Upper Limb Injuries

12/14/20

Upper limb Injuries

www.belmatt.co.uk

1 Jeshni Images Amblum Pearsons Education

By the end of the session student will: - Be able to identify anatomical structures of the upper limb - Develop skills in examination of elbow, wrist and hand Learning - Recognise functional importance - Recognise common pathology related to above Outcomes structures. - Be able to assess and manage minor injury presentations of the upper limb

Jeshni Images Amblum Pearsons Education History

• Past history : Medical/ Surgical

• OPQRSTU/ SOCRATES

• Drug History

• Social History

• Other

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Jeshni Images Amblum Pearsons Education History

• Pain • Swelling • Stiffness • Deformity • Weakness • Instability • Neurovascular Changes • Loss of Function

Jeshni Images Amblum Pearsons Education Physical Examination

• Compare limbs

• Look

• Feel

• Move - Active - Passive - Resisted

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Views of Elbow

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Fat pad signs

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Common fracture in FOOSH usually Radial adults head/neck Assure proper alignment of fractures Detection may head on require oblique capitellum view (radiocapitellar line)

Radial head fracture

State location and function of Trochlea structures below: Elbow Capitulum Olecranon fossa Joint

Medial Lateral epicondyle epicondyle

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Supination & Pronation

Supination Pronation

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Muscles - Elbow

• Pronation • Pronator Teres • Pronator Quadratus • Brachioradialis

Anterior Aspect of Elbow

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EXTENSORS FLEXORS

Case Study

A 32 year old woman who was learning to play tennis practised daily for about 2weeks. She reported to her coach that she felt pain over the lateral region of her elbow that radiated down her forearm Familiar with this complaint in beginners he asked her to hold the tennis racket and extend her hand at the wrist. She felt no pain until he resisted extension of her hand. She pinpointed the area of most pain over her lateral epicondyle. Pressure on this area made pain worse. Intense pain was also felt when the coach compressed the common extensor tendon.

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Lateral Epicondylitis

• Tennis elbow

Lateral Epicondylitis

Golfers or tennis elbow Repetitive use of superficial extensor muscles of forearm. Pain over lateral epicondyle and radiates down posterior surface of forearm. Advise stop repetitive movement, rest and anti inflammatories. Later physio.

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Nerve supply - Sensory

q Sensory

q Digital nerves: Each finger has two which run on the volar aspect of each digit laterally. Each supplies half of the finger.

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• Median nerve: passes through the carpal tunnel. It supplies the thenar muscles of the Nerve thumb. Supply - • Ulna nerve: Passes through ulna side of wrist. It supplies all the interossei , 2-3 Motor lumbricals and hypothenar muscles .

• Radial : No motor function in hand

Case Study

• A 12 year old boy fell off his skateboard hitting his right elbow on the sidewalk. Because he was suffering considerable elbow pain and numbness on the right side of his hand his mother brought him to hospital. He tells you he fell on his funny bone and right away his little finger began to tingle. • Exam : The boy shows no response to pinpricks of his little finger and the medial border of his palm. He is unable to grip a piece of paper placed between his fingers. • X-ray shows considerable displacement of the epiphyses of the medial condyle of the humerus and possible nerve stretching and compression are evident.

Jeshni Images Amblum Pearsons Education Questions

• What nerve was probably injured? • • Explain the numbness of the boy’s fifth digit and his inability to hold a piece of paper between his fingers?

• Drawing on knowledge of degeneration and regeneration of nerves make an attempt to forecast the probable degree of recovery of the boy’s motor and sensory functions that may occur.

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Case Study • A 52 year old carpenter visits his general practitioner(GP) with severe ‘pins and needles’ sensations in his right hand which also involved the palmar surface of his thumb and lateral two and a half fingers. He told the GP that the pain was becoming progressively worse and often awakened him during the night. He also experienced difficulty using his hand tools and buttoning his shirt. • Exam - No objective impairment of sensation in the hand noted. However, slight weakness of the thenar muscles present. The GP told the patient he has a nerve entrapment syndrome.

