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Flashcards in hand and wrist Deck (121):
1

At the wrist, the ______ gives off a superficial palmar branch which completes the superficial palmar arterial arch.

At the wrist, the RADIAL ARTERY gives off a superficial palmar branch which completes the superficial palmar arterial arch.

2

the ULNAR ARTERY enters the hand anterior to the _____ just lateral to the pisiform

The ULNAR ARTERY enters the hand anterior to the flexor retinaculum, just lateral to the pisiform bone. It gives off the deep palmar branch and continues onto the palm as the superficial palmar arterial arch.

3

ulnar nerve passes between

passing between hook of hamate

4

radial nerve superficial branch travels above

Superficial branch above radial styloid

5

median nerve travels through the

Median nerve: through carpal tunnel

6

Superficial radial nerve supplies

Superficial radial nerve supplies skin on the lateral side of the dorsum of the hand, and a small portion of the thenar eminence

7

the recurrent branch of the median n. supplies

the recurrent branch of the median n. supplies the muscles of the thenar eminence

8

cutaneous branch of the median nerve is responsible for

b. cutaneous branches to the skin on the palmar surfaces of the of the first 3½ digits

9

The ulnar nerve enters the palm of the hand through the ___-

1. The ulnar nerve enters the palm of the hand through the ulnar canal

10

Prior to entering the ulnar canal, ulnar n gives off:

a palmar cutaneous branch
(ulnar aspect of the palm)


A dorsal cutaneous branch

(the ulnar aspect of the dorsum of the hand)

11

what is the most frequent injury of the hand and commonly fractured


what is the most common finger

Lacerations most frequent injury

Distal phalanx most commonly fractured

Little finger most common in US

12

how do you document hand injury

i. Dominant hand
ii. Occupation
iii. Tetanus status
iv. Traumatized or non traumatized documentation


always think in terms of anatomy (ulnar or radial aspect of the hand)

volar or dorsal (flexor or extensor)

13

this nerve is responsible fo

the ulnar nerve innervates all the intrinsic muscles of the hand not innervated by the median nerve.

14

how to document trauma

1. Ascertain hx of trauma
2. Time elapsed since injury (golden window = 6 hours)
3. Environment of injury
4. Mechanism of injury

15

how to document non-trauma

v. Nontraumatized
1. When did sx begin
2. What functional impairment
3. What activities worsen sx

16

what are the NEVER rules with excessive bleeding

i. Elevation
ii. Apply a sterile wet-compression dressing.

NEVER LEAVE BP CUFF FOR MROE THAN 30

never ligate a hand vessel without directly visualizing the bleeding vessel and all surrounding structures

17

dorsum of first web space.

radial

18

how do you test strength of R/U/M nerve

1. Radial: extension at wrist and MP joint

2. Ulnar: forcible spread of fingers

3. Median: flexion of wrist and PIP of thumb and index against resistance

19

5th finger sensory what N

ulnar

20

flexor aspect of index and middle

medial

21

document ROM in

degrees

22

this PE finding is common with tendon injury

Patients unable to flex one finger together with the others often found to have associated tendon injury.


pain with flexion is indicative of a partial tear

23

testing flexor digitorum profundus and Flexor Pollicis Longus

hold down all other fingers in extension and have pt just test finger needed

24

Test by holding all other fingers in extension and have the pt flex the finger to be tested

Flexor Digitorum Superficialis

25

how to test extension

: hand palm-down on a table and extend the fingers off the table one at a time.

26

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.

27

whenever there is glass involved

get an xray

XRAYS sensitive for glass > 2mm

ULS is also sensitive for glass
Sensitive 95-100% < 1-4mm

28

best imaging for organic FB

uls

29

Consideration for the management of FB

anbx

might need OR removal

30

why are hands a scary place for infx?

infections extend QUICKLY across the fascial planes of the hand without resistance.

many structures and a lil meat

31

finger infections can ended mid-palmar space through

Proceed through the flexor tendon sheath and enter the mid-palmar space.

32

Infections in the mid-palmar space

i. Extend rapidly into the thenar space.
ii. Devastating effects: may resist aggressive treatment with IV antibiotics.

