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EM - EBMedicine Summaries > Hand > Flashcards

Hand Flashcards

1
Q

DDx of Acute Hand Injury

(1) Limb-threatening/very high morbidity
(2) High morbidity if missed or if diagnosis is delayed
(3) Moderate Morbidity if missed

A 
(1) 
Compartment Syndrome
High pressure injection injury
Arterial injury
(2) 
Fight Bite
Bennett/Rolando Fracture
Scaphoid Fracture
Scapholunate Dissociation
Lunate/Perilunate Dislocation
Gamekeeper Thumb
(3)
Flexor Tendon Injury
Mallet Finger
Jersey Finger
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2
Q

9 Components of Hand Exam

A

(1) Inspection
(2) Palpation
(3) A/PROM
(4) Ligamentous Stability
(5) Flexor and Extensor Tendons
(6) Ulnar Nerve
(7) Medial Nerve
(8) Radial Nerve
(9) Vasculature

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3
Q

Laceration features associated with high risk of infection (7)

A

(1) Tendon Injury
(2) Open Fracture
(3) Joint Violation
(4) Crush Injury
(5) Puncture Wounds
(6) Immunocompromised Host
(7) Human/Animal bites
- —-Need PPx Abx

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4
Q

What should be considered with any wound over an MCP?

A

Fight bite

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5
Q

What is the IDSA recommendation for empiric therapy for fight bite?

A

Augmentin

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6
Q

Distal Fingertip Amputations

(1) Types
(2) Treatments

A

Type 1: No bone exposure
Wound care
Nonadherent Dressing
Heal by 2/2 intention

Type 2: Bone exposure distal to lunula
Type 3: Bone exposure proximal to lunula
Both get treated with rongeur and wound care
Severe type 3 may require distal finger amputation
Get hand involved

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7
Q

What is the current practice related to subungual hematomas?

A

Trephination for subungual hematomas of all size without plate disruption

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8
Q

Clinical Pathway: Metacarpal fx, uncomplicated

A

Reduce, ulnar vs radial gutter splint, refer to hand surgeon

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9
Q

Clinical Pathway: Metacarpal fx, complicated

A

Emergent consult with hand surgeon

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10
Q

Clinical Pathway: Phalanx fracture, complicated*

A

Emergent consult with hand surgeon

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11
Q

Indications of complicated fractures

A

(1) Inability to achieve postreduction goals
(2) Rotational deformity
(3) Displaced intra-articular fractures

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12
Q

Clinical Pathway: Distal phalanx fracture, uncomplicated

A

Reduce, volar digital splint

immobilizing the DIP joint, and refer to hand surgeon

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13
Q

Clinical Pathway: Middle or proximal phalanx fracture, uncomplicated

A

Reduce, splint, and refer to hand surgeon

Splints:
Finger 2-3: Radial Gutter
Finger 4-5: Ulnar Gutter

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14
Q

Clinical Pathway: Tuft fracture, distal phalanx, open

A

Wound care, wound closure, volar digital splint

immobilizing the DIP joint, and refer to hand surgeon

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15
Q

Clinical Pathway: All open hand fractures (that are not tuft fractures)

A

Emergent consult with hand surgeon

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16
Q

Clinical Pathway: Scapholunate Instability

A

Splint and refer to hand surgeon

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17
Q

Clinical Pathway: DIP, PIP, MCP dislocation

A

Reduce, splint, and refer to hand surgeon

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18
Q

Clinical Pathway: Lunate Dislocation

A

Emergent Hand Consult

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19
Q

Clinical Pathway: Perilunate Dislocation

A

Emergent Hand Consult

20
Q

Clinical Pathway: Gamekeeper’s Thumb

A

Thumb Splint and refer to hand surgeon

21
Q

Clinical Pathway: Flexor tendon, closed

A

Splint and refer to hand surgeon

22
Q

Clinical Pathway: Flexor tendon, open

A

ED wound care, loose primary closure, dorsal splint in intrinsic plus, and refer to hand surgeon (Class III)
Consult hand surgeon for operative planning (Class II)

23
Q

Clinical Pathway: Jersey Finger, Mallet Finger

A

Splint and refer to hand surgeon
Jersey: Dorsal Hand and Wrist Splint in intrinsic plus
Mallet: Dorsal Splint only of DIP

24
Q

Clinical Pathway: Extensor Tendon Injury, Closed

A

Spint and refer to hand surgeon

25
Q

Clinical Pathway: Extensor tendon, open

A

Wound care, wound closure, volar splint in extension, and refer to hand surgeon (Class II)

Consider ED repair for injuries to zones II-IV (Class III)

26
Q

Clinical Pathway: High-pressure injection injury

A

Emergent consult with hand surgeon
Antimicrobial PPx
Avoid Regional Nerve Block

27
Q

Clinical Pathway: Fight Bite

A

Consider emergent consultation with hand surgeon

Augmentin

28
Q

Clinical Pathway: Compartment Syndrome

A

Emergent Consult with Hand Surgeon

29
Q

Clinical Pathway: Subungual Hematoma, Uncomplicated

A

Nail Plate Trephination Alone

30
Q

Clinical Pathway: Subungual Hematoma with nail plate disruption

A

ED nail plate removal and nail bed matrix repair

Consider consult with hand surgeon for nailbed matrix repair

31
Q

What is the timeframe for all hand surgeon referrals?

