Hand & Wrist Injuries Flashcards
(180 cards)
1
Q
where do the tendons of the lumbricals & interossei muscles insert?
A
on the lateral bands of the extensor expansions of the medial 4 digits
2
Q
the line of pull of the tendons of the lumbricals & interossei muscles are:
A
ventral to the MP joints, but dorasal to the PIP & DIP joints
3
Q
the lubricals & interossei muscles can assist in flexion of the?
A
MP joints & extension of the DIP & PIP joints
4
Q
what do you want to remember to do before you inject anesthesia into hand?
A
pt’s sensation
lacerated nerves are common!
5
Q
what tunnel does the median nerve run thru?
A
carpal tunnel
6
Q
what does the ulnar nerve pass between?
A
hook of hamate
7
Q
the superficial branch of the radial nerve lies above what?
A
radial styloid
8
Q
does the radial nerve supply muscles in the hand?
A
NO
9
Q
what does the radial n, supply?
A
skin on the lateral side of the dorsum of the hand, and a small portion of the thenar eminence
10
Q
what branches does the median nerve give off in the palm?
A
recurrent branch of the median n.
branches of the first 2 lumbricals
cutaneous branches to the skin on the palmar surfaces of the 1t 3.5 digits
11
Q
what does the recurrent branch of the median n. supply?
A
supplies the muscles of the thenar eminence
12
Q
the ulnar n. enters the palm of the hand through what?
A
the ulnar canal (just lateral to the pisiform bone)
13
Q
prior to the ulnar n. entering the ulnar canal, it gives off what branches?
A
palmar cutaneous branch
dorsal cutaneous branc
14
Q
palmar cutaneous branch provides cutaneous innervation to what?
A
skin of the medial side of the palm
15
Q
the dorsal cutaneous branch provides cutaneous innervation to the skin of what?
A
the medial side of the dorsum of the hand
16
Q
what n. innervates all the intrinsic muscles of the hand not innervated by the median n.?
A
ulnar nerve
17
Q
what is the most frequent hand injury?
A
lacerations
18
Q
which part of hand is most commonly fractured?
A
distal phalanx
little finger MC in U.S.
19
Q
documenting hand injury
A
dominant hand occupation tetanus status traumatized nontraumatized
20
Q
traumatized documentation
A
ascertain hx of trauma
time elapsed since injury
environment of injury
mechanism of injury
21
Q
nontraumatized documentation
A
when did sx begin
what functional impairment
what activities worsen tx
22
Q
initial assessment of hand injury
A
remove rings, watches, jewelry
compare hands for symmetry
23
Q
examination of hand injury
A
- cyanosis, pallor, edema, erythema, ecchymosis, blistering
- radial, ulnar, volar, dorsal, flexor, extensor surfaces
- capillary refill, skin color (do bilaterally)
- radial & ulnar pulses
- if swelling of dorsum of the hand, but otherwise nml, turn hand over; r/o palmar puncture wound or other injury
24
Q
what to do with excessive bleeding
A
elevation & sterile wet-compression dressing (a BP cuff can be inflated to about 100 mmHg above pt’s SBP, never leave on >30 min)
NEVER ligate a hand vessel w/o directly visualizing the bleeding vessel & all surrounding structures
-never blindly clamp bleeding vessel- trauma to n., tendon, or assoc. vessels
25
how do you check for sensory nerve injury
radial: dorsum of 1st web space
ulnar: 5th finger
median: flexor aspect of index & middle finger
26
how do you check for motor nerve injury
radial: extension at wrist & MP joint
Ulnar: forcible spread of fingers
median: flexion of wrist & PIP of thumb & index against resistance
27
range of motion
documentation of presenting motor exam!
pts unable to flex one finger together w/ the others often found to have associated tendon injury
weak mvnt of the joint may signal an incomplete tendon injury
note that pain may also limit functional exam (false +)
28
how do you test flexor digitorum profundus & flexor pollicis longus?