Case Study

• A depressed 15year old girl who had slashed her wrists with a razor blade attends the emergency department. The moderate bleeding from her left wrist was soon stopped with slight pressure. The small spurts of blood coming from lateral side of her right wrist were more difficult to stop. O/e - Left hand - movements normal and no loss of sensation. Right Hand - Two superficial tendons and a nerve were cut, she could adduct her thumb but could not oppose it and she had lost some fine control of movements of her 2nd and 3rd digits and she also experienced anaesthesia over the lateral half of her palm and digits.

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Superficial Flexors Flexor Tendons Deep Flexors of Forearm Located in anterior compartment and supplied by median and ulna nerve

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Olecranon Bursitis

Another view?

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Fall on elbow with concentrated triceps contraction pulling elbow apart. Often avulsion fracture Fracture of the Look for posterior fat pad as Olecranon positive. Broad arm sling if undisplaced. Surgery if avulsion fracture because of traction of triceps muscle.

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Dislocation of Elbow

Mechanism of injury

• Fall on outstretched arm • Hyperextension • Severe twist with elbow in flexed position • Blow to posterior humerus with fixed radius/ulna

Signs & Symptoms

• Ulna and/or radius displaced posteriorly, w/ olecranon process sitting posteriorly • Severe swelling/bleeding • Disability • LOM • Extreme pain

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Wrist Anatomy

• Bones • Quiz - What bones comprise the wrist? • Joints • Quiz - What joints comprise the wrist?

37 Jeshni Images Amblum Pearsons Education Anatomy of the wrist

• Bones - Interosseus membrane - Distal radius - Distal ulna - Carpal bones • Arteries and Veins • Nerves • Muscles

Carpals

Scaphoid (boat shaped) Lunate (moon shaped) Triquetrum (3 cornered) Pisiform (pea shaped) Trapezium Trapezoid Capitate (head shaped) Hamate (hooked)

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Anatomical Snuffbox

Extensor pollicis longus (medial side)

Medial Abductor Extensor Lateral pollicis longus pollicis brevis (lateral side) (lateral side)

The Normal Wrist

• AP and Lateral are the standard views • AP Radial Styloid should be more distal than Ulnar styloid

• Lateral Radial articular surface should have 50 of palmar angulation • Distal radius, Lunate and Capitate should be in alignment

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Wrist and Hand Anatomy

• Nerves/Vessels –Radial & ulnar artery and veins – Radial, ulnar, & median nerves • Carpal Tunnel - – Flexor Tendons - 9 – Median Nerve

Wrist Injuries • Strains • Onset usually acute – FOOSH or Overexertion • S/S: Active ROM limited • Wrist Ganglion • Herniation of the joint capsule or synovial sheath of a tendon.

Wrist Injuries

• deQuervain’s Disease - thumb/wrist • stenosing tenosynovitis of the extensor pollicis brevis and abductor pollicis longus. • S/S: crepitation, tenderness, strength loss. • Special Test: = Finkelstein’s test • Tx: RICE, NSAIDs

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Carpal Tunnel Syndrome

• Carpal Tunnel Syndrome • Compression of median nerve • Fibrosis of the synovium of flexor tendons secondary to tenosynovitis • MOI: Insidious onset with repetitive wrist movement (and finger movement); Acute onset with trauma; Progressive degeneration • S/S: numbness palmar thumb, index, middle fingers, dull ache, weak finger flexion (grip). May worsen with sleep. • Poor posture may predispose. • Special Tests: Tinel’s sign and Phalen’s • Tx: Conservative (PRICE, NSAIDs) and Surgical

Nerve Injuries

• Biker’s Palsy • Ulnar nerve compression • Ulnar nerve passes through tunnel of Guyon between pisiform and hamate. • MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar deviation • Tx: Padding (Gloves), Ice, NSAIDs • Drop Wrist Syndrome • Radial nerve compression at elbow • Inability to extend wrist and fingers