A

Within 1 week

32
Q

What are the grades of extensor tendon injury?

Which are considered for ED repair if open?
What are indications for hand surgeon repair of open extensor tendon injuries?

A 
Grade I: DIP
II: Middle Phalanx
III: PIP
IV: Proximal Phalanx
V: MCP
VI: Metacarpal
VII: Wrist joint

(2) II-IV
(3) Gross contamination
Fracture
Neurovascular injury
Thumb involvement
Pt populations (rheumatoid dz, professional athletes)

33
Q

How do you diagnose Gamekeepers thumb?

What is the major complication?

A

Pain and swelling of ulnar aspect of 1st MCP
>30* laxity with radial deviation of 1st MCP
-or-
>15* more than the opposite hand (MUST compare both hands)

(2) Sterner Lesion: entrapment of the adductor pollicis aponeurosis between the ruptured ends of the UCL

34
Q

Scaphoilunate Dissociation (1) Common Mechanism

(2) Presentation
(3) Rad’s Finding
(4) Tx

A

(1) FOOSH with wrist hyperextension and ulnar deviation
(2) Swelling/TTP over Scapholunate Joint, dec. ROM
(3) >3mm diastasis between scaphoid and lunate
(4) Thumb Spica + Hand Surgeon Referral

35
Q

Perilunate/Lunate Dislocation

(1) Common Mechanism
(2) PE findings
(3) Radiographic Findings
(4) Treatment

A

(1) FOOSH with wrist hyperextension
(2) Wrist deformity, TTP/Swelling over the dorsal aspect scapholunate joint, dec. ROM
(3)
Perilunate:
- Lat: displacement of capitate (typically dorsal)
- PA: “Jumbled Carpus” with loss of continuity of the 3 carpal arcs

Lunate:

  • Lat: “spilled teacup”
  • PA: “pie in the sky” with triangular lunate
    (4) Emergent Hand Surgeon Consultation
36
Q

How to evaluate hand plain films

(1) PA view
(2) Lateral

A

(1) PA View
- Middle metacarpal axis and radius axis shoudl line up; the ulnar styloid should project laterally from the distal ulna
- The carpal bones shoudl for 2 arches and 3 distinct smooth arcs (Gilula arcs)
- Spacing between carpal bones should be no more than 2 mm

(2) Lateral
- Middle metacarpal axis forms a line through capitate, lunate, and radius
- Scapholunate angle should be between 30-60*

37
Q

Middle and Proximal Phalanx Fractures:

(1) Indication for emergent hand surgey consultation
(2) Indications for consultation or urgent referall

A

(1) Open fractures

```
2
Inability to reduce
>10* angulation
2mm shortening
ANY rotation
Intra-articular fx > 30% articular surface
~~~

38
Q

What is the acceptable degree of angulation in metacarpal shaft and neck fractures?

A 
(1) Shaft
2nd digit: 0*
3rd digit: 0*
4th digit: 20*
5th digit: 30*
(2) Neck
2nd digit: 10*
3rd digit: 15*
4th digit: 30*
5th digit: 40*
39
Q

Boxer Fractures

(1) What is it?
(2) MCC
(3) How to reduce

A

5th Metacarpal neck fracture

(2) Closed fist injury
(3) 90-90 maneuver

40
Q

Thumb Fractures - Phalangeal and Metacarpal Shaft Fx

(1) Tx
(2) Indications for emergent hand consultation

A 
(1) If Closed: reduce, thumb spica, referral
(2)
Open
> 30* angulation
ANY rotation
inability to reduce
41
Q

Bennett/Rolando Fractures

(1) What are they?
(2) Treatment
(3) (

A

Bennett Fx:
Two part 1st metacarpal base fracture and dislocation
Rolando Fx:
Comminuted Bennett Fx

(2) Reduce with axial traction, opposition, radial pressure over metacarpal base.
Thumb Spica
Referal

42
Q

What is the timeframe for repeat films in ? scaphoid fractures?

A

10-14 days

43
Q

High Pressure Injection Injuries:

(1) What are important Hx elements to ask for high pressure injection injuries?
(2) Tx
(3) What needs to be avoided?
(4) Optimal timing of surgery

A

(1)

  • Type and volume of material injected
  • Pressure (PSI) at which it was injected

(2)
- Analegsia
- PPx Broad Spectrum Abx
- Tetanus
- Emergent Hand Cs

(3)AVOID
Ice
Nerve Blocks
Local Infiltration of Anes

(4) 6 hours

44
Q

Compartment Syndrome

(1) High Risk Mechanisms
(2) Presentation
(3) Tx

A 
(1)
Crush Injury
High Pressure Injection
Prolonged Immob. from casting
Metacarpal fx
Extravasation IV contrast
Burn w eschar formation
Complication of A-line

(2)
Pain out of proportion
Hand held in intrinsic minus (MCP’s extended, IP’s flexed)
Tenderness with passive stretching of compartments
Impaired sensation
Impaired perfusion

(3) Emergent Hand c/s

45
Q

Can we use lido with epi in the hand? Who should we not do it in?

A

YES!
Lalonde - 2005 - 3110 patients with local infiltratio/digital block with lidocain and 1:100,000 epi with no cases of digital ischemia
Wilhelmi - 2001 - RCT 60pts no issues

(2)  Pts with
PVD
Buergers
Scleroderma
Compartment Syndrome

EM - EBMedicine Summaries (5 decks)

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