InjuriesToTheHand2[1]

InjuriesToTheHand2[1] - Injuries To The Hand And Digits And...

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Unformatted text preview: Injuries To The Hand And Digits And Chrisnel Jean, D.O. May 30, 2006 Reviewed by Dr. Batizy Outline Outline Anatomy Principles of Evaluation General Hand Examination Anesthesia and Direct Wound Anesthesia Examination Examination Radiographs, Consultation, Radiographs, and Disposition and Tendon Injuries Flexor / Extensor Tendons Ligaments And Dislocation Ligaments Injuries Injuries Compartment Syndrome High-Pressure Injection Injury Hand Anatomy Hand Hand consist of 27 Hand bones: bones: 14 Phalangeal bones 5 Metacarpal bones 8 Carpal bones Carpal bones are Carpal made up of two rows of four bones bridged by flexor retinaculum which forms the carpal tunnel. tunnel. Carpal tunnel consist Carpal of the median nerve and the nine long flexor of the fingers flexor Hand Anatomy Hand Intrinsic muscle of the Intrinsic hand: hand: Have their origins and Have insertions within the hand. hand. Consist the following: Thenar, Hypothenar, Thenar, adductor pollicies, the interossei and the lumbricals. (Refer to pg lumbricals (Refer 1665 for anatomical description) description) Hand Anatomy Hand Extensor Tendons: Courses over the dorsal side of the forearm, Courses wrist and hand. wrist 9 extensor tendons pass under the extensor extensor retinaculum and separate into 6 compartments compartments Surface anatomy of the hand. The tendons that are palpated with thumb abducted and extended form an anatomic snuff-box. Hand Anatomy Hand Extensor Tendons: The extensor tendons gain entrance to the hand from the forearm through a series of six canals, five fibroosseous and one fibrous The communis tendons are joined distally near the MP joints by fibrous interconnections called juncturae tendinum. Beneath the retinaculum, the extensor tendons are covered with a synovial sheath. Hand Anatomy Hand Extensors digitorum communis are Extensors connected by junctura. connected Because of this, a complete tendon Because laceration proximal to the junction may still result in normal extensor fuction. still Hand Anatomy Hand Flexor Tendons: Courses over the volar side of the forearm, wrist, Courses and hand. and Unlike the extensor tendons, the flexor tendons are Unlike enclosed in synovial sheaths making them prone to deep space infections. to Hand Anatomy Hand Flexor Tendons: Flexor carpi Flexor radialis, flexor carpi ulnaris, and palmaris longus primarily flex the wrist flex Hand Anatomy Hand Hand Anatomy Hand 9 flexor tendons pass through the carpel flexor tunnel: tunnel: 1 tendon go to the base of the dist. Phalanx of the tendon thumb thumb The other 4 digit has 2 tendon each (FDS / FDP). Hand Anatomy Hand Flexor digitorum Flexor superficialis (FDS) insert into middle phalanx. phalanx. Flexor digitorum Flexor profundus (FDP) runs deep to the FDS until the level of the MP joint where FDS bifurcates. where FDP inserts at the base FDP of the distal phalanx and acts primarily to flex the DIP joint as well as all other joints flexed by FDS. (Figure 268-5). by Hand Anatomy Hand Blood supply (BS): Hand and digits has Hand dual (BS) with contributions from the radial and ulnar arteries. arteries. Hand Anatomy Hand Blood supply (BS): Proximal portions of the hand (BS) come from Proximal the deep and superficial arches on the palmar and dorsal side. and BS of the fingers is distributed by the digital BS arteries that arises from the superficial palmer arch. arch. Hand Anatomy - Blood supply Hand The Allen's test. Hand Anatomy Hand The cutaneous nerve supply in the hand. M, median; R, radial; U, ulnar; PCM, palmar cutaneous branch of median nerve; DCU, dorsal cutaneous branch of ulnar nerve Principles of Evaluation Principles History: Should include the time, the cause of the Should injury and eval for the possibility of crush, burn, or chemical exposure. The patient’s occupation, prior hand injuries, The and handedness should be documented and Principles of Evaluation Principles The position of the hand at the time of The injury should be determined. injury Injuries with the digits in flexion may Injuries result in retraction of the cut end of the tendon when the digit is examined in neutral position. neutral Principles of Evaluation Principles Physical Exam Should detail the extent of injury by Should documenting the following: documenting Amount of devascularization Status of the skin Posture of the fingers Presence of deformity Active bleeding B/L grip strength B/L Principles of Evaluation Principles Physical Exam ROM and strength should be