The Hand Bucky Boaz, ARNP-C. Examination of the Upper Extremity A detailed history should include: Patient’s age Handedness Occupation Hobbies Chief complaint

The Hand

Bucky Boaz, ARNP-C

Examination of the Upper Extremity

A detailed history should include:Patient’s ageHandednessOccupationHobbiesChief complaintDescription of how and when the problem startedDuration of symptomsAggravating 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

BonesDistal radius and ulnaCarpals metacarpalsPhalanges

ProximalMiddleDistal

Anatomy Review

JointsDRUJCarpal-MetacarpalMetacarpal-PhalangealProximal InterphalangealDistal Interphalangeal

DRUJ

C-M

M-P

PIP

DIP

Anatomy Review

Muscles & TendonsExtrinsic

Flexor tendonsFlexor carpi ulnarisFlexor carpi radialisPalmaris longusFlexor pollicis longus (FPL)Flexor digitorum profundis (FDP)Flexor digitorum superficialis (FDS)

Anatomy Review

Muscles & TendonsExtrinsic

Extensor tendonsAbductor pollicis longusExtensor pollicis brevisExtensor carpi radialis longus and brevisExtensor digitorumExtensor digiti minimiExtensor carpi ulnaris

Anatomy Review

Muscles & Tendons

ExtrinsicExtension of MPFlex of IP

IntrinsicAbduct and adduct fingersFlexion of MPExtension of IP

Anatomy Review

NervesMedianUlnarRadial

Examination of the Hand and Wrist

Complete exam:ObservationPalpationRange of motionNeurologic testingVascular assessmentStability testing

Observation

Hands at restCurved postureLook for one finger curvedAsymmetryColorSpooning or clubbingMuscle atrophy

Palpation

Lateral epicondyleRadial headGroove of ulnar nerveOlecranonLister’s tubercleRadial/ulna styloidSnuffboxCarpalsMetacarpalsPhalanges

Neurologic Testing

SensoryLight touch – pin prickTwo-point descrimination

MotorMedianUlnarRadial

Neurologic Testing

Motor testingOK signFDPFDSFPL

Vascular Examination

Radial arteryLocated radial to the FCR

Ulnar arteryLocated radial to the FCU

Allen test

Stability Testing

Ulnar collateral ligamentsRadial collateral ligamentsGamekeeper’s/ skier’s thumb

Special Tests

Finklestein’s testFroment’s signWatson testShuck testBasal joint grindCompression testPhalen’s testTinel’s sign

TAP

Common Traumatic Injuriesof the Hand

Bone and Soft Tissue

Considerations on Treating Hand Injuries

Type of injuryThe patient

Associated diseasesSocioeconomic factorsAbility to cooperate with treatment planMotivation to get well

Managing the patientRecognizing the injuryMaking the proper diagnosisInitiating the appropriate care plan

Referrals

Emergent referralsOpen fracturesFractures with neurovascular compromiseSignificant soft tissue injuryIrreducible dislocations or fractures with significant deformity

Referrals

Urgent referrals (next day or two)Closed flexor or extensor tendon injuriesDisplaced, angulated, or malrotated closed fracturesCarpal bone and distal radius fractures

History

Complete historyHand dominanceOccupationAvocationsCircumstances surrounding the injury

When and whereMechanism of injury

Location and character of painNumbness or tingling

Radiographs

Examine prior to ordering filmsStress views are useful in demonstrating injuries not present on plain viewsOccasionally 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 involvedOpen or closed fractureIntraarticular or extraarticularWhether the fracture is shortened, displaced, malrotated, or angulatedFracture 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 dislocationRadial vs ulnar dislocationCan have a combination of two

Complications

By far, the largest potential problem with any hand or wrist injury is stiffness.Soft tissue complications:

Tendon adhesionsCapsular contractures

Fracture healing timeHand: 3-4 weeksDistal radius: 5-7 weeks

Complications

Bony complications:MalunionAngulationMalrotationShorteningIntra-articular step-offNonunion 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


Applied AnatomyExtensor and flexor tendons insert into the base of the distal phalanxRoutinely not a deforming fracture


Mechanism of Injury

Crush injurySudden extension against a flexed finger (rugger jersey)Sudden flexion against an extended finger (baseball hitting end of extended finger)


Associated Injuries

Nailbed lacerationsNail plate avulsionSkin lacerationsSubungal hematoma

History and Physical Exam

Check both flexor and extensor functionDocument sensory exam


Radiographs2 – 3 views to look for fractureUse hot light if needed

ClassificationLongitudinalTransversecomminuted

TreatmentNon-displaced or minimally displaced can use variety of splints

Immobilize the DIP only

Reduce displaced fracturesOpen wounds may need more definitive treatment


OutcomesCold intoleranceTip sensitivityStiffnessNailplate irregularities

When to referOpen fractures in need of nail bed repairLarge skin lossSuspected flexor or extensor tendon involvement

Nailbed Injury

Nailbed lacerations need to be repaired

Use 6-0 absorbable to repair matrixPrevents nail growth problems

Reinsert nail and secure

Subungual Hematoma

Results from blunt trauma to nailVery painfulRelieved by

CauteryHeated paperclip18g needle

Subungual Hematoma

Clean with alcoholInstrument of choicePierce nailGauze for 24 hours

Mallet Fingers(soft tissue and bony)

Applied AnatomyTerminal extensor tendon inserts into the dorsum of the distal phalanx

Mechanism of injury

Occurs with a sudden flexion force against an extended digitResults in flexion deformity of the DIP joint



Pain and deformity of the DIP joint after bumping the end of the fingerInability to straighten the end jointTest for tendon function


