sign in sign up
<<
Home , Hand injury

26 EMN ■ November 2011

Tendon of the : InFocus Flexor Tendon

By James R. Roberts, MD laceration, can mislead even a hand sur- As with most issues in emergency Part 1 in a Series geon on the first examination. This is medicine, an accurate history is the first mergency physicians are frequently especially true of flexor tendons. Even step in understanding the extent of any Ecalled on to evaluate hand injuries uncover real problems on the first visit. a significant extensor tendon can injury. The author suggests allowing the that may harbor an injury to flexor NPs and PAs in your fast track are also be missed unless attention is paid to the patient to describe the mechanism of in- tendons. The hand is anatomically com- held to this standard. Hopefully these details of the examination. Fortunately, jury, including position of the hand at the plex and its function complicated, ren- colleagues are also cognizant of the is- the emergency physician’s job is usually time of the injury (closed, open, fist), and dering this somewhat unforgiving sues, perhaps even more so than most infinitely easier than that of the hand the time of injury. Listen to the patient’s of a missed diagnosis, incorrect initial physicians who greatly respect hand surgeon who has to deal with delayed description of the object used to produce treatment, delayed definitive therapy, injuries, and appreciate the nuances. care, reconstruction, finicky tendons, pa- the injury, the possibility of foreign bod- and even splinting snafus. Leaving a in the hand tient compliance, and the rigors of hand ies, and whether the injury occurred in a Once deep hand structures are seri- or missing a tendon, , or vascular rehabilitation. clean or dirty environment. The patient ously injured, it may be difficult ever injury is relatively easy when one is jug- should be allowed to voice subjective to regain full function, certainly not gling patients with complicated cardio- A Flexor Tendon Injury to the motor and sensory changes, a perceived without significant time and energy on vascular, neurologic, traumatic, or res- Hand decrease in strength, or any other prob- the part of a compliant and motivated piratory emergencies. A quick glance, a Euhara D lems with movement or sensation prior patient and access to a physical thera- cursory examination, or a truncated ex- Emerg Med Clinics NA to the physician’s examination. The au- pist and hand surgeon. While EPs rarely planation to the patient about potential 1993;11(3):625 thors emphasize that a great amount of perform definitive repair of complex problems and the need for follow-up data concerning possible tendon injuries hand injuries, we are on the forefront of are common pitfalls for even a gray- Not much has changed in the ED ap- can be obtained by a detailed history and diagnosis, and must have the acumen haired professor. Each hand laceration proach to hand injuries since I was an knowledge of the mechanism of injury to diagnose obvious injuries, the perspi- should be approached with the notion intern 40 years ago. It’s still a bread-and- prior to actual examination. cacity to intuit potential problems, and that there is something wrong until butter problem. This is an excerpt of a Ask the patient if he thinks he has a the wherewithal to limit morbidity and proven otherwise. Physician hubris, in- longer chapter on flexor tendon injuries serious hand injury, if the work, initiate proper referral. attention to detail, a hurried evaluation, that appeared in the Emergency Medi- and if there is a chance for a retained In the long run, educated patients or a less-than-ideal patient often lead to cal Clinics of North America. Other foreign body or broken bone. Prior to expect a hand surgeon to be involved problems for doctor and patient. excellent reference articles include the touching the hand, noting the posture in any complicated hand injury. Many The next few columns will discuss Orthopedic Clinics of North America of the hand in a resting position can be indigent patients rely on the ED to the diagnosis and treatment of flexor (1992;23[1]:129) and Emergency Med- helpful to intuit flexor tendon injuries. provide most of their care. While all pa- and extensor tendon injuries. Few clini- ical Clinics of North America: Or- The natural attitude of the hand is one tients usually understand that a major cians would miss a completely lacer- thopedic Injuries (1999;17[4]:806). All of slight flexion of all , and if even hand injury will be a frustrating struggle ated extensor or flexor tendon, assum- major texts reiterate the party line con- a single does not assume the nat- to regain normal function, they rarely ing that tendon function was adequately tained in this article, but few address ural flexed position, some type of ten- forgive any clinician’s failure to at least evaluated, but a major partial tendon the practical matters and nuances of ED don injury is immediately suspect. The do a complete exam, listen to them, injury, often initially clandestine in the care that can only be learned through flexor digitorum profundus (FDP) and anticipate potential problems, and depths of a swollen, bloody, and tender experience (or mistakes). the flexor digitorum superficialis (FDS) tendon of each finger must be tested in- dividually. If the distal phalanx cannot be flexed against resistance, an injury