have pt flex DIP while proximal joints are held in extension
29
test for flexor digitorum superficialis
test by holding all other fingers in extension & have the pt flex the finger to be tested
30
pt position when testing extension
hand palm-down on a table & extend the fingers off the table one at a time
31
testing extension general info
test against resistance for partial lacerations; if you suspect an extensor tendon laceration but cannot visualize in the wound, try putting the hand in the position it was in when the injury occurred; moving the associated finger also increases the chances of seeing a tendon injury in the wound
32
MC foreign bodies in hand injuries
glass
metal
wood
33
glass & metal detected on what?
x-ray
34
large foreign bodies tend to cause?
fibrous rx & become symptomatic
35
x-rays sensitive for glass when it is larger than?
2mm
36
most commonly missed FB?
retained glass
37
missed FB's rarely include what?
plastic, wood, organic
| x-ray neg but suspicion high= closer examination
38
if pt comes into the ER with a feeling of something stuck in their hand, be sure to what?
tell them x-rays don't pick up certain things and that they need to return to the ED if it worsens d/t possible retained FB!! document this & that pt understands
39
FB identification
ULS
sensitive 95-100% <1-4mm
CT most sensitive
40
FB mgnt
```
mechanical & inflammatory effects
remove based on size, composition & location
small FB deeply imbedded best left
Abx- depends on object & mech
ortho consult
```
41
what is the MC complication of FB?
infection
42
anatomy of hand infxns
infxns extend across the various planes of the hand w/o resistance
43
infections that start in the fingers do what?
proceed thru the flexor tendon sheath & enter the mid-palmar space
44
infxns in the mid-palmar space do what?
extend rapidly into the thenar space
| devestating effects: may resist aggressive tx w/ IV abx
45
hadn infxns often require what?
I & D in OR
46
what is a felon?
subcutaneous pyogenic infxn of the finger tip (tuft)
47
how does a felon present?
severe throbbing pain
48
MC organism causing felon?
S. aureus
49
tx of felon
```
I&D
incision 5mm distal to the digital crease & extend to the pulp space
midline incision
avoid neurovascularl bundle
consult ortho if complex
```
50
what is the most serious complication of felon?
acute tenosynovitis
51
what is paronychia
inflammation involving the lateral & posterior fingernail folds
52
predisposing factors for paronychia
overzealous manicuring
nail biting
thumbsucking
DM
occupations in which the hands are frequently immersed in water
also reported in assoc. w/ antiretroviral therapy for HIV infxn
53
tx of paronychia
I&D
separate the nail plate from the lateral nail fold
packing vs. warm soaks
54
the 4 cardinal signs of flexor tenosynovitis
tenderness over flexor tendon
swelling of the finger
pain on passive extension
flexed posture of the digit
55
tendons have____________blood supply & blood flow is easily interrrupted by relatively little__________& may cause destruction of underlying tendon
scant
| edema
56
peri-tendonous scarring leads to what?
subsequent loss of function of the hand
57
tx of flexor tenosynovitis
prompt drainage in the OR & admit w/ appropriate IV abx
58
pyogenic flexor tenosynovitis
```
often begin as benign puncture wound
PE: slight digital flexion
uniform volar swelling
flexor tendon sheath tenderness
pain on passive extension
Admit: surgical drainage & IV abx
```
59
what to think about with wounds
```
control bleeding
thru irrigation w/ high pressure NS
consider delayed closure of "dirty" wounds
debridement
FB removal
```
60
incisional wound
caused by sharp object
| usually may be closed primarily
61
avulsion wound
full thickness require skin grafting
62
blast/crush
considered "dirty" d/t maceration of tissue & microvasculatrue
often require debridement
63
degloving injuries
require skin grafting
64
puncture wounds
may require "coring"
greater risk of infxn
elevate extremity
low threshold for abx tx
65
what often complicates crush injuries?
open wounds
massive levels of contamination
thermal injuries
66
what may result from damage to local microcirculation from the crush, from damage to major blood vessels, or a combo of these?