Radiographs2 views looking for dorsal avulsion fragmentMay be negative

ClassificationSoft tissue (- x-ray)Bony (+ x-ray)

FleckDorsal articular pieceSubluxation of DIP joint


TreatmentClosed reductionContinuously 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 AnatomyFlexor digitorum profundus tendon inserts into the base of the distal phalanx


Mechanism of Injury

Hyperextension against a flexed DIP jointRelatively uncommon, but devastating is missedRing finger most commonly involved


Associated injuriesNone

History and Physical ExamPain on volar surface of digit

May extend into palm with eccymosis

Cannot flex tipResting hand has extension of DIP jointNo active flexion


RadiographsDIP to look for avulsion, but also hand to look for retracted segmentMost are normal

ClassificationPure tendon avulsionBony avulsion


TreatmentShould be splinted and referred in a semi-urgent fashionSurgery is required

OutcomesResults correlate with delay in treatment

Early do wellPostoperative hand therapy is important

Middle and Proximal Phalangeal Fractures

Applied AnatomyThe central slip inserts into the proximal dorsal middle phalanxThe flexor digitorum superficialis (FDS) inserts into each side of the base of the middle phalanx


Applied AnatomyIntrinsic muscles of the hand act to flex the MCP joints and extend the PIP and DIP through the actions of the lateral bands


Mechanism of Injury

Direct blow to the digit or a twisting injury

Associated InjuriesOpen injuriesLacerations to tendons or neurovascular bundlesImportant to evaluate for DIP injuries


Evaluate for malrotation

Subtle fractures on x-ray can have significant malrotation when flexed


Radiographs3 views

Evaluate joint proximal and distalSpiral fracture may appear on only 1 view

ClassificationLocationMidshaftCondylarIntra-articular

PatternSpiralObliqueComminutedTransverseAvulsion


TreatmentMost can be treated non-surgically

Protect range of motionBuddy tape

What to referDisplaced, malrotated, joint involvementComminuted, spiral, and oblique are unstable

Stable nondisplacedSplint 8-10 days followed by buddy tapeFollow-up x-ray 8-10 days to ensure no displacement

Boutonniere

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

Boutonniere

Applied AnatomyThe 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 furtherTension pulls the DIP joint into extension

Boutonniere

Mechanism of InjuryAcute flexion force to PIP jointPIP does not immediately fall into a flexed positionSeveral weeks after the injury the digit assumes a buttonhole posture.Other mechanism include PIP dislocation and central slip lacerations


Pain and swelling about PIPInability to fully extend PIPDIP flexion is limitedLongstanding cases

PIP flexionPassive extension not possible

Boutonniere

RadiographsMost often negativeOccasionally small fragments dorsally off middle phalanx

ClassificationsAcuteChronic

Stiffsupple

Boutonniere

TreatmentIf not sure of central slip, assume it is and splint the PIP in full extensionAcute boutonnieres

4 weeks of full extension splinting of PIP with active DIP flexion exercisesOccasionally need surgery

Chronic boutonnieresHand therapyPossible surgery

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

Most common orthopedic hand injury that can result in long-term digital stiffness and impairment


Applied AnatomyPIP is a hingeLigaments along palmar aspect - volar plate

Prevents hyperextension

Related to volar plate are collateral ligaments


Applied AnatomyEach 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


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 InjuryIf the skin tears open, it is an open dislocation


Joint swollen and tenderTest collateral ligaments to ascertain partial vs complete


Radiographs2 views to check for fracturesPost-reduction films if done

ClassificationsI – do not compromise stabilityII – partial compromise, at risk for complete disruptionIII- complete disruption, can compromise stability


TreatmentEarly 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

OutcomesThese 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 stabilityBecause of its location, it is particularly vulnerable to injury


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)


Moderate swelling and eccymosis over ulnar side of MP jointIn complete tears stress testing of UCL shows a poor endpoint


RadiographsTypically negativePossible avulsion fragment off proximal phalanx or metacarpal

TreatmentIncomplete – non-operatively (splint)Complete - surgically

Bennett's Fracture Dislocation

Most frequent of all thumb fractureDescribed in 1882 by Dr. Edward BennetIt is a fracture dislocation, intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb


Mechanism of Injury

Results from axial blow directed against the partially flexed metacarpal; (ie. from fist fights)


Moderate swelling and eccymosis over the CMC jointPain with ROM or palpation


RadiographsOblique fracture line with a triangluar fragment at ulnar base of metacarpalTriangular fragment remains attached to trapezium w/ proximal displacement of the metacarpal

TreatmentImmobilizationReferral for surgical pinning

Infections of the Hand

Conditions That Mimic Infection

GoutPyogenic granulomaAcute calcificationForeign body reactionHerpetic whitlowMetastatic lesions

PseudogoutRheumatoid arthritisGranuloma annulareLocal reactions

Paronychia

Infection localized to the proximal and lateral skin folds of fingers and toes

Staph aureus Group A or D StrepPseudomonasGram-negative bacteriaanerobes

Paronychia

Clean area with alcohol or betadinePerform digital nerve blockArea of greatest fluctuanceRemove pusDebride nail if necessaryAntibioticsDressing

Paronychia

Felon

Abscess of distal pulpResults from penetrating traumaBacteria trough eccine sweat glandsPulp is tense and tenderSignificant edema

Felon

Fish-mouth incisionHockey-stick/ J-incisionTransverse palmar incision

Questions?

Documents

The Hand Bucky Boaz, ARNP-C. Examination of the Upper Extremity A detailed history should include: Patient’s age Handedness Occupation Hobbies Chief complaint