The Hand Bucky Boaz, ARNP-C

Examination of the Upper Extremity A detailed history should include: Patient’s age Handedness Occupation Hobbies Chief complaint Description of how and when the problem started Duration of symptoms Aggravating and alleviating factors

Examination of the Upper Extremity If an injury is involved: The environment in which the injury or insult occurred should be determined. If crush injury, are heat or chemicals involved? Was the environment clean or dirty? Past medical history is useful in the presence of systemic conditions that have manifestations in the hand.

Anatomy Review Bones Distal radius and ulna Carpals metacarpals Phalanges Proximal Middle Distal

Anatomy Review Joints DRUJ Carpal-Metacarpal Metacarpal-Phalangeal Proximal Interphalangeal Distal Interphalangeal DIP PIP M-P C-M DRUJ

Anatomy Review Muscles & Tendons Extrinsic Flexor tendons Flexor carpi ulnaris Flexor carpi radialis Palmaris longus Flexor pollicis longus (FPL) Flexor digitorum profundis (FDP) Flexor digitorum superficialis (FDS) The flexor carpi ulnaris and the flexor carpi radialis are the main flexors of the wrist and are located on the radial and ulnar side of the wrist, respectively. The palmaris longus, a rudimentary muscle that runs down the center of the forearm, inserts the palmar fascia in the palm. The remaining flexors of the hand pass beneath the transverse carpal ligament within the carpal canal and include the flexor pollicis lungus (FPL), flexor digitorum profundus (FDP), the flexor digitorum superficialis (FDS). The FPL inserts on the distal phalynx and flexes the IP joint of the thumb. Each finger, excluding the thumb, has a flexor profundus and flexor superficialis. The FDP inserts on each distal phalanx and flexes all three joints in the finger. The superficialis tendon insert on the middle phalanx and flexes the PIP.

Anatomy Review Muscles & Tendons Extrinsic Extensor tendons Abductor pollicis longus Extensor pollicis brevis Extensor carpi radialis longus and brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris

Anatomy Review Muscles & Tendons Extrinsic Intrinsic Extension of MP Flex of IP Intrinsic Abduct and adduct fingers Flexion of MP Extension of IP The intrinsic muscles of the hand are the interosseous muscles, the lumbricals, and muscles of the thenar and hypothenar region. The intrinsic muscles of the hand provide the fingers with the ability to abduct and are involved with flexion at the MP joint and extension of the IP joints. The extrinsic muscles extend the MP joint and flex the IP joints. When the intrinsic system is weakened, the hand will take on an intrinsic minus posture (extension at the MP joints and flexion of the MPO joints). An intrinsic plus posture is the reverse (flexion at the MP joints and extension of the IP joints).

Anatomy Review Nerves Median Ulnar Radial

Examination of the Hand and Wrist Complete exam: Observation Palpation Range of motion Neurologic testing Vascular assessment Stability testing

Observation Hands at rest Curved posture Look for one finger curved Asymmetry Color Spooning or clubbing Muscle atrophy

Palpation Lateral epicondyle Radial head Groove of ulnar nerve Olecranon Lister’s tubercle Radial/ulna styloid Snuffbox Carpals Metacarpals Phalanges

Neurologic Testing Sensory Motor Light touch – pin prick Two-point descrimination Motor Median Ulnar Radial