ischemia
67
tx of crush injuries
Abx
supportive care
watch for compartment syndrome
68
nail bed injuries
subungal hematoma
>50%= remove nail plate to eval for nail bed laceration
repair nail bed w/ absorbable suture
removed nail may be used as splint
*decrease possibility of post traumatic ridged nail or cosmetic deformities
69
survival & function of amputations depend on what?
type of injury
ischemia of the injured part (particularly if warm)
general condition & comorbidities
70
what is recommended for reimplantation?
thumb
index finger proximal to the PIP joint
multiple digits
single amputated digits in children
71
mgnt of the amputation pt
if stable do NOT delay eval for transplant
minimal manipulation
AVOID extensive cleaning
DO NOT INJECT W/ LOCAL ANESTHESIA
saline gauze, bulky dressing, splint, elevate
update tetanus & NPO
72
what Abx do you want to give to amputation pt
Ancef 1 gm IV
73
mgnt of amputated part
save ALL parts & rinse w/ NS- remove gross contamination only
xray stump & part
wrap in DRY gauze
place in DRY zip lock bag & place bag ON ice (do not use dry ice, do not bury in ice)
cooling part to 40F enhances survival
1 hr of warm ischemia= 6 hrs cold ischemia
74
amputations & reimplantation absolute indications
ANY amputation in CH
clean amputations of hand, wrist, distal forearm
multiple digit amputations
amputated thumbs
75
Zone I for finger amputation zones
secondary intention: irrigate/debride, Abx dressing, protective splint
76
zone II
flap reconstruction
77
zone III
amputation
78
2 ways to remove fish hooks?
advance & cut
| yank technique
79
extrinsic muscles of hand
tendons responsible for the gross movements of the hand & digits
commonly involved in hand injuries
80
abductor pollicis longus & extensor pollicis brevis check
ask pt to forcefully spread their fingers
81
extensor pollicis longus check
ulnar border of the snuff box
| ask pt to hyperextend distal phalanx of thumb against resistance
82
intrinsic muscles of hand responsible for what?
fine detailed mvnt
83
dorsal interossei check
tested by spreading the hand forcibly against resistance
84
volar interossei check
tested by placing paper between extended fingers & asking pt to resist its removal
85
thenar & hypothenar muscles check
pinch & opposition
86
lumbrical tendons check
extend wrist & fingers while examinar presses down on finger tips
87
MC site of injury is the__________of the hand where____________tendons are superficial & more exposed to injury
dorsum
| extensor
88
tendon injuries may be partial or_________?
complete
| 70-90% of tendon lacerated & still function
89
it is important to determine the_________of the hand at time of injury
position
90
DO NOT close....
bites
crush injury
contaminated wound
91
DO start what if dirty wound?
Abx
92
DO consult who in ED for timing of repair
ortho
93
open flexor tendon injuries
```
lacerations
NEVER repair in ED
assess for vascular injury
surgical consult for timing of repair
irrigate, close skin & flexion splint
consider Abx
```
94
open extensor tendon injury
most dorsal wounds effect extensor tendons
| repair based on: >50% lacerated, zone of injury (consider ED repair if zone VI), severity & contamination
95
timing of primary tendon repair
w/in 72 hrs of injury
96
timing of delayed tendon repair
1st wk after injury
97
secondary tendon repair
after all edema has subsided & the scar has softened (4-6 wks)
98
splint tendon injury in what position?
neutral
99
swan neck deformity
```
untreated mallet
overactive pull of extensor on middle phalanx
PIP hyperextension
flexion of DIP
compensatory swan neck
```
100
in Swan neck deformity the PIP is ___________ & the DIP is?
PIP hyperextension
| Flexion of DIP
101
Boutonniere deformity
disruption of the tendon at the PIP
flexion of PIP w/ hyperextension of DIP
results from jamming/forced flexion injury that disrups the extensor tendon insertion into the dorsal base of the middle phalanx
102
tx of Boutonniere deformity
extension splint to immobilize PIP x 4-6 wks
103
flexion of PIP w/ hyperextion of DIP is what type of deformity?