Wrist Injuries

• Wrist Fractures • Distal Radius/Ulna and Forearm Fractures • Onset is acute • MOI: Hyperextension or hyperflexion combined with rotatory motion – FOOSH • S/S: Deformity felt and observed; Crepitus • Evaluated Neurovascular status • Tx: Splint, Ice, Referral

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Wrist Injuries • Wrist Fractures • Distal Radius/Ulna • Colles’ Fracture • MOI: hyperextension-fall on outstretched • S/S: “silver fork deformity” - radius & ulna posteriorly • Smith’s Fracture (Reverse Colles) • MOI: hyperflexed • S/S: “garden spade deformity” - radius & ulna anteriorly

Wrist Injuries

• Wrist Fractures • Scaphoid - most common carpal • MOI: fall on outstretched hand • S/S: wrist aches, pain in anatomical snuff box, • painful handshake or with overpressure • Tx: Splint, Referral, Ice • Plain X-rays may not be enough • Immobilization (long and/or short) – 12 weeks • Risk: aseptic necrosis and non-union fractures • Preiser’s Disease • Surgery may be necessary

Wrist Injuries

• Wrist Dislocations • Radius or Ulna • Lunate is very common • MOI: force hyperextension • Dorsal displacement = perilunate dislocation • Palmar displacement (total rupture) = lunate dislocation • S/S: Deformity, 3rd Knuckle is lower (Murphy’s sign), Paresthesia of middle finger, weak finger flexion • Risk: Untreated or repeated trauma • Kienbock’s Disease • Decreased grip, pain with ulnar deviation, weak extension, pain with passive 3rd finger extension • Immobilization – 6-8 weeks; Surgery may be necessary

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While playing football you fall on your outstretched hand with your wrist deviated and abducted (deviated laterally). You thought you had sprained your wrist and paid no attention to the injury for 2 weeks. You later sought medical advice because the wrist pain was still present and getting worse. On Deep palpation of anatomical snuff box localised tenderness present. Most of the pain was on lateral side of Case Study wrist and worse with extension. X-ray Report: A small undisplaced fracture of the largest and most lateral carpal bone in the anatomical snuffbox

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Which carpal bones lie in the floor of the anatomical snuffbox? • The distal end of which forearm bone is also on the floor of this depression? • Which carpal bone bone would most likely be fractured? • Name the x-ray views that would have been requested? • How would you treat this fracture? • Why is a fracture of this bone difficult to detect. • If the fracture is not detected and rigidly immobilised, which serious condition may develop? • Explain why this may happen.

Clinical diagnosis initially

Typical mechanism

Tender anatomical snuffbox or The anterior scaphoid

Scaphoid Initial X-Ray may be normal

Follow up in 10 days

If missed may undergo avascular necrosis

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Scaphoid Fracture

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SCAPHOID

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• A 75yr old female slipped on a patch of ice landing on her open hand with forearm pronated. She tells you she heard her wrist crack and that it is very sore. • Exam : In addition to the swelling you observe an obvious bend just proximal to Case Study the wrist and that her hand was laterally deviated. X-ray shows a comminuted fracture of the distal end of a forearm bone is evident?

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Colles Fracture

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Fractures

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Anatomy Review

•Bones • Distal radius and ulna • Carpals metacarpals • Phalanges • Proximal • Middle • Distal

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1. Radial styloid 2. Scaphoid 3. Lunate 4. Triquetral 5. Pisiform 6. Trapezium 7. Trapezioid 8. Capitate 9. Hamate 10. Metacarpal 11. Proximal phalanx 12. Middle phalanx 13. Distal phalanx 14. ulna styloid

Bony Structure

•

• Carpal bones: • scaphoid (some) • lunate (lovers) • Triquetral (try) • Pisiform (positions) • Trapezium (that) • Trapeziod (they) • Capitate (can’t) • Hamate (handle) • • (right hand dorsum)

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Is it nerve?

What other test is common for nerve injury?

How else can you detect a neural injury? What test is this?

Is it muscle or tendon?

How do you assess the function of a muscle?

What are some distinguishing characteristics of a muscle injury?

What test assesses these structures?

Is it bone?

