NSAID’s-splint position of
          Infections of the Hand
► Paronychia
   nail fold infection-Staph & Strep-Treat with I&D
► Felon
   fingertip infection-Staph-Treat with I&D
   Incision through the pulp of the finger laterally
    with wick placed though the incision-remove in
    72 hours
        Infections of the Hand
► Herpetic   Whitlow-
   viral infection of distal finger-HVS I or II-pain,
    burn, itching and herpetic lesions then form.
   Treatment-splint and analgesics-may give oral
      Infections of the Hand
► Human   bite or fight bite
  punch to the mouth usually
  DO NOT suture over the MCP-heal by secondary
  Eikenella corrodens
  Treatment-ortho consult, xrays, wound cultures,
   irrigate, IV antibiotics if necessary
            Infections of the Hand
► Tenosynovitis
   Typically from punture wound-staph or strep
   Diagnose-Kanavel four cardinal signs
        ► Held in slight flexion
        ► Symmetric swelling of the finger
        ► Tender along flexor tendon sheath
        ► Pain with passive extension of the finger

► Tx:   IV antibiotics, culture, tetanus
   Penetrating trauma penicillinase-resistant
    antistaphylococcal PCN or 1st gen. cephalosporin
   No history of trauma in a sexually active adult, consider
    GC-treat with ceftriaxone

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