33

what is a felon

Subcutaneous pyogenic infection of the pulp space of the finger tip (tuft)

Paronychia but just of the tip of the finger

34

felons can present like this

severe throbbing pain
1. Can be hx of trauma or finger nail biters

35

what is the most common management and approach to felons

iii. Most common org = staph aureus

I&D

midline incision and draw packing strp in

36

most common complication of felon

Avoid neurovascular bundle

Most serious complication is acute tenosynovitis

37

what is a paronychia

Inflammation involving the lateral and posterior fingernail folds.

38

predisposing factors for paronychia

1. Overzealous manicuring
2. Nail biting
3. Thumb sucking
4. Diabetes mellitus
5. Occupations in which the hands are frequently immersed in water

39

tx of paronychia

TX=I&D: separate the nail plate from the lateral nail fold

1. Iodoform Packing vs warm soaks

2. If doing I&D, don’t usually need to put them on abx


is packing bring back in two days recheck

40

four cardinal signs of flexor tenosynovitis

1. Tenderness over the flexor tendon,

2. Swelling of the finger

3. Pain on PASSIVE extension,

4. Flexed posture of the digit.

41

what are we worried about with flexor tenosynovitis

ii. Tendons have scant blood supply; blood flow easily interrupted by relatively little edema and may cause destruction of underlying tendon.

42

Peri-tendonous scarring results in

iii. Peri-tendonous scarring = subsequent loss of function of the hand.

43

tx of flexor tenosynovitis

tx the operating room and admit with appropriate intravenous antibiotic therapy.

44

Pyogenic Flexor Tenosynovitis

Uniform volar swelling

Flexor tendon sheath tenderness

Pain on passive extension

45

Pyogenic Flexor Tenosynovitis tx

Admit: surgical drainage and IV antibiotics

46

Pyogenic Flexor Tenosynovitis often beings with

i. Often begins as benign puncture wound
ii. Slight digital flexion

47

wound management and consideration


Control bleeding

Copious irrigation with high pressure NS (1 liter of irrigation)


Consider delayed closure of “dirty” wounds
Debridement

Foreign body removal

48

Incisional mngmt

1. Caused by a sharp object
2. Usually may be closed primarily

49

avulsion mngmt

1. Full thickness require skin grafting

50

Considered this wound MOA “dirty”

what is the mangement

Blast/Crush injuries

Considered “dirty” due to maceration of tissue and microvasculature

Often require debridement

51

Degloving injuries require

i. Require skin grafting

52

special considerations for puncture wounds

May require “coring”

Greater risk of infection
iii. Elevate extremity
iv. Low threshold for antibiotic tx

53

Crush injuries--> tx and complications

Tx: antibiotics, supportive care, watch for compartment syndrome

Ischemia may result from damage to local microcirculation/damage to major blood vessels

54

Subungal hematoma

mngmt

> 50% = remove nail plate to evaluate 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

55

recommended reimplantation with these types of amputations (4)

Recommend reimplantation of

thumb
the index finger proximal to the PIP joint
multiple digits
and single amputated digits in children.

56

mngmt of patient with amputation

1. If stable do not delay evaluation for transplant

2. Minimally manipulate/Avoid extensive cleaning

3. Do NOT inject with local anesthesia -->you will cause ischemia to the part

4. Saline gauze, bulky dressing, splint, elevate

5. Ancef 1 gm IV

6. Update Tetanus and NPO


Save all parts and rinse with normal saline remove gross contamination only

2. Xray stump and part

57

management of amputated part and time window


Wrap in DRY gauze

Place in DRY zip lock bag and place bag ON ice

Do not use dry ice, do not bury in bag

Cooling part to 40° F enhances survival

1 hr of warm ischemia = 6 hrs cold ischemia


of hanging on a thread wrap in saline gauze and keep it cool

58

management of a zone I amputation

before the bone

secondary intention

Irrigate/Debridement
Antibx dressing
Protective splint


Lorraine does dissect out tissue and cover with this for fun rather than let an open wound grannualte in

59

Zone II mnmgt

= flap reconstruction

60

zone III mngmt

Zone III = amputation

does not help to attach distal pahlaynx

61

fish hook removal

 advance them a little bit and then cut off the bar
1. Can use the yank technique as well

62

1. Tendons responsible for the gross movements of the hand and digits

extrinsic tendons

63

ask pt to forcefully spread their fingers helps test which tendons

Abductor pollicis longus and extensor pollicis brevis: ask pt to forcefully spread their fingers

64

2. Most commonly involved in hand injuries

extrinsic tendons

65

how to test extensor pollicis longus:

ulnar border of the snuff box; ask pt to hyperextend distal phalanx of thumb against resistance

66

Intrinsics are responsible for

Responsible for fine detailed movement

67

Volar interossei test by

tested by placing paper between extended fingers and asking pt to resist its removal.

