MSK - Hand injury

Question 1

How do you Ix & Rx a hand injury?

Answer 1

XR, US

Rx: rest (splint in position of function, elevation, compressoin, clean wounds, antibiotics, tetanus status, analgesia)

Referral/discharge

Question 2

How do you examine a hand injury (3)?

Answer 2

Look, draw +/- take a photo
keep wounds moist with sterile dressing
test function to assess underlying structures (NOT by direct exploration of wound)

Question 3

How do 2 ischaemias present with lack of inflow or outflow?

Answer 3

Lack of inflow: pale white

Lack of outflow: very red/purple

Question 4

What is Allen’s test?

Answer 4

Checking which artery is supplying the tissue

1. Ask pt to make a fist
2. occlude radial & ulnar artery
3. release whichever you’re interested in & see if the hand is reperfused.

Question 5

Contrast function of flexor digitorum superficialis form profundus

Answer 5

FDP flexes distal IP joint

FDS flexes the proximal IP joint

Question 6

What allows a natural tendon cascade? Why is it important in examination of a hand injury?

Answer 6

Flexor tendon posture.

If a laceration to a tendon, the finger will stand out (extended) & drop out of the cascade.

If you press on the flexor tendons in the forearm, the cascade is exaggerated - indicating that the tendons are all intact.

Helpful examination esp in small children/uncooperative pts

Question 7

When do you typically get a Mallet injury?

Answer 7

Cricket ball injury

Terminal tendon that extends the DIP joint is broken -> flexion at DIP.

Question 8

What & how do you test median nerve?

Answer 8

• Abductor pollicis brevis
• FDS, FPL, radial half of FDP, FCR
• sensation

Question 9

What & how do you test ulnar nerve?

Answer 9

• adductor pollicis (Froment’s test)
• Interossei (abduction)
• Ulnar half of FDP, FCU
• Sensation

Question 10

What & how do you test radial nerve?

Answer 10

• Long extensors

- Sensation

Question 11

What is Froment’s test?

Answer 11

Grab a piece of paper in b/w a thumb & the side of index finger.

If adductor pollicis is not strong enough, the thumb will flex to grab the paper. This is a positive Froment’s test.

Question 12

How do you test stability in a hand injury exam?

Answer 12

• stabilise proximal joint
• stress joint
• compare with other joints
• may have to use local anaesthetic for pain relief (by specialist)

Question 13

Describe paediatric finger tip injury

• mechanism of injury
• anatomy
• Ix
• Rx
• Referral

Answer 13

• mechanism of injury: CRUSH e.g. door hinge
• anatomy: distal phalanx directly under nail bed
• Ix: XR
• Rx: clean wounds, compression, rest in splint in position of function, elevation, ABx, tetanus status, analgesia
• Referral: plastic surgery r/v; re accurate nail bed repair, suture finger tip & clean wound

Question 14

How do you manage an animal bite?

Answer 14

• Tetanus
• ABx to include anaerobes e.g. Augmentin duo forte
• XR torsion causing #
• thorough and early debridement & lavage; Staph aureus is the most common organism in dog bite infection
• rest, splint, elevation
• refer to plastics

Question 15

Describe a punch hand injury

• mechanism of injury
• anatomy
• Ix
• Rx
• Referral

Answer 15

• mechanism of injury: PUNCH
• anatomy: metacarpals
• Ix: XR
• Rx: clean wounds, compression, rest in splint in position of function, elevation, ABx, tetanus status, analgesia
• Referral: plastic surgery r/v; re accurate nail bed repair, suture finger tip & clean wound

Question 16

Describe an amputated hand injury

• Ix
• Rx
• Care of the amputated part
• Referral

Answer 16

• Ix: XR of limb & part
• Rx: clean wounds, compression, rest in splint in position of function, elevation, ABx, tetanus status, analgesia
• Care of the amputated part: saline gauze into plastic bag next to ice (not in ice) to reduce the metabolic rate.
• urgent referral & nil oral

Question 17

Would more distal or proximal amputation lead to a better functional outcome when reconnected?

Answer 17

The more distal the amputation, the more likely the better functional recovery

Question 18

How does leech help correct a venous congested tissue that is not draining properly?

Answer 18

Creates an artificial venous outflow

Leech has heparin derivatives in its saliva thinning the blood & likes sucking out the congested venous flow.

Question 19

Describe tenosynovitis

• definition
• 4 Px

Answer 19

infection within tendon sheath

Px with:

• fusiform swelling of digit
• partially flexed posture
• tender along sheath
• pain with passive extension

Question 20

How do you Ix necrotising infections?

Answer 20

FBE
U&E
LFT
blood cultures
swabs

Question 21

What are the principles of hand injury management?

Answer 21

ABC
Medical history (in general)
Age
Occupation
hand dominance
pain management