tested against ROM resistance. resistance. Nerve testing: Nerve Test median nerve: Test median Have the pt flex the distal phalanx of the thumb against Have resistance resistance Test opposition by touching the tip of the thumb to the tip of Test the little finger the The pt will be unable to oppose against resistence if The median nerve function is lost. median Principles of Evaluation Principles Nerve testing Test median nerve: Test median Test thumb abduction by placing the hand palm up Test and raising the thumb to the perpendicular while palpating the belly of the abductor pollicis muscle to insure it is contracting. to Principles of Evaluation Principles Nerve testing: To test ulnar nerve To ulnar Spread the fingers apart against resistance and Spread then push them together against resistance. then Test the hypothenar muscle, extend the fingers Test and then move the fifth finger away from the others and Test thumb adduction (ulnar nerve innervates the Test adductor pollicis muscles) bring the thumb tightly against the side of the index finger. against Principles of Evaluation Principles Nerve testing: To test ulnar nerve To ulnar Adductor strength can be further tested by Adductor interposing a piece of paper between the thumb and the side of the index finger and then trying to pull the paper away. pull To test radial nerve: To radial Extend the fingers and wrist. With the thumb in the hitchhiking position, test its With resistance to further extension. resistance Principles of Evaluation Principles Nerve testing: Sensation Determined by 2-point discrimination. Normal 2-point discrimination is <6 mm at the Normal fingertips and is often <2 mm. Both injured and non-injured fingers must be compared. and Repeat 2-point discrimination testing 2 – 4 Repeat times on each side of the digit (80% accuracy is considered acceptable) is Principles of Evaluation Principles Nerve testing: Sensation A sensory deficit implies a potential digital sensory artery laceration because of the close proximity of the two. proximity Tendon testing: Full ROM of each tendon against resistance Full should be assessed and compared with the uninjured side. Principles of Evaluation Principles Tendon testing: Important to test resistance because up to Important 90 % of a tendon can be lacerated with preservation of ROM without resistance. preservation Pain along the course of the tendon during Pain resistance testing suggests a partial laceration even if the strength appears adequate. even Principles of Evaluation Principles Tendon testing: FDP is tested by flexing the DIP against FDP resistance while the MP and PIP are held in extension. extension. FDS is tested by flexing the PIP against FDS resistance while the remaining fingers are held. held. Principles of Evaluation Principles FDP is tested To test for an intact profundus tendon, the examiner maintains the digit in extension while the patient attempts to flex the terminal phalanx. Principles of Evaluation Principles FDS is tested Examination to assess function of flexor digitorum superficialis. Principles of Evaluation Principles Anesthesia and Direct Wound Anesthesia Examination: Examination: Sensation and ROM should be tested before Sensation anesthesia applied. anesthesia Exam should be done under a bloodless field Exam by applying local tourniquet or penrose drain around the base of the finger. around Principles of Evaluation Principles Radiographs, Consultation, and Radiographs, Disposition: Disposition: XRAY: should include a PA, lateral , and XRAY: oblique view. oblique Injuries requiring immediate and delayed Injuries follow-up by a hand surgeon are listed in Tables 268-1 and 268-2. Tables Guidelines for adequate immobilization and Guidelines follow-up for specific hand injuries are listed in Tables 268-3 Tables Principles of Evaluation Principles Tendon injuries: Flexor tendons Most common cause of flexor tendon injury is Most a laceration. laceration. A distal to proximal five zone (I – V) distal classification system for flexor tendon injuries has been developed based on location, treatment considerations, and prognosis. Refer to pg 1670 for specific descriptions. Principles of Evaluation Principles Tendon injuries: Extensor tendons Are the most common site of tendon injuries Are because of the superficial nature of the tendons on the dorsum of the hand. tendons A separate zone classification system (I – VIII) separate has been developed for assessing injury patterns, repair techniques, and rehabilitation. patterns, Refer to pages 1670 – 1671 for specific Refer description. description. Ligament and Dislocation injuries Ligament