Boutonniere deformity
104
types of fractures
```
comminuted
transverse
spiral
oblique
torus
avulsion
```
105
a finger forced upward may cause?
volar plate rupture or dorsal dislocation
106
a finger that has been compressed is more likely to have?
fx or mallet finger injury
107
a joint that is stressed sideways should raise suspicion of a?
collateral ligament injury
108
anterior dislocations
combo of varus/valgus force
| anteriorly directed force
109
combo of varus/valgus force in anterior dislocations may cause?
rupture of the collateral ligament & volar plate
110
anteriorly directed force in anterior dislocations displace what?
the base of the middle phalanx forward & rupturing the central slip of the extensor mechanism
111
posterior dislocations
d/t hyperextension of PIP
| assoc. w/ rupture of volar plate or collateral ligaments
112
lateral dislocations
abduction or adduction stresses while in extension
| commonly assoc. w/ radial collateral ligament rupture
113
volar plate collateral ligaments are the main stabilizers of?
PIP
114
hyperextension of volar plate collateral ligaments avulses?
volar plate
115
what are the MC dislocations of volar plate collateral ligaments
dorsal
116
ligaments of ________most commonly injured in hand
PIP
117
PIP joint injuries general
often dismissed as a simple sprain & left untreated
| may have occult fxs, dislocations, or ligament injury
118
mgnt of dislocations
```
digital block
closed relocation
mandatory x-rays
active ROM & PROM assess after reduction
splinting; ortho f/u
```
119
unable to reduce=
entrapment= volar plate, collateral ligament, or fx
120
ulnar collateral ligament rupture is also known as a?
gamekeeper's/skier's thumb
121
gamekeeper's/skier's thumb general info
weakened pinch
cannot resist an adduction stress
examine thumb in extension; if > 20 degrees of instability= surgical repair
122
mgnt of skier's thumb
xray for underlying avulsion fx
w/ or w/o fx full tear= surgical fixation
partial tear= splint & refer
123
any pain in distribution of UCL or inability to oppose thumbe=
UCL injury until proven otherwisw
124
types of distal phalanx fx's
tuft
comminuted
transverse
mallet
125
transverse fx of distal phalanx is often assoc. w/?
nail bed laceration
126
mallet fx of distal phalanx assoc. w/?
avulsion injury at the attachment of the extensor tendon
127
mallet finger
flexion deformity at the DIP w/ complete passive but incomplete active extension of the DIP joint
128
a mallet finger is usually sustained from a?
sudden flexion force to the tip of the extended finger
129
mallet fingers can also be d/t
- avulsion of the extensor tendon at the site of insertion
| - avulsion fx of the distal phalanx w/ tendon attached
130
mgnt of middle & proximal phalanx extra-articular fx's
ulnar or radial gutter splint
131
mgnt of middle & proximal phalanx fx's that are oblique, spiral, displaced, or unstable
refer for reduction or surgical fixation
132
mgnt of middle & proximal phalanx intra-articular fx's
reduced anatomically; often require surgical intervention
133
metacarpal fx's occur most commonly at the
metacarpal neck
134
metacarpal fx involving the 4th or 5th digit is called a
boxer's fx
| it is a clenched fist injury
135
index or middle finger anulation > 15 degrees & 4th/5th digit angulation >30 degrees requires what?
reduction
136
metacarpal fx's can be?
transverse
oblique
spiral
comminuted
137
check for rotational malalignment by doing what?
complete flexion of 2nd-4th digits
nml flexion of fingers pointing toward region of schaphoid- if any fingers point in different direction they are malrotated
138
what do you call a fx at the base of the thumb metacarpal involving the joint?