What is are distinguishing signs of a potential fractures?

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Observation

• Functional Evaluation • Range of motion in all movements of wrist should be assessed • Active, resistive and passive motions should be assessed and compared bilaterally • Wrist - flexion, extension, radial and ulnar deviation • Wrist “attitude” • How do the carpals and metacarpals align with the distal radius and ulna? • Is there symmetry? • How are those tendons looking? • Is there a palmaris longus? - 10% of population it is absent • Become a “palm reader”?

Observation

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• 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.

Examination of the Hand

Flexor tendon arrangement

Lumbricals

Dorsal Interossei 4 1 Palmar 3 2 Interossei

Extensor Hood, Long extensor tendon, and lateral bands

Finger flexor tendons

Unique finger Look at pulley system

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• Relaxed position of hand • Fingers slightly flexed • Relative shortness of finger flexors • Skin and Nail health • Discoloration, texture, hair patterns • Finger alignment • Tips of fingers should align with finger flexion • Hand abnormalities • Finger and metacarpal positioning • Muscle atrophy • Range of motion

Observation

• Carpometacarpal • Flexion (70-80o)/Extension • Abduction (70-80o)/Adduction • Opposition • Metacarpophalangeal • Flexion (85-105o)/Extension (20-35o) • Abduction/Adduction (20-25o) • Interphangeal joints • Thumb flexion (80-90o) • PIP flexion (110-120o) • DIP flexion (80-90o)

Range of Motion

Palpation

Metacarpals and joints • Collateral ligaments of MCPs

Phalanges and joints • Collateral ligaments of PIPs and DIPs

Thenar compartment • muscles

Thenar webspace • muscles

Central compartment • Palmar fascia and muscles

Hypothenar compartment • muscles

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Pathology

• Tendon pathology • Trigger Finger/Thumb • Mallet Finger • Boutonniere Deformity ’ • Jersey Finger Dupuytren s Contracture • Dupuytren’s Contracture • Swan Neck Deformity • Joint pathology • Sprains • Bony pathology • Fractures Swan Neck Deformity • Dislocations

Tendon pathology

• Trigger Finger or Thumb • Etiology • Repeated motion of fingers may cause irritation, producing tenosynovitis • Inflammation of tendon sheath (flexor tendons of wrist, fingers and thumb, abductor pollicis) • Thickening forming a nodule that does not slide easily • Signs and Symptoms • Resistance to re-extension, produces snapping that is palpable, audible and painful • Palpation produces pain and lump can be felt w/in tendon sheath • Management • Immobilization, rest, cryotherapy and NSAID’s • Ultrasound and ice are also beneficial • Injection

Tendon pathology

• Mallet Finger (baseball or basketball finger) • Etiology • Caused by a blow that contacts tip of finger avulsing extensor tendon from insertion • Avulses extensor digitorum at distal phalanx • Signs and Symptoms • Unable to extend distal end of finger (carrying at 30 degree angle) • Point tenderness at sight of injury • X-ray shows avulsed bone on dorsal proximal distal phalanx • Management • RICE and splinting in hyperextension for 6-8 weeks

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Tendon pathology

• Boutonniere Deformity • Etiology • Rupture of extensor tendon dorsal to the middle phalanx – bone passes through central slip • Forces DIP joint into extension and PIP into flexion • Signs and Symptoms • Severe pain, obvious deformity and inability to extend DIP joint • Swelling, point tenderness • Management • Cold application, followed by splinting in PIP extension and DIP flexion • Splinting must be continued for 5-8 weeks

• Jersey Finger Tendon • Etiology • Rupture of flexor digitorum profundus tendon pathology from insertion on distal phalanx • Often occurs w/ ring finger when athlete tries to grab a jersey • Signs and Symptoms • DIP can not be flexed, finger remains extended • Pain and point tenderness over distal phalanx • Management • Must be surgically repaired • Rehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re- rupture

Tendon pathology

• Dupuytren’s Contracture • Etiology • Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity • Signs and Symptoms • Often develops in 4th or 5th finger (flexion deformity) • Management ’ • Tissue nodules must be removed Dupuytren s Contracture as they can ultimately interfere w/ normal hand function