DIP Dislocation at DIP are uncommon because of Dislocation the firm attachments of the skin and subq tissue to the underlying bone. tissue Dislocations at the DIP are usually dorsal. Reduction can be done by longitudinal Reduction traction and hyperextension, followed by direct dorsal pressure to the base of the distal phalanx after a digital block. phalanx Ligament and Dislocation injuries Ligament Dorsal dislocation at the DIP jt without associated fracture Volar dislocation of DIP joint of little finger. Ligament and Dislocation injuries Ligament PIP Dislocation: One of the most common ligamentous injuries Mechanism: Mechanism: Usually due to axial load and hyperextension. Usually Dorsal dislocation occurs when the volar plate Dorsal ruptures. ruptures. Lateral dislocation occurs when one of the Lateral collateral ligaments ruptures with at least a partial avulsion of the volar plate form the middle phalanx. avulsion Volar dislocations are rare. Ligament and Dislocation injuries Ligament Lateral dislocation of middle finger PIP joint. Ligament and Dislocation injuries Ligament PIP Dislocation: Reduction Perform similarly to DIP dorsal dislocations Active ROM and strength should be tested after Active reduction. reduction. If testing is normal, then splint in 30-degree flexion If for 3 wks. for If the joint is irreducible or there is evidence of If complete ligamentous disruption, operative repair is required. is Ligament and Dislocation injuries Ligament MP dislocation: Less common than at the PIP jt Mechanism: Usually due to hyperextension forces that rupture Usually the volar plate causing dorsal dislocation. the In subluxation (simple dislocation) – the jt appears In to be hyperextended 60 – 90 degrees and the articular surfaces are still in contact. articular Volar dislocation are rare and usually require Volar operative reduction. operative Ligament and Dislocation injuries Ligament MP dislocation: Reduction: Does not involve hyperextension (this might Does convert it from a simple to a complex dislocation) convert Performed with the wrist flexed to relaxed the Performed flexor tendon and applying pressure over the dorsum of the proximal phalanx in a distal and volar direction. volar Splint the MP jt in flexion after reduction. Ligament and Dislocation injuries Ligament CMC jt dislocation: Are uncommon because the jt is supported by Are strong dorsal, volar, and interosseous ligaments and reinforced by the broad insertions of the wrist flexions and extensors. insertions Ligament and Dislocation injuries Ligament CMC jt dislocation: Mechanism: Usually due to high-speed mechanisms (MVC, Usually falls, crushes, or clenched fist trauma). falls, Usually occurs via dorsal and with associated Usually fractures. fractures. Ligament and Dislocation injuries Ligament CMC jt dislocation: Reduction: Attempt after regional anesthesia with traction and Attempt flexion with simultaneous longitudinal pressure on the metacarpal base. the Pt need early referral after reduction to determine Pt if further fixation is needed. if Ligament and Dislocation injuries Ligament Thumb IP dislocation Are rare but, if present, usually open. Mechanism: Usually hyperextension with rupture of the volar Usually plate. plate. Reduction: Similar to the IP jt of the other digits Immobilized for 3wks in mild flexion. Ligament and Dislocation injuries Ligament Thumb MP dislocation: Usually dorsal Can be simple (subluxation) or complex Mechanism: Hyperextension force causing rupture of the volar Hyperextension plate. plate. Ligament and Dislocation injuries Ligament Thumb MP dislocation: Reduction: After a radial nerve block. Performed with pressure directed distally on the Performed base of the proximal phalanx with the metacarpal flexed and abducted. flexed Ligament and Dislocation injuries Ligament Thumb MP Collateral Ligament Rupture: Rupture of the ulnar collateral ligament Rupture (gamekeeper’s thumb, skier’s thumb) Occurs when the mechanism causes radial Occurs deviation (abduction) of the MP jt. deviation Tear usually occur at the insertion into the Tear proximal phalanx. proximal Significant injury occurs to the dorsal capsule and Significant volar plate. volar Ligament and Dislocation injuries Ligament Thumb MP Collateral Ligament Rupture: Rupture of the ulnar collateral ligament Rupture (gamekeeper’s thumb, skier’s thumb) Type 1 Avulsion fracture, nondisplaced Type Type 2 Avulsion fracture, displaced Type Type 3 Torn ligament, stable in flexion Type Type 4 Torn ligament, unstable in flexion Type Ligament and Dislocation injuries Ligament Gamekeeper's thumb. Gamekeeper's (1.) The normal