1. The Hand
Bucky Boaz, ARNP-C

2. 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

3. 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.

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

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

6. 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.

7. 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

8. 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).

9. Anatomy Review
Nerves
Median
Ulnar
Radial

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

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

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

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

14. 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.

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

16. 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).

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

18. Common Traumatic Injuries of the Hand
Bone and Soft Tissue

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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

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

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

30. 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)

31. 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

32. 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

33. 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

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

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

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

37. 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

38. 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

39. 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

40. 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

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

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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

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

52. 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

53. 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

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

55. 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

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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. 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

68. Infections of the Hand

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

70. 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.

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

72. Paronychia

73. 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).

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

75. Questions?