68

Dorsal interossei test by

tested by spreading the hand forcibly against resistance

69

Thenar and hypothenar muscles

pinch and opposition

70

Lumbrical tendons

extend wrist and fingers while examiner presses down on fingertips

71

most common site of injuries to tendons

Most common site of injury is dorsum of hand where extensor tendons are superficial and more exposed to injury.


Tendon injuries may be partial or complete
1. 70-90% of tendon lacerated and still function

72

mngmt of tendon injuries

dos and do NOT (1)

DO (2)

Determine the position of the hand at the time of injury

DO NOT close bites, crush injury, contaminated wounds

DO Start prophylactic antibiotics if dirty

DO Consult Ortho in the ED for timing of repair

73

Extensor tendons need to be repaired in

Extensor tendons need to be repaired in about 72 hours

74

mnmgt of open Flexor Tendon Injuries

i. Lacerations
ii. Never repair in ED
iii. Assess for vascular injury

Surgical consult for timing of repair
Irrigate, close skin and flexion splint

Consider antibiotics

75

primary timing of tendon repair

Primary repair: within 72 hours of injury

Delayed repair: first week after injury

Splint in a neutral position

76

why would secondary repair be indicated for tendon injury and when would it occur

after all edema has subsided and the scar has softened
1. (4-6 weeks)

Splint in a neutral position

77

Swan Neck Deformity occurs after

Untreated Mallet

Overactive pull of extensor tendon on middle phalanx

78

why is the classic swan neck

PIP Hyperextension
Flexion of DIP

79

boutonniere deformity -what is it

Extensor Tendon Injury: Boutonniere Deformity

Flexion of PIP with hyperextension of DIP

80

boutonniere deformity occurs after

Disruption of the tendon at the PIP

Results from jamming or forced flexion injury that disrupts the extensor tendon insertion into the dorsal base of the middle phalanx

81

tx of extensor tendon injury

Tx: Extension splint to immobilize PIP x 4-6 wks

82

tendonitis is usually caused by

Usually etiology =repetitive stress
1. Active and passive movement accentuates pain with well localized tenderness


Tx with NSAIDS and/or local steroid injection

83

Tenosynovitis:

hx of excessive stress on the affected tendon

-friction between tendon and sheath causes synovial thickening

84

what is trigger finger

Painful blocking of flexion and extension at the involved joint

Hypertrophy of the tendon and pulley as a result of excess repetitive strain

85

sxs of trigger finger

iii. Localized tenderness over the proximal flexor pulley

86

mc tirgger finger and tx

Ring and middle fingers most common


Tx: steriod injection / surgical release

87

main stabilizer that is disrupted in dislocations (hyperextension_

Volar Plate Collateral Ligaments

88

MC dislocation dorsal or ventral?

DIP or PIP

dorsal

PIP most commonly injured

89

treatment of volar plate avulsion

splinting and early ROM after reduction

always XRAY before and after

90

general mngmt of finger dislocations

i. Digital block
ii. Closed relocation
iii. Post reduction Xrays
iv. Access Active ROM and PROM after reduction
v. Unable to reduce = entrapment: volar plate, collateral ligament, or fracture
vi. Splinting & Ortho f/u

91

Gamekeeper’s/Skier’s Thumb what ligament is injure in this and what purpose does it serve

i. Ulnar collateral ligament rupture
1. Ulnar collateral ligament – keeps the thumb from opening too much