Neurologic Testing Motor testing OK sign FDP FDS FPL Motor Testing The median nerve is responsible for pronation of the forearm, wrist flexion, flexion of the thumb IP joint, and flexion of the DIP joint to the index finger as well as for opposition of the thumb. Resistive testing of thumb IP flexion best isolates median nerve function. The uInar nerve is responsible for flexion of the DIP joint to the ring and little finger. It innervates most of the intrinsic muscles of the hand, which provides grip strength and the ability to abduct and adduct the fingers. The radial nerve is responsible for wrist and finger extension. It is important to note that even in the presence of a complete radial nerve palsy, the fingers can be extended by the uInar innervated intrinsic muscles. Therefore, testing for radial nerve function must be performed with the wrist and MP joints supported in extension, which eliminates the effect of the intrinsics. Testing the ability to give the OK sign is a quick, easy way to test the function of all three nerves (Fig. 16). At this point in the examination, test for the integrity of the tendons to the hand and wrist. Begin with resistive testing of wrist flexion and extension followed by radial and uInar deviation. In the hand, test the integrity of the FDP by having the patient bend at the DIP joint of each finger while holding the MP and PIP joints in full extension. The FDS to each finger is tested by having the patient bend at the PIP joint while holding the other fingers extended (Fig. 17). At the thumb, test the FPL by resistive testing at the thumb IP joint. The intrinsic tendons are tested by resistive testing of finger abduction and adduction.

Vascular Examination Radial artery Ulnar artery Allen test Located radial to the FCR Ulnar artery Located radial to the FCU Allen test

Stability Testing Ulnar collateral ligaments Radial collateral ligaments Gamekeeper’s/ skier’s thumb Stability Testing There are certain joints in the upper extremity that are prone to injury and subsequent instability. Careful attention should be given to these joints as part of a routine examination. The elbow should be examined for both varus instability (laxity of the lateral ligaments) and valgus instability (laxity of the medial ligaments). One hand is placed on the patient's humerus as a post, and the elbow is stressed laterally and medially in both the fully extended position and in 30' of flexion. Excessive opening of the joint or reproduction of pain is noted. Instability of the DRUJ is confirmed by pain at the site and a prominence of the ulna head dorsally as compared to the other side. With the patient's arm in a pronated position, the examiner should press on the uInar head and note the amount of ballotment as it reduces into the radius. At the wrist, instability can occur either between bones of the carpus (dissociative) or between carpal rows (nondissociative). The most common intercarpal instability is between the scaphoid and lunate, which is confirmed by pain in the scapholunate region and with a positive Watson test (see Special Tests). Lunotriquetral instability is characterized by pain over the ligament between the lunate and triquetrurn and with a positive shuck test (see Special Tests). For the small joints of the hand, stability testing is performed by stabilizing the proximal bone and placing medial and lateral stress on the bone distal to the joint in question. Gamekeepers or skier's thumb is an injury of the uInar collateral ligament of the thumb MP joint. Opening of the thumb MP joint to lateral stress on the proximal phalanx is diagnostic (Fig. 18).

Special Tests Finklestein’s test Froment’s sign Watson test Shuck test Basal joint grind Compression test Phalen’s test Tinel’s sign TAP

Common Traumatic Injuries of the Hand Bone and Soft Tissue

Considerations on Treating Hand Injuries Type of injury The patient Associated diseases Socioeconomic factors Ability to cooperate with treatment plan Motivation to get well Managing the patient Recognizing the injury Making the proper diagnosis Initiating the appropriate care plan

Referrals Emergent referrals Open fractures Fractures with neurovascular compromise Significant soft tissue injury Irreducible dislocations or fractures with significant deformity

Referrals Urgent referrals (next day or two) Closed flexor or extensor tendon injuries Displaced, angulated, or malrotated closed fractures Carpal bone and distal radius fractures

History Complete history Hand dominance Occupation Avocations Circumstances surrounding the injury When and where Mechanism of injury Location and character of pain Numbness or tingling

Radiographs Examine prior to ordering films Stress views are useful in demonstrating injuries not present on plain views Occasionally CT scan or MRI are needed to evaluate an injury

Description of Fractures Be able to accurately describe a radiograph to a colleague Correct name of bone or joint involved Open or closed fracture Intraarticular or extraarticular Whether the fracture is shortened, displaced, malrotated, or angulated Fracture pattern

Description of Dislocations Be able to accurately describe a dislocation Described with the position of the distal bone relative to the proximal bone Dorsal vs volar dislocation Radial vs ulnar dislocation Can have a combination of two

Complications By far, the largest potential problem with any hand or wrist injury is stiffness. Soft tissue complications: Tendon adhesions Capsular contractures Fracture healing time Hand: 3-4 weeks Distal radius: 5-7 weeks