thumb MCP jt ulnar collateral ligament. (2.)Tear in the extensor mechanism overlying the disrupted ligament acts as a buttonhole and (3.) traps the ligament end. In this position, spontaneous healing and recovery of stability is prevented. Ligament and Dislocation injuries Ligament Thumb MP Collateral Ligament Rupture: Rupture of the ulnar collateral ligament Hand surgery referral is recommended for all Hand patients with weakness of pincer function and point tenderness at the volar – ulnar aspect of the thumb MCP jt resulting from a forced the abduction mechanism of injury. abduction Ligament and Dislocation injuries Ligament Thumb MP Collateral Ligament Rupture: Rupture of the ulnar collateral ligament If XRAY negative for fracture, then abduction If stress testing of the ulnar collateral ligament maybe performed for added information. maybe Test the thumb MCP both in full extension and 30degree flexion, by stabilizing the metacarpal with degree one hand while applying lateral (radial) stress on the proximal phalanx with the other. the Ligament and Dislocation injuries Ligament Thumb MP Collateral Ligament Rupture: Rupture of the ulnar collateral ligament More than 40 degrees radial angulation indicates More complete rupture and requires surgical consultation. consultation. Repair best accomplished in 1 wk. Rupture of the radial collateral ligament Not as common Mechanism is forced adduction Ligament and Dislocation injuries Ligament Thumb CMC: Isolated dislocation is rare compared to the Isolated more common Bennett fracture dislocation. more Easy to reduce but unstable after reduction. Apply thumb spica splint after reduction. Need surgical referral. ROM of the Thumb ROM Fractures Fractures Distal Phalanx: Account for 15 – 30 present of all hand Account fractures. fractures. Are usually from crush or shearing forces. Can be classified as tuft, shaft, or Can intraarticular. intraarticular. Tuft fractures – can be associated with nail Tuft bed lacerations bed Fractures Fractures Distal Phalanx: Fractures at the base Fractures may be associated with flexor or extensor tendon involvement. tendon These fractures are These treated as soft tissue injuries with protective splinting. splinting. Fractures Fractures Proximal and Middle Phalanx Proximal phalanx Has no tendinous attachments Fractures frequently have volar angulation from the Fractures forces of the extensor and interosseous muscles. forces Fractures Fractures Proximal and Middle Phalanx Middle Phalanx: Has the FDS insert on the entire volar surface and Has the extensor tendon insert at the proximal base the Fractures at the base have dorsal angulation and Fractures fractures at the neck result in volar angulation. fractures Most often these fractures are stable and Most nondisplaced. nondisplaced. Can be treated with early protected motion by Can buddy taping. buddy Fractures Fractures Proximal and Middle Phalanx Unstable fractures amenable to closed Unstable reduction can be splinted from the elbow to the DIP with the wrist at 20-degree extension and the MP jt in 90-degree flexion. and Midshaft transverse fractures, spiral fractures Midshaft and intraarticular fractures often require internal fixation. internal Fractures Fractures Metacarpal (II to V) Fractures 2nd and 3rd metacarpals are relatively immobile and fractures require anatomic reduction. and 4th and 5th MC have 15 to 20-degree AP motion, which allows for some compensation. motion, MC fractures are categorized as head, neck, MC shaft, or base fractures. shaft, Fractures Fractures Metacarpal (II to V) Fractures Head: Usually caused by a direct blow, crush or missile. Fractures are distal to the insertion of the collateral Fractures ligaments and are often comminuted. ligaments If a laceration is present a human bite must be If considered. considered. Treatment: Ice, elevation, immobilization, and referral to a hand Ice, surgeon. surgeon. Fractures Fractures Metacarpal (II to V) Fractures Neck: Usually caused by a directed impaction force. Fracture of the fifth MC neck is often referred to as Fracture a boxer’s fracture boxer’s Fracture are usually unstable with volar angulation. Angulation of < 20 degrees in the 4th and 40 degrees in the 5th MC will not result in functional degrees impairment impairment Fractures Fractures Metacarpal (II to V) Fractures Neck: If greater angulation in these MC occur, reduction If should be attempted should Fractures should be splinted with the wrist in 20degree extension and the MP flexed at 90 degree degrees. degrees. In the 2nd and 3rd MC, angulation of <15 degrees is acceptable. If significantly displaced or