to the FDP is likely. If the PIP can- not be fully flexed against resistance, an injury to the FDS is suggested. The prescient, sagacious, and likely previously mistaken clinician knows that partial flexor tendon injuries may simply be impossible to detect on the first examination. Clues to the presence of a partial tendon injury are subjective weakness voiced by the patient, pain upon flexion, or weakness when the digit is flexed against resistance. Other- wise, the fingers may seem to work just fine. should be anesthetized prior to complete examination. Obvi- Lydia Roberts Lydia Roberts ously a complete neurologic evaluation The function of the flexor digitorum profundus tendon (left) and flexor digitorum superficialis tendon (right), the latter also called the flexor digitorum subimis, in each finger are tested separately by isolating the respective tendon’s is performed prior to local anesthesia. function. The specific procedure is documented on the chart. “Tendons intact” is a standard phrase used, but this is Get familiar with the term two-point probably not sufficient to convince anyone that a sophisticated exam was performed. Better to document “individual discrimination. Good lighting, a blood- FDP/FDS function normal.” Naming the specific tendons tested certainly makes you look like a pro; you even know less field, adequate time, and good ex- specific anatomical terms! To test the FDS tendon, place the dorsum of the hand on a flat surface, hold all fingers posure of the are required for an in extension except the one being tested, and ask the patient to flex the proximal interphalyngeal joint. To test the FDP, check for fingertip flexion by immobilizing the rest of the finger. Also test flexion against resistance, looking for ideal examination. A tourniquet can be weakness. Although patients are always reluctant to move injured digits, weakness may be a sign of a partial tendon used around the finger. For the hand, laceration. a BP cuff can be inflated above arterial

LLWW-EMN_NOV-11-0907-Map-BP.inddWW-EMN_NOV-11-0907-Map-BP.indd 2626 110/21/110/21/11 4:364:36 PMPM InFocus November 2011 ■ EMN 27

pressure. This is painful, but can usually charts. Make injury now, but I informed the patient be tolerated for the time it takes for a an electronic that they are not always diagnosed on proper examination. macro that de- the first visit, so we have scheduled The authors stress that the patient scribes you best a recheck in three days.” Document has to cooperate for the examination hand exam ever, the actual date of follow-up and the to proceed as planned. If the patient is and use it if ap- time, place, and consultant’s name and uncooperative or otherwise unable to propriate. I urge number to be overly paranoid, if not participate fully in the examination, a va- the clinician to pristine. Document that you did not riety of options exist. The author of this note carefully give any 100 percent guarantees. paper suggests an examination under the positives anesthesia, but this is often not practical and especially Testing Functional Status or generally considered standard. the negatives. Examine each finger individually, with The very inad- specific testing for the profundus and Comment: Flexor tendon injuries should equate “NVT superficialis tendons. Let the chart not be taken lightly. Special attention intact” does lit- know you are familiar with the specific is required to prevent long-term seque- tle to convince tendon names, a nice erudite touch. lae. Assuming that function is evaluated, anybody that a Lydia Roberts Many patients who have painful inju- Testing two-point discrimination is an excellent way to assess few clinicians would miss a completely proper exami- digital nerve integrity. Simply because of the location of ries are reluctant to move digits, but ruptured tendon. Unfortunately, many nation was per- this laceration, a digital nerve injury should be immediately usually some motion can be detected. flexor tendon injuries are often quite formed if that is suspected. To make sure the patient understands the nerve Motion limited by pain can indicate a subtle, and can fool even the most ex- all that appears testing concept, use an uninjured finger as a control, with the normal tendon or one that is 90 percent perienced EP. Entire books have been on the record. patient closing his eyes. A straightened paper clip is a readily lacerated. Never conclude that a patient available testing device. Perform the test with a single point written about flexor tendon injuries, but Although this and with two points, about 4-5 mm apart. If the patient can who says his finger won’t work is in I will address only the evaluation of discussion con- consistently distinguish the two points of a paper clip distal to too much pain, too drunk, or just being flexor tendons secondary to penetrating centrates on the laceration, the digital nerve is unscathed. Do not place the uncooperative to move it. trauma. flexor tendons, two prongs on the distal finger fat pad, but rather along the side If a finger doesn’t move, regardless No clinician would disagree that also consider to isolate only one digital nerve, and avoid crossover sensations of the apparent severity of the injury or from the opposite digital nerve. The paper clip can also be mechanism of injury and a complete the fact that gently stroked over the skin to test light touch. The