Complications Bony complications: Malunion Angulation Malrotation Shortening Intra-articular step-off Nonunion is uncommon in hand or wrist

Fractures of the Distal Phalanx The distal phalanx is the most common fracture in the hand, accounting for approximately 50% of hand fractures

Fractures of the Distal Phalanx Applied Anatomy Extensor and flexor tendons insert into the base of the distal phalanx Routinely not a deforming fracture

Fractures of the Distal Phalanx Mechanism of Injury Crush injury Sudden extension against a flexed finger (rugger jersey) Sudden flexion against an extended finger (baseball hitting end of extended finger)

Fractures of the Distal Phalanx Associated Injuries Nailbed lacerations Nail plate avulsion Skin lacerations Subungal hematoma History and Physical Exam Check both flexor and extensor function Document sensory exam

Fractures of the Distal Phalanx Radiographs 2 – 3 views to look for fracture Use hot light if needed Classification Longitudinal Transverse comminuted Treatment Non-displaced or minimally displaced can use variety of splints Immobilize the DIP only Reduce displaced fractures Open wounds may need more definitive treatment

Fractures of the Distal Phalanx Outcomes Cold intolerance Tip sensitivity Stiffness Nailplate irregularities When to refer Open fractures in need of nail bed repair Large skin loss Suspected flexor or extensor tendon involvement

Nailbed Injury Nailbed lacerations need to be repaired Use 6-0 absorbable to repair matrix Prevents nail growth problems Reinsert nail and secure

Subungual Hematoma Results from blunt trauma to nail Very painful Relieved by Cautery Heated paperclip 18g needle

Subungual Hematoma Clean with alcohol Instrument of choice Pierce nail Gauze for 24 hours

Mallet Fingers (soft tissue and bony) Applied Anatomy Terminal extensor tendon inserts into the dorsum of the distal phalanx Mechanism of injury Occurs with a sudden flexion force against an extended digit Results in flexion deformity of the DIP joint

Mallet Fingers (soft tissue and bony) History and Physical Exam Pain and deformity of the DIP joint after bumping the end of the finger Inability to straighten the end joint Test for tendon function

Mallet Fingers (soft tissue and bony) Radiographs 2 views looking for dorsal avulsion fragment May be negative Classification Soft tissue (- x-ray) Bony (+ x-ray) Fleck Dorsal articular piece Subluxation of DIP joint

Mallet Fingers (soft tissue and bony) Treatment Closed reduction Continuously splint DIP in full extension for 6 to 10 weeks Only immobilize the DIP Acceptable results may still be obtained with continuous extension splinting if it is as long as 2-3 months after initial trauma

Flexor Tendon Avulsion Applied Anatomy Flexor digitorum profundus tendon inserts into the base of the distal phalanx

Flexor Tendon Avulsion Mechanism of Injury Hyperextension against a flexed DIP joint Relatively uncommon, but devastating is missed Ring finger most commonly involved

Flexor Tendon Avulsion Associated injuries None History and Physical Exam Pain on volar surface of digit May extend into palm with eccymosis Cannot flex tip Resting hand has extension of DIP joint No active flexion

Flexor Tendon Avulsion Radiographs DIP to look for avulsion, but also hand to look for retracted segment Most are normal Classification Pure tendon avulsion Bony avulsion

Flexor Tendon Avulsion Treatment Should be splinted and referred in a semi-urgent fashion Surgery is required Outcomes Results correlate with delay in treatment Early do well Postoperative hand therapy is important

Middle and Proximal Phalangeal Fractures Applied Anatomy The central slip inserts into the proximal dorsal middle phalanx The flexor digitorum superficialis (FDS) inserts into each side of the base of the middle phalanx

Middle and Proximal Phalangeal Fractures Applied Anatomy Intrinsic muscles of the hand act to flex the MCP joints and extend the PIP and DIP through the actions of the lateral bands