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Tendon pathology

• Swan Neck Deformity Etiology • Distal tear of volar plate or finger trauma may cause Swan Neck deformity • Flexed MCP, extended PIP, and flexed DIP • Signs and Symptoms • Pain, swelling w/ varying degrees of hyperextension • Tenderness over volar plate of PIP • Indication of volar plate tear = passive hyperextension • Management • RICE and analgesics • Splint in PIP 20-30 degrees of flexion/DIP extension for 3 weeks; followed by buddy taping

• Sprains Phalanges Joint • Etiology • Phalanges are prone to sprains caused by pathology direct blows or twisting • Signs and Symptoms • Recognition primarily occurs through history • Sprain symptoms - pain, severe swelling and hemorrhaging

Joint pathology

• Gamekeeper’s Thumb • Etiology • Sprain of UCL of MCP joint of the thumb • Mechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextension • Signs and Symptoms • Pain over UCL in addition to weak and painful pinch • Management • Immediate follow-up must occur • If instability exists, athlete should be referred to orthopedist • If stable, X-ray should be performed to rule out fracture • Thumb splint should be applied for protection for 3 weeks or until pain free • Splint should extend from wrist to end of thumb in neutral position • Thumb spica should be used following splinting for support

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Joint pathology

• Sprains of Interphalangeal Joints of Fingers • Etiology • Can include collateral ligament, volar plate, extensor slip tears • Occurs w/ axial loading or valgus/varus stresses • Signs and Symptoms • Pain, swelling, point tenderness, instability • Valgus and varus tests may be possible • Management • RICE, X-ray examination and possible splinting • Splint at 30-40 degrees of flexion for 10 days • If sprain is to the DIP, splinting for a few days in full extension may assist healing process • Taping can be used for support

Joint pathology

• PIP Dorsal Dislocation • PIP Palmar Dislocation • Etiology • Etiology • Hyperextension that disrupts • Caused by twist while it is volar plate at middle phalanx semiflexed • Signs and Symptoms • Signs and Symptoms • Pain and swelling over PIP • Pain and swelling over PIP; point • Obvious deformity, disability and tenderness over dorsal side possible avulsion • Finger displays angular or • Management rotational deformity • Treated w/ RICE, splinting and • Management analgesics followed by reduction • Treat w/ RICE, splinting and • After reduction, finger is splinted analgesics followed by reduction at 20-30 degrees of flexion for 3 • Splint in full extension for 4-5 weeks -- followed by buddy weeks after which it is protected taping for 6-8 weeks during activity

Open Dislocation

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Joint pathology

• MCP Dislocation – Etiology • Caused by twisting or shearing force – Signs and Symptoms • Pain, swelling and stiffness at MCP joint • Proximal phalanx is angulated at 60-90 degrees – Management • RICE, following reduction splinting in slight flexion (3 weeks) • Buddy taping following splinting • Therapy

• Metacarpal Fracture Bony • Etiology Pathology • Direct axial force or compressive force • Fractures of the 5th metacarpal = Boxer’s Fracture • Signs and Symptoms • Pain and swelling; possible angular or rotational deformity • Management • RICE, analgesics are given followed by X-ray examinations • Deformity is reduced, followed by splinting - 4 weeks of splinting after which therapy starts • Unstable fracture may need to be surgically pinned

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Bony pathology

• Bennett’s Fracture • Etiology • Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb • Signs and Symptoms • CMC may appeared to be deformed - X-ray will indicate fracture • Athlete will complain of pain and swelling over the base of the thumb • Management • Structurally unstable and must be referred to an orthopedic surgeon • Surgery and immobilization – season ending

• Distal Phalangeal Fracture Bony • Aetiology pathology • Crushing force • Signs and Symptoms • Complaint of pain and swelling of distal phalanx • Subungual hematoma is often seen in this condition • Management • RICE and analgesics are given • Protective splint is applied as a means for pain relief • Subungual hematoma is drained