angulated then anatomic reduction and surgical fixation is needed needed Fractures Fractures Metacarpal (II to V) Fractures Shaft: Usually occur via a direct blow Rotational deformity and shortening are more often Rotational in shaft fractures than in neck fractures. in If reduction is needed, than operative fixation is If usually indicated. usually Fractures Fractures Metacarpal (II to V) Fractures Base Usually caused by a direct blow or axial force. They are often associated with carpal bone They fractures. fractures. Fractures at the base of the 4th and 5th MC can result in paralysis of the motor branch of the ulnar nerve. nerve. Fractures Fractures Thumb MC Because of the mobility of the thumb MC, Because shaft fractures are uncommon shaft Fractures usually involve the base. Two type: Extraarticular Intraarticular Intraarticular Fractures Fractures Thumb MC Extraarticular: Are caused by a direct blow or impaction Are mechanism. mechanism. Mobility of the CMC jt can allow for 20-degree Mobility angular deformity. Angulation greater than this requires reduction and thumb spica splint for 4 wks. wks. Spiral fractures often require fixation. Fractures Fractures Thumb MC Intraarticular Caused by impaction from striking a fixed object Caused (two type) (two Bennett fx Bennett Is an intraarticular fx with associated subluxation or dislocation at the CMC jt. dislocation The ulnar portion of the MC usually remains in place. The distal portion usually subluxes radially and dorsally The from the pull of abduction pollicis longus and the adductor pollicis adductor Treatment – thumb spica and referral Fractures Fractures Bennett's fracture Bennett's Avulsion fracture of Avulsion the articular surface of the first metacarpal with subluxation at the CMC jt. Fractures Fractures Thumb MC Intraarticular Rolando fracture An intraarticular comminuted fracture at the base of the An metacarpal. metacarpal. Mechanism of injury is similar to the Bennett fracture, but Mechanism less common. less Treatment – thumb spica splint and surgery consultation. COMPARTMENT SYNDROME COMPARTMENT May occur in crush injury of the hand with May or without associated fracture. or Involved compartments of the hand Involved includes: includes: Thenar Hypothenar Adductor pollicis Four interossei COMPARTMENT SYNDROME COMPARTMENT Cross section Cross through the palm showing compartments of the hand hand COMPARTMENT SYNDROME COMPARTMENT Edema of tissues or hemorrhage within Edema any of these compartments may lead to elevated pressures that result in tissue necrosis and subsequent loss of hand function due to contracture. function Sign and symptoms: Pain and paresthesias occur early Paralysis and pulselessness occurring later COMPARTMENT SYNDROME COMPARTMENT Sign and symptoms: Pain Pain Most consistent clinical sign usually described as deep, constant, poorly usually localized and disproportionate to clinical findings. localized PE findings: “iintrinsic minus” position at rest (MCP ntrinsic extended with PIP slightly flexed) extended Pain with passive stretch of the involved Pain compartmental muscle compartmental COMPARTMENT SYNDROME COMPARTMENT PE findings: Pain with passive stretch of the involved Pain compartmental muscle compartmental Interosseous: performed with MCP extended and Interosseous: PIP fully flexed with slight radial ulnar deviation PIP Thenar / Hypothenar: performed by extension of Thenar MCP MCP Tense swelling of the affected compartment COMPARTMENT SYNDROME COMPARTMENT Diagnosis Confirmed by compartment pressure Confirmed measurement – high rate of false readings. measurement In the setting of severe crush injury with signs In and symptoms suggestive of compartment syndrome, emergent hand surgeon consultation for fasciotomy is mandatory. consultation High – Pressure Injection Injury High The initial dissipation of kinetic energy The through the soft tissue of the hand produce tissue edema and resultant ischemia of the tissue. ischemia Most common injected substances include Most grease, paint, hydraulic fluid, diesel fuel, paint thinner, and water. paint High – Pressure Injection Injury High Definitive treatment of high – pressure injection Definitive injuries is early surgical decompression and debridement of injected areas. debridement These must be recognized as surgical These emergency and obtain immediate hand surgery consultation, immobilize and elevate the affected hand, initiate tetanus prophylaxis, broadhand, spectrum antibiotics and provide adequate spectrum analgesia. analgesia. ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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