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Hand-and-Wrist

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					Hand and Wrist
Hand
Basic Exam -Neuro exam -For pure sensory evaluation, test the radial nerve proximal to the first dorsal web space (radial side of the index metacarpal). -For the ulnar nerve, test the volar tip of the little finger. -For the median nerve, test the volar tip of the index finger. -Have the patient extend the thumb fully (like hitchhiking). Next have the patient spread the fingers widely apart. Finally, ask the patients to move the tip of each finger and thumb (one at a time) in a circle around the tip of a pen. If the patient can perform all of these simple actions, then all three major nerves to the hand are intact. -Radiology Radiographs of the hand should be obtained in any hand problem beyond minor trauma Fractures -Any open fracture needs orthopedic irrigation Distal Tuft -Consider draining all subungual hematomas >50% of nail bed -If the nail is removed or lost, use a gauze stent to hold open the nailbed matrix -When splinting for protection, do not immobilize the PIP Proximal and Middle Phalanyx -Any rotational defect needs correction, consult a hand surgeon Metacarpal -Any head fracture needs consultation -Evaluate any laceration over the head for possibility of a fight bite and intra-articular injury -Metacarpal neck fractures rule of angulation 15 degrees for index and middle, up to 40 degrees for ring and little fingers -Metacarpal shaft fractures tolerate less: 10 degrees for index and middle, up to 20 degrees for ring and little -ANY rotational deformity requires correction Thumb -Metacarpal fractures not involving the joint can have up to 20 degrees of angulation -ANY rotational deformity or any intra-articular metacarpal base fractures need a hand surgeon Dislocations DIP -Many times will break the skin. Don’t assume a simple laceration, if there was a significant force, consider an open dislocation. PIP -Reduce with anesthesia, traction and mild hyperextension -Once reduced, assess the joint stability. Anything greater than 20 degrees of instability indicates a complete ligament tear and needs a hand surgeon. -ANY volar dislocation should have immediate consultation prior to reduction. MP

-Volar dislocations are rare and require open reduction -For simple dorsal dislocations, reduction can be completed by flexing the wrist to relax the flexor tendons and then pushing on the proximal end of the finger in a volar direction. Do NOT use traction or hyperextension here, as it increases the risk of causing further damage. Look for widening of the joint space on x-ray, this suggests entrapment of the volar space and needs orthopedic consultation. Gamekeepers By using the opposite thumb for comparison, the joint is place in neutral and 30 degrees flexion. Greater than 30 degrees of widening is diagnostic for this injury. Even if this is not clear, they are hard to diagnose. Any suggestion of a UCL tear needs thumb spica and orthopedic follow up. Tendon Injuries -The tendons of the hand can have normal motion with 90% tears, be careful -Examine the hand in the position of injury and put through a range of motion -Any laceration >50% needs repair -Significant lacerations have pain with motion and decreased strength Extensor Tendons -Any tendon injury of the MP joint is a suspected fight bite until proven otherwise -Can be repaired by properly trained EM physicians -Very small and benign wounds to the dorsal hand can result in tendon laceration, and a high suspicion for tendon injuries should be maintained in these patients. -Patients with complete disruption of the EPL can still extend the thumb due to other tendon involvement -The thumb, index, and little fingers have dual extensors and can maintain full strength with a significant tendon laceration. Flexor Tendons -Because of their deep location, palmar surface wounds need to be fully explored under bloodless, sterile and anesthetic conditions to rule out flexor tendon injury. -Remember to test the FDP (at the DIP) and the FDS (at the PIP) separately. -The FDS can be completely severed and there still be active flexion at both joints. -Closed disruptions of the FDP are common in athletes, and are classically described as gripping an opponent’s clothing in attempted tackle and having the clothing pulled forcefully from the clenched fist (jersey finger). The patient will have no flexion at the DIP joint when the PIP joint is held in extension. These patients should be splinted with the wrist in 30° of flexion, MPs at 70° of flexion, and PIPs at 30-45° of flexion -All repairs need a hand surgeon Nerve Injuries -Repair can be either immediate or delayed, depending on the case. . Delayed repairs are best done in less than 10 days from the injury with median and ulnar nerves. As the radial nerve is purely sensory in the hand, delayed repair can be done up to three months after the injury without affecting the outcome. Digital nerve repair often is done for nerves affecting the grip of the hand. The ulnar side of the little finger also is repaired to provide sensation when resting the hand on surfaces. Amputations -There are many factors that affect the decision for replantation. The best strategy for the ED physician is to wrap the amputated part in saline-moistened gauze, place it in a watertight plastic