chart should an assessment of the cooperation of the physical exam are paramount to proper tendon injuries reflect “light touch/2 PD intact.” patient, one should assume a complete medical care. I urge you to look at the often accom- tendon laceration. With a little bit of last chart of a simple hand laceration pany nerve and vascular injuries. more subtle findings can be uncovered coaxing, even a very painful injury can that you treated to see if your charting by an x-ray. Almost all glass is visible on demonstrate some movement. Even if was up to snuff. Assume that a previous History plain x-rays, even very small pieces. At a tendon is 80 percent lacerated, how- patient had a partial tendon laceration, The mechanism of injury is an important least two projections should be taken to ever, it will provide some function, and but a complete tendon rupture was part of the ED record. Many patients remove the possibility of overlying bone many will appear surprisingly normal. noted on suture removal. Critically read will not be able to inform the doctor obscuring a small fragment of glass. For If tested against resistance, however, the chart to see if your documentation about all specifics. If a patient can’t the patient who fell on an outstretched weakness may be apparent. Certainly demonstrated careful, conscious, and tell you whether the hand was flexed hand in a field, stuck his hand in the it is not out of the question and prob- prudent evaluation and treatment in the or opened, such information should be garbage can, or punched out a window, ably prudent to administer analgesics ED, and one that would convince the documented. At least you asked. It’s an x-ray is mandatory unless the lacera- or local anesthesia if the patient is in so patient that you made a good faith ef- very important to ask the patient and tion is obviously superficial. Plain radio- much pain that you cannot even begin fort to evaluate fully his injury at 2 a.m. document on the record if he thinks he graphs have a high sensitivity for detect- to examine flexor tendon function. The vast majority of clinicians give has a serious injury, if the hand or fin- ing most foreign bodies. (Ann Emerg cursory attention to etiology. “Cut with gers all work OK, if he thinks there is a Med 1996;28[1]:7.) Partial Injuries knife” is a triage complaint, not a phy- retained foreign body, or a broken bone. Most gravel, pencil, graphite, and In most cases, a partially lacerated sician history. I almost never see the You would be surprised how many pa- other foreign bodies that should not be flexor tendon will escape detection un- patients’ own words quoted about their tients with missed foreign bodies of the left in the hand are visible by radiograph, less the tendon injury can be fully visu- perception of sensation, function, or hand or ruptured tendons testify that but wood and aluminum can be occult. alized or the clinician maintains a high possibility of foreign body. Believe them: the doctor never asked questions, that For those who naively believe that they degree of suspicion. Succinctly stated, if they can’t move it, especially after a they specifically told the doctor that can accurately suspect a foreign body it is simply impossible to diagnose all pain pill or local anesthesia, it’s likely they thought glass was in the wound, or by history or can find foreign bodies in partial flexor tendon injuries accurately true. If they think something is still in there was numbness, or a finger did not wounds by a careful examination, you on the initial ED visit. The most com- the wound, believe them. A huge chunk work right. Two years later, they claim are not that smart. I urge the hubris-laden mon clinical error is to assume that of glass can be a denizen of the palm that the clinician ignored their specific clinician to read an article by Steele et al. full range of motion guarantees an un- with few outward clues. I try to docu- complaint or simply failed to look. Un- (Am J Emerg Med 1998;16[7]:627.) In scathed tendon. Partial injuries often ment that “the patient does NOT think less pertinent negatives are charted, it’s that prospective study, retained glass progress to complete rupture at follow- there is a foreign body or nerve injury.” difficult to counter patient accusations was found by x-ray in 16 of 146 wounds up or suture removal, or with the first In my experience (usually with litiga- that the evaluation was hurried or lax. that were deemed free of foreign bod- forceful grip, often complicating repair tion), it’s almost unheard of to encounter Foreign bodies are notorious for their ies by the patient’s history and patient or delaying definitive intervention. documentation of the specifics of such clandestine presence. I always chart perception! Eight foreign bodies were Some subtle clues may suggest the things as the attitude of the hand prior that “no foreign body was suspected seen on x-ray in 165 wounds when the presence of a partial tendon lacera- to evaluation or the results of testing by the patient,” and that none was seen physician’s wound exploration was neg- tion. The first clue is the patient’s own against resistance. As a final check, see by me. At least I asked and looked. Our ative. Puncture wounds should always description of hand and finger activity. if that old chart documented response computerized discharge instructions be most suspect. Listen