92

gamekeeper thumb exam

Weakened “pinch”
iii. Cannot resist an adduction stress

93

gamekeeper thumb mngmt

1. Xray for underlying avulsion fx

2. Any pain in distribution of UCL or inability to oppose thumb = UCL injury until proven otherwise

3. With/without fracture full tear = surgical fixation

4. Partial tear = splint and refer

thumb spika

94

fx of distal phalanx that you do nothing about

Tuft --> does not affect functionality; painful, not intraarticular

95

Transverse fx is often associated with

often associated with nail bed laceration

96

avulsion injury at the attachment of the extensor tendon

Mallet

soft ball vs. finger

bam jam jam

97

deformity associated with mallet finger

a. Flexion deformity at DIP with complete passive but incomplete active extension of DIP joint

98

Extra-articular fractures of k. Middle and Proximal Phalanx Fractures

ulnar or radial gutter splint

early ROM is necessary

Oblique, spiral, displaced, or unstable
1. refer for reduction or surgical fixation

99

Avulsion fx of distal phalanx with tendon attached.

mallet

100

Metacarpal Fractures MC occur at

i. Most commonly at the metacarpal neck

think 4th or 5th digit = boxer’s fx
clenched fist injury

101

when would reduction be required with metacarpal fx

Index or middle finger:

angulation > 15 degrees;

4th or 5th digit angulation > 30 degrees

102

check for rotational alignment with metacarpal fx by

flexing fingers and looking for alignment

Make sure all fingernails are pointing to the same place

103

what is a bennet's

i. Fracture at the base of the thumb metacarpal involving the joint

104

MOA of bennet's

ii. Sustained from an axial load with a closed hand

105

tx of bennet's

iii. Must be reduced and requires surgical intervention

106

Most common of all carpal fractures

what is the sxs

scaphoid

2. Anatomic snuff box tenderness (if present, place thumb spica splint)

107

dx and tx of scaphoid fx

4. Scaphoid views will often demonstrate a fx not seen on plain wrist films.
5. Immobilize in thumb spica splint.

108

smith's fx-what is it

need to check for

fx of distal radius with volar displacement


1. Check for associated median nerve or flexor tendon injury.

109

Colles fx what is it and managemet

fx of distal radius with dorsal displacement; more commonly seen

Reduce after traction and hematoma block

110

DeQuervain’s also known as... what is it

Stenosing tenosynovitis

Involves the abductor pollicis longus and extensor pollicis brevis

111

need to document this with DeQuervain’s

Finkelstein’s test
a. Sharp pain with ulnar deviation of wrist
5. Splint

112

Carpal tunnel caused by

Compression of the median nerve in the carpel canal

Etiology = any condition which produces chronic swelling

Repetitive motion


anything causing flexion or extension

113

documentation and tx of carpal tunnel

Tinels and Phalen’s sign

Splint them and tell them to wear it to bed

114

Most common tumor of the hand

Ganglion Cyst

115

physiology ganglion Cyst

Synovial cyst from joint or synovial lining of a tendon that has herniated

116

Grease gun, paint sprayers, or compressed air devices cause

what are the complications of this

high pressure injuries

deposit toxins into tendon and synovial sheaths.

117

MC site of high pressure injection injury

what are the sxs

Most common site of injection = index finger followed by the palm and long finger.

The patient may develop intense throbbing and pain shortly after the injury leading to compartment syndrome.

118

complications of high pressure injection injury

True extent injury hidden behind tiny puncture wound

Even with early dx high incidence of amputation

Act aggressively!

119

mngmt of high pressure injury

Xrays
b. Pain control
c. No digital blocks = worse outcomes
d. NPO and Tetanus

Early extensive surgical debridement and decompression of the wound / fasciotomy.

Prophylactic broad-spectrum antibiotics

Corticosteroids?

120

prognoses of high pressure injury

Time since injection critical

Patients requiring amputation presented 6-48 hours after injury

Chemical properties contribute to the severity of the injury.

Paint and paint solvents = most irritating to tissue.

Rapid compromise of circulation to digits.

121

Hand wound complications = highest # medicolegal actions against ED

how do you avoid these


Consider retained foreign bodies or deep tissue injury in all open wounds

Inform all patients of possibility of complications: pain, limitation of mobility

Carefully document initial neuro exam, procedures and follow-up for all patients

When in doubt , refer to ORTHO