11/4/2013 The Hand Exam: Tips and Tricks Nikki Strauss Schroeder, MD Assistant Clinical Professor, UCSF Department of Orthopaedic Surgery November 4, 2013 Outline Surface Anatomy � Hand Anatomy � Exam � Management of ER/traumatic injuries 1
11/4/2013 Hand Radiograph Distal Phalanx hyponychium Middle Phalanx Sterile matrix Proximal Phalanx paronychium Germinal matrix eponychium lunula Metacarpals Carpals Wrist radiograph Finger Radiographs Trapezoid Capitate Hamate Trapezium scaphoid Pisiform Triquetrum Lunate So Long To Pinky, Here Comes the Thumb 2
11/4/2013 Hand Motion Thumb Motion Courtesy ASSH Courtesy ASSH Vascular exam Allen’s Test � Clinical appearance � Radial, ulnar � Allen’s Test � Digital Allen’s test � Doppler 3
11/4/2013 Sensory Exam Sensory Exam � What nerves provide sensation to the hand? � Median � Palmar cutaneous branch � Digital nerves to thumb, index, and middle and radial half of ring fingers � Ulnar � Dorsal and palmar cutaneous branches � Digital nerves the small, ulnar half of ring finger � Radial � Sensory branch Sensation: quick and dirty 4
11/4/2013 Motor exam Sensory exam: 2-point discrimination � Median � Normal= 2.5-6 mm � Anterior Interosseous � In kids, see if hand � Recurrent motor branch wrinkles when placed in � Radial water � Posterior Interosseous � Ulnar Motor exam: quick and dirty � Median- thumb palmar abduction (touch tip of small finger) � AIN- OK sign � Ulnar- spread index and long finger apart (peace sign) ) � Radial/PIN- retropulse thumb (palm flat on table, extend thumb) 5
11/4/2013 Specific Tests- FDS/ FDP ER Cases… ER Management The ER Hand Exam � Patient Stabilization � Evaluation for other injuries � Complete but brief assessment � Tetanus, Antibiotics, Irrigation � History � Physical Exam � Imaging 6
11/4/2013 ER History The ER Hand Exam Inspect � Age, Hand Dominance, Occupation � � Document wound location (finger, volar/dorsal, radial/ulnar), size � Mechanism of Injury Sensory Exam � � 2PD � Onset/Location/Duration � Its OK to do a digital block after sensory exam is done!! � Exam Motor exam � � FDP/FDS, extensors, EPL � Range of motion/Rotation Vascular � � Digital Allen’s, Doppler Imaging � Is there a fracture? � Is there a dislocation? Green’s Hand Surgery Photo courtesy of L Lattanza 7
11/4/2013 Choosing the right imaging… Case 1 � Case 2 Case 3 8
11/4/2013 Hand Emergencies � Replants � Revascularizations � Flexor Tenosynovitis � Compartment Syndrome � Acute Carpal Tunnel Syndrome Amputations: Field E&M Field E&M � Control with Save all parts!!! � Direct pressure � Place parts in moist (Ringers) gauze and into a plastic bag � Rare tourniquet (temporary use only) � Bag is placed on ice. NO dry ice! � No clamps � Urgent transfer to ED- Surgical emergency � Elevate arm Wilhelmi BJ, Lee WP, Pagenstert GI, Pagensteert GI, May JW Jr. Replantation in the mutilated hand. Hand Clin. Feb 2003;19(1):89-120 9
11/4/2013 ER Management The bleeding arm that won’t stop � Patient Stabilization � Please LET THE TOURNIQUET DOWN and assess the wound � Evaluation for other injuries � Direct pressure stops bleeding MUCH better � Complete but brief assessment � Tetanus, Antibiotics, Irrigation � History � Physical Exam � Imaging Hand Emergencies: Revascularizations Hand Emergencies: Flexor Tenosynovitis 10
11/4/2013 Hand Emergencies: Compartment Flexor Tenosynovitis: Kanavel Signs Syndrome � Flexed resting position of the digit � Rare entity � Fusiform swelling � Does not include flexor tenosynovitis � Tenderness to � 10 compartments of the hand palpation of the flexor � Dorsal and palmar IO tendon sheath � Thenar, hypothenar � Pain on passive � Adductor digital extension � Carpal Tunnel First Image: Essentials of Hand Surgery 2002 Second Image: Regional Review Course 1998 Acute Carpal Tunnel Syndrome High Pressure Injection Injuries � 1-10% incidence with distal radius fractures � Typically high-energy injury � Peri-lunate, lunate dislocations � Document 2PD prior to reduction and post-reduction � Elevate, check again within 1-hour after reduction 11
11/4/2013 What about the artery that just won’t Conclusions stop bleeding? � Hand Anatomy � Ex: Isolated ulnar or radial artery � Radiographs � In a perfused hand: � Physical Exam � Direct pressure…. Up to 1 hour of compression � Specific ER Cases � Likely a shear injury to vessel � Obtain the correct radiographs � If doesn’t stop, OR to ligate vs repair � Do sensory exam first, then OK to do a block! Thank You � Nikki Schroeder � schroedern@orthosurg.ucsf.edu 12
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