carefully to the patient. The next to light touch and two-point discrimina- caution patients that not all foreign bod- Knife blades can break off in , red flag is weak flexion against resist- tion. Finally, evaluate your follow-up ies or other injuries can be diagnosed on and extremely large and nasty foreign ance. If you don’t test a tendon against instructions and splinting and bandaging the first visit, but there is little solace in bodies can be embedded deep in a hand resistance, you will not appreciate this techniques. that boilerplate disclaimer. wound, which may initially fool patient subtle abnormality. Merely asking the To produce the best possible docu- and clinician. I don’t know whether it patient to flex the finger while you ment, one should be crystal clear about Radiography always helps, but maybe the conversa- watch doesn’t always equate to a com- charting etiquette. I find templated charts Obviously, radiographs are used when tion and chart should read: “I don’t plete evaluation. A completely intact to be far superior to freeform handwritten there is a possibility of bony injury, but see/suspect a foreign body or tendon Continued on next page

LLWW-EMN_NOV-11-0907-Map-BP.inddWW-EMN_NOV-11-0907-Map-BP.indd 2727 110/21/110/21/11 4:364:36 PMPM 28 EMN ■ November 2011 InFocus

FLEXOR TENDON puncture wounds of the palm should tendon injury, be viewed as potential problems, with is first a phone Suggested Electronic Record Macro for Continued from previous page the understanding that you may not consultation Hand Examination be able to evaluate fully the extent of with an appro- Default History: flexor tendon is strong, and should not the damage on the first ED visit. The priate specialist. give way with an opposite force. If the prudent clinician will tell every patient Of course, care- *Detailed history includes ______. patient says he can move his finger but with a puncture wound of the palm fully document- *Position at time of injury ______. it feels weak, assume a partial flexor that there may be a partial tendon ing his advice *Occurred_____ hrs prior to admission. tendon injury. laceration that requires further evalu- and follow-up *Environment of injury ______. One frantic ED visit may not be ation when the pain and swelling have requirements is *Care prior to ED visit ______. enough for total care. Because no mere subsided. If you are wrong, so what? a given. I always *Pt. denies sensation/concern for fracture, foreign body, mortal can always detect a 50-90 per- give the consult- excessive debris, numbness/tingling of fingers, weakness cent laceration of a deep flexor tendon, Consultation and Referral ants the option of fingers, or difficulty moving any joint. proper initial wound care, splinting, Most articles written by hand and or- of performing and timely follow-up are the patient’s thopedic surgeons naively state that their own exami- *Prior hand/finger problems ______. and EP’s best friends. Let someone else emergency physicians should immedi- nation, but they Default Exam: make another assessment a few days ately refer all questionable flexor tendon rarely take me up *Hand/wrist/fingers held in normal resting position. later when the anxiety, rage, alcohol, problems to a hand surgeon. This sound on it. *Flexor tendons: Full active/passive ROM, and normal and swelling have dissipated. good on paper, but I have yet to meet When they do flexion of all superficialis/profundus tendons against Another suspicious finding is pain at a hand surgeon who will immediately and come to the resistance. the area of the wound when flexion is come to the ED to comply with their same conclusion, performed. Cut edges of tendons may own mandate. Certainly a hand surgeon the course of ac- *Extensor tendons: Full active/passive ROM, and normal irritate delicate tissues and don’t always cannot sober up an intoxicated patient tion is usually the extension of all fingers against resistance. glide well in the tendon sheath, so pain nor wake up an unconscious one. Un- same as it would *No FB seen on exam consisting of ______. with active flexion or passive extension cooperative patients will not move the have been over *Normal light touch/sharp/two-point discrimination of may be subtle signs of a partial tendon hand for a guy in an Armani suit any bet- the phone. Don’t all fingers. injury. Also, a partial tendon laceration ter than for a harried ED doc in scrubs. attempt to handle *Tendon visualization ______. may result in an abnormal resting pos- I usually get the instructions to clean, equivocal cases Attention to detail: Most EPs do not document their ture of the hand. Somehow the body close, and splint the injury, give antibi- on your own. Al- history or exam anywhere close to this detail, and just seems to know that a partially lac- otics, and send them to the office. Try ways make the this is not intended to define standard of care. It is an erated tendon should be rested and not to get an expeditious hand surgeon of- phone call. Relay attempt to strive for your best chart ever, peppered with stressed. Finally, neurologic or vascular fice visit for a patient who grabbed an your findings and paranoia and an attempt at excellence in charting that deficits are guilt by association, and equally drunk opponent’s knife in a bar concerns, and can, in the course of normal ED stresses, be a laudable such findings may signal an