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Bony pathology

• Middle Phalangeal Fracture – Aetiology • Occurs from direct trauma or twist – Signs and Symptoms • Pain and swelling w/ tenderness over middle phalanx • Possible deformity; X-ray will show bone displacement – Management • RICE and analgesics • No deformity - buddy tape w/ splint for activity • Deformity - immobilization for 3-4 weeks and a protective splint for an additional 9-10 weeks during activity

Bony pathology

• Proximal Phalangeal Fracture – Aetiology • May be spiral or angular – Signs and Symptoms • Complaint of pain, swelling, deformity • Inspection reveals varying degrees of deformity – Management • RICE and analgesics are given as needed • Fracture stability is maintained by immobilization of the wrist in slight extension, MCP in 70 degrees of flexion and buddy taping

Lacerations

• Superficial location of tendons and nerves predisposes athletes to damage form shallow lacerations. • Any laceration to the fascia below the cutaneous layer should receive a referral • R/O trauma to tendons and nerves • Prevent infection • Suture to ensure minimal scarring

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Normal hand position

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Hand - oedema

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Hand functional positions

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Normal alignment and rotational deformity

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Scissoring

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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

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Wrist & Hand Evaluation

• History • Ask Generic history questions - MOI, ?noises/sensations, Burning/Stinging? • Ask Specific history questions - was your hand planted? Did you fall on an outstretched hand? • Observation • Discoloration, swelling • Posture of hand • Deformity, palmar creases, color of skin & fingernails, thenar & hypothenar eminences, thenar webspace • Murphy’s sign, Silverfork deformity, Boutonniere deformity, mallet finger deformity, rotational malalignment, missing knuckle

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Wrist & Hand Evaluation

Palpation Stress/Special Tests Ulna (styloid process), Radius (Lister’s ROM, Grip strength, Pinch test, test ea. tubercle, styloid process), Carpals, joint on a finger Metacarpals, Phalanges, joints, muscles, Valgus/Varus Stress tests of all joints, ligaments, Carpal Tunnel, Anatomical Glide testing of ligaments snuffbox Phalen’s Test Temperature, deformity, swelling

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Palpation

• Lateral epicondyle • Radial head • Groove of ulnar nerve • Olecranon • Radial/ulna styloid • Snuffbox • Carpals • Metacarpals • Phalanges

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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

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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

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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

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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

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Complications

vBy far, the largest potential vBony complications: problem with any hand or wrist vMalunion injury is stiffness. vAngulation vSoft tissue complications: vMalrotation vTendon adhesions vShortening vCapsular contractures vIntra-articular step-off vFracture healing time vNonunion is uncommon vHand: 3-4 weeks in hand or wrist vDistal radius: 5-7 weeks

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Hand Fractures

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Metacarpal fracture: transverse

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Metacarpal fracture: oblique

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Inter articular Fracture

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Epiphyseal fracture

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

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Fractures of the Distal Phalanx

•Applied Anatomy • Extensor and flexor tendons insert into the base of the distal phalanx • Routinely not a deforming fracture

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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)

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• Radiographs • 2 – 3 views to look for fracture • Use hot light if needed • Classification • Longitudinal • Transverse • comminuted Fractures • Treatment of the • Non-displaced or minimally displaced can use variety of Distal splints Phalanx • Immobilize the DIP only • Reduce displaced fractures • Open wounds may need more definitive treatment

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• Outcomes • Cold intolerance • Tip sensitivity • Stiffness • Nailplate irregularities Fractures •When to refer of the •Open fractures in need of nail bed repair Distal •Large skin loss Phalanx •Suspected flexor or extensor tendon involvement

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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

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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

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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

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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

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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

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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

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Middle and Proximal Phalangeal Fractures

•Radiographs • 3 views • Evaluate joint proximal and distal • Spiral fracture may appear on only 1 view •Classification

Location Pattern Midshaft Spiral Condylar Oblique Intra-articular Comminuted Transverse Avulsion

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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

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Inter articular Fracture

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Boutonniere

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

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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