bag, and immerse the bag in a container of ice water (half ice, half water). The stump can be treated in a similar fashion except for cooling. There should be NO debridement or clamping of vessels and a hand surgeon should be consulted right away. -For fingertip amputations, if there is any bone exposure, the patient needs evaluation in the emergency department. Infections -Herpetic whitlow can be a mimic of infection. Remember to think of whitlow in a lesion that looks like a paronychia or felon, but has a history of starting out as a clear vesicle. -A paronychia is treated with local incision and drainage of the pus followed by warm soaks to encourage drainage. If more advanced with pus spread underneath the nail, then the involved section of the nail should be elevated and possibly removed. -There is considerable controversy for the best drainage options for a felon. While it does need expedited drainage, it is probably wise to consult a hand surgeon before attempting drainage. -Flexor tenosynovitis is characterized by the following: (Knavel’s signs) -Pain on passive extension -Tenderness along the tendon sheath -Fusiform swelling -Finger held in the position of flexion -This tends to be a rapidly spreading infection and needs admission and hand surgeon evaluation. -Necrotizing fasciitis is actually fairly common in the hand; keep it in mind in patients who have a history of IV drug abuse -High pressure injection injuries should be treated with radiographs to look for extent of injection, pain medication (NO digital blocks) and immediate hand surgeon referral.

WRIST
-Wrist injuries can be very subtle. Beware of the diagnosis of “wrist sprain.” It should only be the diagnosis of exclusion after all other possibilities of injury have been eliminated. - On an AP view, two arcs should be identified. The first arc consists of the radiocarpal row, which should be smooth and continuous. Disruption is suggestive of a lunate dislocation. Other rules for wrist films include: There should be no more than 2-3mm between the individual carpal bones The radius articulates with greater than 50% of the lunate -The second arc consists of the midcarpal row, which also should be smooth and continuous. disruption of this arc is suggestive of a perilunate dislocation. -The appearance of the lunate is important on the AP view. Normally, the lunate is quadrangular. With lunate dislocations, it becomes triangular. This may be an additional clue to dislocation. -On the lateral view, visualize the column, which consists of the radius, lunate, and capitate. The lunate should lie within the radius cup and the capitate should rest within the lunate cup. Loss of this normal column implies lunate or perilunate dislocation. -Lunate fractures require a short-arm spica cast or splint with thumb immobilization. -Emergency treatment of capitate, trapezium, and trapezoid fractures consists of position of function and orthopedic consultation. Volar splinting is acceptable. -Fractures of the pisiform can be immobilized with a volar splint. -Injuries to the triquetrum are best treated with a sugar tong splint.

Scaphoid -Classic history is a FOOSH mechanism with pain on palpation of the scaphoid body in the anatomic snuffbox being the most reliable diagnostic maneuver -All suspected fractures should be place in a thumb spica splint and sent to an orthopedist for follow up. Scapholunate Dissociation -Again, a FOOSH/hyperextension mechanism is the usual history, with pain that localizes to the schapholunate junction. They may also complain of weakness and a clicking in the wrist with gripping. Widening of the schapholunate junction greater than 3mm is one of six radiographic criteria. Treat with thumb spica and orthopedic follow up. Capitate -Like the scaphoid, can be injured in a FOOSH mechanism and has a somewhat tenuous blood flow, that can lead to avascular necrosis. Immobilize in position of function and refer. Radiolunar dislocations -Patients complain of a painful loss of forearm rotation. Dislocations can be both dorsal and palmar and very hard to recognize and need urgent orthopedic evaluation. Hamate hook fractures -Seen in sports with stick/bat/etc. Look for other injuries and get a carpel tunnel view to look at the hamate. Treatment is in a short arm cast with ortho follow up. Carpometacarpal dislocations Require a large amount of force. Look for ulnar and median nerve injuries, Deep palmar arterial arch injuries and disruption of the wrist extensor tendons. These patients are also at risk for compartment syndrome of the hand. Distal Radial/Ulnar fractures Can injure most commonly the median nerve. High-risk radial fractures include: Angulation > 20 degrees Ulnar separation Dorsal comminution Shortening more than 5-10mm > 2mm of articular step off Median nerve dysfunction If these criteria are met, the patient needs urgent orthopedic evaluation. ___________________________________________________________________________________ Beeson, Michael S, Dislocations, Wrist, E Medicine, 2004, available at: http://www.emedicine.com/emerg/topic149.htmeMedicine (review, 6 references)

Brady, William J, Challenging and Elusive Orthopedic Injuries: Diagnostic and Treatment Strategies for Optimizing Clinical Outcomes, Part I: Upper Extremity Fractures and Dislocations, Emergency Medicine Reports, 1999 (review, 16 references) Hals, Gary D., The Acute Hand: Assessment, Diagnosis, and Management in the ED Setting, Parts I, II, and III, Emergency Medicine Reports, 2002, (review, 112 references) Hill, Scott, Wasserman, Eric, Wrist Injuries: Emergency Imaging and Management, Emergency Medicine Practice, 2001 (review, 111 references) Hoynak, Bryan, Fractures, Wrist, E Medicine, 2005, available at: http://www.emedicine.com/emerg/topic844.htmeMedicine (review, 7 references)


				
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