Bennett's fx
139
a Bennett's fx is sustained from?
axial load w/ closed hand
140
mgnt of Bennett's fx
must be reduced
| requires surgical intervention
141
what is the MC carpal fx?
scaphoid fx
142
with a scaphoid fx, you'll have tenderness where?
snuff box
143
the more proximal the schaphoid fx, the more common is?
avascular necrosis
144
what type of xray do you want in a schaphoid fx?
scaphoid views
| they often demonstrate a fx not seen on a plain wrist film
145
mgnt of scaphoid fx
immobilize in thumb spica splint
146
fx of distal radius w/ volar displacement is what type of fx?
Smith's fx
| check for assoc. median n. or flexor tendon injury
147
fx of distal radius w/ dorsal displacement is what type of fx?
Colles fx
| reduce after traction & hematoma block
148
usual etiology of tendonitis?
repetitive stress
149
active & passive mvnt accentuates pain with well localized tenderness in what?
tendonitis
150
tenosynovitis
hx of excessive stress on the affected tendon
| friction between tendon & sheath causes synovial thickening
151
tx for tendonitis
NSAIDs &/or local steroid injection
152
what do you have when you have painful blocking of flexion & extension at the involved joint?
trigger finger
153
what causes trigger finger
hypertrophy of the tendon & pulley as a result of excess repetitive strain
154
sx's of trigger finger
localized tenderness over the proximal flexor pulley
155
what fingers are most commonly affected in trigger finger?
ring & middle fingers
156
tx for trigger finger
steroid injection/ surgical release
157
DeQuervain's is also known as?
stenosing tenosynovitis
158
DeQuervain's involves the?
abductor pollicis longus &
| extensor pollicis brevis
159
with DeQuervain's pt's complain of what?
pain at the radial aspect of wrist localized to the radial syloid
160
what test can be used to determine if it is DeQuervain's or not?
Finkelstein's test
161
Finkelstein's test will illicit what?
sharp pain w/ ulnar deviation of wrist
162
carpal tunnel syndrome is caused by compression of what?
median nerve in the carpal canal most often d/t repetitive motion
pain awakens pt from sleep
163
etiology of carpal tunnel syndrome
any condition which produces chronic swelling
164
you will have paresthesias over what nerve distribution in carpal tunnel syndrome?
median nerve
165
what tests can you do to check for carpal tunnel syndrome?
Tinels & Phalen's sign
166
the MC tumor of the hand is a?
ganglion cyst
167
a ganglion cyst is a synovial cyst from?
joint or synovial lining of a tendon that has herniated
168
ganglion cysts contain what?
gel-like fluid that forms a cyst or connects w/ the synovial cavity
169
what is the MC site for ganglion cysts?
dorsum of the wrist
170
tx of ganglion cyst
surgical excision is TOC
171
grease guns, paint sprayers, or compressed air devices can cause?
serious penetrating injuries that require wide debridement
true extent of injury hidden behind tiny puncture wound
***high incidence of amputation
ACT AGGRESSIVELY!!!!
172
high pressure injection devices generate pressures that range from 1500-7000 psi and can deposit toxins into?
tendon & synovial sheaths
173
MC site of high pressure injection injury?
index finger followed by palm & long finger (3rd digit)
174
complications of high pressure injection injuries
intense throbbing & pain shortly after injury leading to compartment syndrome
175
mgnt of high pressure injury
```
xrays
pain ctrl
NO digital blocks= worse outcome
NPO & tetanus
early extensive surgical debridement & decompression of the wound/fasciotomy
prophylactic broad spectrum Abx
corticosteroids often used
```
176
prognosis of high pressure injury
time since injection critical
pt requiring amputation presented bet. 6-48 hrs after injury
chemical properties of agent contribute to severity
177
what is the most irritating to tissue in high pressure injury?
paint & paint solvents
178
in a high pressure injury, what may rapidly compromise circulation to the digits?
swelling d/t injury
substance induced irritation
material deposited w/in sheath
179
what makes up the highest # of medicolegal actions against ED docs?
complications of hand wounds
180
what do you want to consider in all open wounds?
retained FBs or deep tissue injury