Middle and Proximal Phalangeal Fractures Mechanism of Injury Direct blow to the digit or a twisting injury Associated Injuries Open injuries Lacerations to tendons or neurovascular bundles Important to evaluate for DIP injuries History and Physical Exam Evaluate for malrotation Subtle fractures on x-ray can have significant malrotation when flexed

Middle and Proximal Phalangeal Fractures Radiographs 3 views Evaluate joint proximal and distal Spiral fracture may appear on only 1 view Classification Location Midshaft Condylar Intra-articular Pattern Spiral Oblique Comminuted Transverse Avulsion

Middle and Proximal Phalangeal Fractures Treatment Most can be treated non-surgically Protect range of motion Buddy tape What to refer Displaced, malrotated, joint involvement Comminuted, spiral, and oblique are unstable Stable nondisplaced Splint 8-10 days followed by buddy tape Follow-up x-ray 8-10 days to ensure no displacement

Boutonniere Applied Anatomy When the central slip insertion at the base of the middle phalanx is disrupted, active PIP joint extension may be limited

Boutonniere Applied Anatomy The flexed position of the PIP joint then allows the lateral bands to fall volar to the axis These lateral bands then act to flex the PIP joint further Tension pulls the DIP joint into extension

Boutonniere Mechanism of Injury History and Physical Exam Acute flexion force to PIP joint PIP does not immediately fall into a flexed position Several weeks after the injury the digit assumes a buttonhole posture. Other mechanism include PIP dislocation and central slip lacerations History and Physical Exam Pain and swelling about PIP Inability to fully extend PIP DIP flexion is limited Longstanding cases PIP flexion Passive extension not possible

Boutonniere Radiographs Classifications Most often negative Occasionally small fragments dorsally off middle phalanx Classifications Acute Chronic Stiff supple

Boutonniere Treatment If not sure of central slip, assume it is and splint the PIP in full extension Acute boutonnieres 4 weeks of full extension splinting of PIP with active DIP flexion exercises Occasionally need surgery Chronic boutonnieres Hand therapy Possible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Most common orthopedic hand injury that can result in long-term digital stiffness and impairment

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Applied Anatomy PIP is a hinge Ligaments along palmar aspect - volar plate Prevents hyperextension Related to volar plate are collateral ligaments

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Applied Anatomy Each PIP joint has a radial and ulnar collateral ligament Tethers the PIP joint in its side-to-side motion Ligaments fail when they are stretched past a certain point

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Mechanism of Injury Sudden force directed to tip of digit results in hyperextension Spectrum ranging from slight hyperextension grade I sprain to frank dislocation Associated Injury If the skin tears open, it is an open dislocation History and Physical Exam Joint swollen and tender Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Radiographs 2 views to check for fractures Post-reduction films if done Classifications I – do not compromise stability II – partial compromise, at risk for complete disruption III- complete disruption, can compromise stability

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations Treatment Early mobilization after a few days of splinting Buddy tape for 4 weeks A rare volar PIP joint dislocation requires 3-4 weeks of splinting in extension Outcomes These injuries can heal with some permanent fusiform swelling from scar tissue. Long term problem is not recurrent instability, but stiffness For this reason, early range of motion program is most often recommended

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper’s Thumb) The ulnar collateral ligament of the thumb is important for pinch strength and stability Because of its location, it is particularly vulnerable to injury

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper’s Thumb) Mechanism of Injury Combination of hyperextension and a radially directed force at the thumb MP joint (fall with a pole in the hand while skiing) History and Physical Exam Moderate swelling and eccymosis over ulnar side of MP joint In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper’s Thumb) Radiographs Typically negative Possible avulsion fragment off proximal phalanx or metacarpal Treatment Incomplete – non-operatively (splint) Complete - surgically

Bennett's Fracture Dislocation Most frequent of all thumb fracture Described in 1882 by Dr. Edward Bennet It is a fracture dislocation, intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb

Bennett's Fracture Dislocation Mechanism of Injury Results from axial blow directed against the partially flexed metacarpal; (ie. from fist fights) History and Physical Exam Moderate swelling and eccymosis over the CMC joint Pain with ROM or palpation

