The Hand Exam: Tips and Tricks - UCSF CME

1 11/4/20131 the hand exam : tips and TricksNikki Strauss Schroeder, MD Assistant Clinical Professor, UCSF Department of Orthopaedic SurgeryNovember 4, 2013 Outline Hand Anatomy Exam Management of ER/traumatic injuriesSurface Anatomy11/4/20132hyponychiumSterile matrixGerminal matrixlunulaparonychiumeponychiumDistal PhalanxMiddle PhalanxProximal PhalanxMetacarpalsCarpalsHand RadiographWrist radiographPisiformTriquetrumLunateHamate CapitateTrapezoidTrapeziumscaphoidSo Long To Pinky, Here Comes the ThumbFinger Radiographs11/4/20133 Hand MotionCourtesy ASSHT humb MotionCourtesy ASSH Clinical appearance Radial, ulnar Allen s Test Digital Allen s test Doppler Vascular examAllen s Test11/4/20134 Sensory Exam What nerves provide sensation to the hand?

2 Sensory Exam Median Palmar cutaneous branch Digital nerves to thumb, index, and middle and radial half of ring fingers Ulnar Dorsal and palmar cutaneous branches Digital nerves the small, ulnar half of ring finger Radial Sensory branchSensation: quick and dirty11/4/20135 Sensory exam: 2-point discrimination Normal= mm In kids, see if hand wrinkles when placed in waterMotor exam Median Anterior Interosseous Recurrent motor branch Radial Posterior Interosseous UlnarMotor exam: quick and dirty Median- thumb palmar abduction (touch tip of small finger) AIN- OK sign Ulnar- spread index and long finger apart (peace sign) Radial/PIN- retropulse thumb (palm flat on table, extend thumb))11/4/20136 Specific Tests- FDS/ FDPER Management Patient Stabilization Evaluation for other injuries Complete but brief assessment Tetanus, Antibiotics, Irrigation History Physical Exam ImagingThe ER Hand Exam11/4/20137ER History Age, Hand Dominance, Occupation Mechanism of Injury Onset/Location/Duration ExamThe ER Hand Exam Inspect Document wound location (finger, volar/dorsal, radial/ulnar)

3 , size Sensory Exam 2PD Its OK to do a digital block after sensory exam is done!! Motor exam FDP/FDS, extensors, EPL Range of motion/Rotation Vascular Digital Allen s, DopplerGreen s Hand SurgeryPhoto courtesy of L LattanzaImaging Is there a fracture? Is there a dislocation?11/4/20138 Choosing the right Case 1 Case 2 Case 311/4/20139 Hand Emergencies Replants Revascularizations Flexor Tenosynovitis Compartment Syndrome Acute Carpal Tunnel SyndromeAmputations: Field E&M Control with Direct pressure Rare tourniquet (temporary use only) No clamps Elevate armField E&MSave all parts!!! Place parts in moist (Ringers) gauze and into aplastic bag Bag is placed on ice.

4 NO dry ice! Urgent transfer to ED- Surgical emergencyWilhelmi BJ, Lee WP, Pagenstert GI, Pagensteert GI, May JW Jr. Replantation in themutilated Clin. Feb 2003;19(1):89-12011/4/201310ER Management Patient Stabilization Evaluation for other injuries Complete but brief assessment Tetanus, Antibiotics, Irrigation History Physical Exam ImagingThe bleeding arm that won t stop Please LET THE TOURNIQUET DOWN and assess the wound Direct pressure stops bleeding MUCH betterHand Emergencies: RevascularizationsHand Emergencies: Flexor Tenosynovitis11/4/201311 Flexor Tenosynovitis: Kanavel Signs Flexed resting position of the digit Fusiform swelling Tenderness to palpation of the flexor tendon sheath Pain on passive digital extensionFirst Image.

5 Essentials of Hand Surgery 2002 Second Image: Regional Review Course 1998 Hand Emergencies: Compartment Syndrome Rare entity Does not include flexor tenosynovitis 10 compartments of the hand Dorsal and palmar IO Thenar, hypothenar Adductor Carpal Tunnel Acute Carpal Tunnel Syndrome 1-10% incidence with distal radius fractures Typically high-energy injury Peri-lunate, lunate dislocations Document 2PD prior to reduction and post-reduction Elevate, check again within 1-hour after reductionHigh Pressure Injection Injuries11/4/201312 What about the artery that just won t stop bleeding? Ex: Isolated ulnar or radial artery In a perfused hand: Direct Up to 1 hour of compression Likely a shear injury to vessel If doesn t stop, OR to ligate vs repairConclusions Hand Anatomy Radiographs Physical Exam Specific ER Cases Obtain the correct radiographs Do sensory exam first, then OK to do a block!

6 Thank You Nikki Schroeder