injury deep fight three days ago. My hospital does fully document albeit uncommon-to-achieve goal. Although not cur- or extensive enough to raise suspicion not even have a hand surgeon on staff! the interaction. rently standard of care, the templated electronic medical of collateral tendon damage. And orthopedic surgeons in Philadel- The best reason record prompts the busy clinician to document details of phia have largely abandoned all hand to persuade the the history and exam to an extent not usually performed . Today, many hand surgeons hand surgeon to Wound Exploration in standard practice. The macro document can be modi- It is usually quite simple to extend a simply will not take ED call. I don’t come to your ED fied to fit individual style, but includes the majority of laceration of the dorsum of the hand or blame them. Who wants to take care of is to teach you information required to memorialize your most perfect fingers, and simply view the superficial a litigious uninsured patient who will the finer points of examination. extensor tendons throughout full range not keep on the splint, blows off a $4 the hand exami- of motion. Flexor tendons are deep Walmart prescription for Keflex, fails nation and to quiz structures of the hand, however, and to show up in the office for free care them about follow-up options. If you routine antibiotics for any soft tissue are not readily visible to the clinician’s as planned, and will not even consider see the rare hand surgeon in the ED, lacerations, except perhaps under the eye. I could find no great insight in the physical therapy. don’t let him get away without picking standard circumstances of immunocom- medical literature concerning ED evalu- Little will be accomplished by a man- his brain to the point of being annoying. promise or obvious infection. Obviously, ation of puncture wounds of the hand, dated hand surgeon evaluation in the antibiotics are not a substitute for proper especially about extending the lacera- ED. An EP can ask the patient to flex the Follow-up wound irrigation, removal of foreign tion and attempting to visualize deep hand as well as a specialist, and there is No special follow-up is required for the bodies, or immobilization. flexor tendons. I would advise against no need for a hand surgeon to repeat the finger injury where flexor tendons can My general rule is to splint it when in extensive attempts at visualizing flexor equivocal or abnormal examination that be visualized throughout the full range doubt. Few puncture wounds or lacera- tendons of the hand if it requires deep has been done in the ED. Maybe the hand of motion and a partial tendon injury tions of the palm leave my care without dissection or other aggressive wound fellow will be available, but there is no can be absolutely excluded. Standard some sort of splinting designed to protect manipulation. One simply has to real- need for a busy surgeon to be there in an wound preparation, suturing, and dress- tendons and limit pain and movement. ize that the emergency department is hour to repeat your examination. Local ings are usually appropriate. For the Next month’s column will discuss not the place to muck around in deep customs vary, but most surgeons will patient with a deep puncture wound of the uncooperative patient and definitive palmar spaces. If the wound is open, not routinely take patients from the ED the hand and for those with suspicious, ED care. good local anesthesia and a BP cuff to the OR merely to explore a laceration. equivocal, or abnormal examinations, it tourniquet can allow for good inspec- This is especially true if the wound is old, is best to treat the injury as a potential tion and adequate wound cleaning. contused, swollen, or dirty. Tendon inju- partial tendon laceration that will rup- Dr. Roberts is I hate palm puncture wounds; most ries are rarely an emergency; it’s all about ture in a few days. the chairman of cannot be cleaned to normal wound the ED care and follow-up. No data support the routine use of emergency med- care standards. Some are done with Most specialists prefer to delay defin- prophylactic antibiotics for penetrating icine and the cooking utensils that carry bagel parts, itive care of even known flexor tendon trauma producing deep punctures or director of the clam juice, or meat. One can slightly lacerations for a few days until swelling, lacerations of the hand, but many clini- division of toxi- extend the superficial margins of a infection, and bleeding can be control- cians will prescribe three to five days of cology at Mercy Catholic Medical puncture wound, but do not place an led or abated. Partial tendon lacerations an antistaphylococcal antibiotic. This is Center, and a professor of emer- irrigation catheter deep in a puncture usually do well with identification and not usually a MRSA issue. Inoculation gency medicine and toxicology at wound and expect forced irrigation splinting only. My approach to a ques- of flexor tendon sheaths can produce the Drexel University College of to help. Often all that does is dissemi- tionable flexor tendon injury in the ED, nasty infections, so I suppose it’s reason- Medicine, both in Philadelphia. nate debris or swell up the palm. All or even the obvious complete flexor able. There is no standard that mandates

LLWW-EMN_NOV-11-0907-Map-BP.inddWW-EMN_NOV-11-0907-Map-BP.indd 2828 110/21/110/21/11 4:364:36 PMPM