Bennett's Fracture Dislocation Radiographs Oblique fracture line with a triangluar fragment at ulnar base of metacarpal Triangular fragment remains attached to trapezium w/ proximal displacement of the metacarpal Treatment Immobilization Referral for surgical pinning

Infections of the Hand

Conditions That Mimic Infection Gout Pyogenic granuloma Acute calcification Foreign body reaction Herpetic whitlow Metastatic lesions Pseudogout Rheumatoid arthritis Granuloma annulare Local reactions

Paronychia Infection localized to the proximal and lateral skin folds of fingers and toes Staph aureus Group A or D Strep Pseudomonas Gram-negative bacteria anerobes ACUTE PARONYCHIA A paronychia is an infection localized to the proximal and lateral skin folds of the fingers and toes (Figs. 3-5). Staphylococcus aureus is the usual offender; however, group A or D Streptococci, Pseudomonas aeruginosa, gram-negative bacteria, and anaerobes may be cultured as well.' 1,32 In children, paronychias are often caused by anaerobes introduced by finger sucking and nail biting.32 A paronychia usually results from nail trauma. This may occur in a number of different ways. One common scenario is a paronychia occurring as the result of an ingrown nail. Some patients have a habit of rounding their nails when cutting them so that a part of the nail grows under the nail fold, trapping bacteria and debris. Patients may also pick their nails, sometimes leaving a nail fragment that acts as a foreign body, growing into and under the nail fold and allowing bacteria to proliferate. Athletes may develop paronychias of their toenails, especially after using improperly worn shoes or from constant trauma. An ingrown nail may subsequently result. The same may occur in those who persistently wear high-heeled shoes. Training nails to grow up, out, and straight is easily accomplished by the use of cotton wicks. While mainly used for toenails, fingernails could be managed similarly. A small piece of cotton is placed under the medial and lateral aspects of the 4,15,35 nail. The wicks are changed daily, and patients are instructed to let the nail grow up until is can be cut squarely across. If infection has occurred in the form of a localized cellulitis, frequent warm saline soaks and topical or oral antibiotics can be tried. Because S. aureus is often the main bacterium involved, short courses of antibiotics such as cephalexin, erythromycin, dicloxacillin, or ampicillin-sulbactam can be prescribed .32 The first two are the most cost-effective and available as generic formulations. Once pus has developed, a drainage procedure is important.

Paronychia Clean area with alcohol or betadine Perform digital nerve block Area of greatest fluctuance Remove pus Debride nail if necessary Antibiotics Dressing

Paronychia

Felon Abscess of distal pulp Results from penetrating trauma Bacteria trough eccine sweat glands Pulp is tense and tender Significant edema A felon is a subcutaneous abscess of the distal pulp of a finger or thumb Felons usually occur as a result of penetrating injury or laceration at the fingertip. Bacteria may also gain entry through eccrine sweat glands that open into the epidermis. If a delay in treatment occurs, a felon can result in osteomyelitis of the distal phalanx or an infectious flexor tenosynovitis. Usually the finger pulp is tense and quite tender to palpation. There is generally significant edema and erythema in the finger that may extend proximally. The most significant tenderness is usually localized to the finger pulp and site of abscess formation. There may be a slightly limited range of motion of the DIP joint; however, more significant pain localized to the DIP joint as well as significant limitation of motion may suggest the possibility of DIP joint septic arthritis. Patients who have developed DIP joint septic arthritis will often have pain, which is quite severe, with attempted motion of the joint. In addition, there is significant palpable tenderness to the dorsal and lateral margins of the DIP joint. Multiple incisions have been described for drainage of a felon, which include the fish-mouth, the hockey stick or J-incision, and a transverse palmar incision (Fig. 9). 1 prefer a longitudinal palmar or unilateral longitudinal approach (Fig. 10).

Felon Fish-mouth incision Hockey-stick/ J-incision Transverse palmar incision

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