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Boutonniere

• Mechanism of Injury • History and Physical Exam • Acute flexion force to PIP joint • Pain and swelling about PIP • PIP does not immediately fall • Inability to fully extend PIP into a flexed position • DIP flexion is limited • Several weeks after the injury the • Longstanding cases digit assumes a buttonhole • PIP flexion posture. • Passive extension not • Other mechanism include PIP possible dislocation and central slip lacerations

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Boutonniere

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

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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

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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

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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

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Proximal Interphalangeal Collateral Ligament Injuries and Dislocations

• Mechanism of Injury • Associated Injury • Sudden force directed to tip of • If the skin tears open, it is digit results in hyperextension an open dislocation • Spectrum ranging from slight hyperextension grade I sprain to • History and Physical frank dislocation Exam • Joint swollen and tender • Test collateral ligaments to ascertain partial vs complete

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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

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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

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Metacarpal fracture: transverse

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Bennett’s fracture

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Rolando fracture

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Thumb Injuries

Figure 1 Figure 2

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Scaphoid waist fracture

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Zones for tendon repair

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Lacerations

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Finger Nail Pathology

• Subungual Hematoma • MOI: finger caught between two surfaces • Presents with bleeding under nail bed • Draining – Drill or Cauterize • Paronychia • Infection around fingernail beds • S/S: Redness, pain, drainage • Warm soaks (Betadine), Antibiotic, Referral • Changes in normal appearance - indicative of a number of different diseases • Scaling or ridging = psoriasis • Ridging and poor development = hyperthyroidism • Clubbing and cyanosis = congenital heart disorders or chronic respiratory disease • Spooning or depression = chronic alcoholism or vitamin deficiency

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Hand Infection

• Bacterial • Viral • Fungal • Protozoal • 64% grow multiple organisms

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Nerve Supply

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Neurologic Testing

•Motor testing • OK sign • FDP • FDS • FPL

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Nerve Injuries

• Hypothenar muscle weakness from ulna nerve lesion. • Thenar muscle weakness – median nerve lesion • Thenar and hypothenar – brachial nerve palsy. • Hand muscles act in concert.Weakness will result in loss of dexterity

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Neurologic Testing

•Sensory • Light touch – pin prick • Two-point descrimination •Motor • Median • Ulnar • Radial

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Neuro assessment in hand

Sensory Testing Motor Testing • Median nerve – skin over • Median nerve – abduction of thenar eminence thumb against resistance

• Ulna nerve – skin medial edge • Ulna nerve – abduction and of palm adduction of the fingers

• Radial nerve – skin dorsal • Radial Nerve – extension of the aspect of first dorsal wrist or fingers interosseus

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Nails

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Nail & Nailbed

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Anatomy

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

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Subungual Hematoma

• Results from blunt trauma to nail • Very painful • Relieved by • Cautery • Heated paperclip • 18g needle

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Web space infection

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Trephining Equipment

• Unbend a paper clip – attach Tape to make handle • Heat tip of paper clip in flame / match / lighter • Heated tip acts in the same way as battery operated system • Disadvantage - time

• Alternative = White Needle with bevel removed – high aluminium

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AntiBiotics ???????????

• What does the experts say??

• Nothing – there isn’t any research!

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Post Trephining

Cleaned with sodium chloride

Iodine dressing – will be effect to prevent colonisation / infection with MRSA

Tubidressing / Adaptic Dressing

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• Analgesia • Keeping Dressing Dry Post • Review Dressing – 48 hours (Leaving Treatment can promote bacterial growth) • Will likely loose nail – allow to grow Advice through • Keep clipped short

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Common Hand Problems

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Paronychia

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

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Felon

• Abscess of distal pulp • Results from penetrating trauma • Bacteria trough eccine sweat glands • Pulp is tense and tender • Significant edema

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CONCLUSION

Take a good history Know anatomy and use terminology Examine systematically Consider contributory factors Be alert for NAI If in doubt, refer or ask someone senior Discharge safely. Health Education….Health Education

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Any Questions?

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