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The Hand. Bucky Boaz, ARNP-C. 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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the hand

The Hand

Bucky Boaz, ARNP-C

examination of the upper extremity
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
examination of the upper extremity1
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
Anatomy Review
  • Bones
    • Distal radius and ulna
    • Carpals metacarpals
    • Phalanges
      • Proximal
      • Middle
      • Distal
anatomy review1
Anatomy Review
  • Joints
    • DRUJ
    • Carpal-Metacarpal
    • Metacarpal-Phalangeal
    • Proximal Interphalangeal
    • Distal Interphalangeal

DIP

PIP

M-P

C-M

DRUJ

anatomy review2
Anatomy Review
  • Muscles & Tendons
    • Extrinsic
      • Flexor tendons
        • Flexor carpi ulnaris
        • Flexor carpi radialis
        • Palmaris longus
        • Flexor pollicis longus (FPL)
        • Flexor digitorum profundis (FDP)
        • Flexor digitorum superficialis (FDS)
anatomy review3
Anatomy Review
  • Muscles & Tendons
    • Extrinsic
      • Extensor tendons
        • Abductor pollicis longus
        • Extensor pollicis brevis
        • Extensor carpi radialis longus and brevis
        • Extensor digitorum
        • Extensor digiti minimi
        • Extensor carpi ulnaris
anatomy review4
Anatomy Review
  • Muscles & Tendons
    • Extrinsic
      • Extension of MP
      • Flex of IP
    • Intrinsic
      • Abduct and adduct fingers
      • Flexion of MP
      • Extension of IP
anatomy review5
Anatomy Review
  • Nerves
    • Median
    • Ulnar
    • Radial
examination of the hand and wrist
Examination of the Hand and Wrist
  • Complete exam:
    • Observation
    • Palpation
    • Range of motion
    • Neurologic testing
    • Vascular assessment
    • Stability testing
observation
Observation
  • Hands at rest
    • Curved posture
    • Look for one finger curved
    • Asymmetry
    • Color
    • Spooning or clubbing
    • Muscle atrophy
palpation
Palpation
  • Lateral epicondyle
  • Radial head
  • Groove of ulnar nerve
  • Olecranon
  • Lister’s tubercle
  • Radial/ulna styloid
  • Snuffbox
  • Carpals
  • Metacarpals
  • Phalanges
neurologic testing
Neurologic Testing
  • Sensory
    • Light touch – pin prick
    • Two-point descrimination
  • Motor
    • Median
    • Ulnar
    • Radial
neurologic testing1
Neurologic Testing
  • Motor testing
    • OK sign
    • FDP
    • FDS
    • FPL
vascular examination
Vascular Examination
  • Radial artery
    • Located radial to the FCR
  • Ulnar artery
    • Located radial to the FCU
  • Allen test
stability testing
Stability Testing
  • Ulnar collateral ligaments
  • Radial collateral ligaments
  • Gamekeeper’s/ skier’s thumb
special tests

TAP

Special Tests
  • Finklestein’s test
  • Froment’s sign
  • Watson test
  • Shuck test
  • Basal joint grind
  • Compression test
  • Phalen’s test
  • Tinel’s sign
considerations on treating hand injuries
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
referrals
Referrals
  • Emergent referrals
    • Open fractures
    • Fractures with neurovascular compromise
    • Significant soft tissue injury
    • Irreducible dislocations or fractures with significant deformity
referrals1
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
history
History
  • Complete history
    • Hand dominance
    • Occupation
    • Avocations
    • Circumstances surrounding the injury
      • When and where
      • Mechanism of injury
    • Location and character of pain
    • Numbness or tingling
radiographs
Radiographs
  • Examine prior to ordering films
  • Stress views are useful in demonstrating injuries not present on plain views
  • Occasionally CT scan or MRI are needed to evaluate an injury
description of fractures
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
description of dislocations
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
complications
Complications
  • By far, the largest potential problem with any hand or wrist injury is stiffness.
  • Soft tissue complications:
    • Tendon adhesions
    • Capsular contractures
  • Fracture healing time
    • Hand: 3-4 weeks
    • Distal radius: 5-7 weeks
complications1
Complications
  • Bony complications:
    • Malunion
    • Angulation
    • Malrotation
    • Shortening
    • Intra-articular step-off
    • Nonunion is uncommon in hand or wrist
fractures of the distal phalanx
Fractures of the Distal Phalanx
  • The distal phalanx is the most common fracture in the hand, accounting for approximately 50% of hand fractures
fractures of the distal phalanx1
Fractures of the Distal Phalanx
  • Applied Anatomy
    • Extensor and flexor tendons insert into the base of the distal phalanx
    • Routinely not a deforming fracture
fractures of the distal phalanx2
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)
fractures of the distal phalanx3
Associated Injuries

Nailbed lacerations

Nail plate avulsion

Skin lacerations

Subungal hematoma

History and Physical Exam

Check both flexor and extensor function

Document sensory exam

Fractures of the Distal Phalanx
fractures of the distal phalanx4
Radiographs

2 – 3 views to look for fracture

Use hot light if needed

Classification

Longitudinal

Transverse

comminuted

Treatment

Non-displaced or minimally displaced can use variety of splints

Immobilize the DIP only

Reduce displaced fractures

Open wounds may need more definitive treatment

Fractures of the Distal Phalanx
fractures of the distal phalanx5
Outcomes

Cold intolerance

Tip sensitivity

Stiffness

Nailplate irregularities

When to refer

Open fractures in need of nail bed repair

Large skin loss

Suspected flexor or extensor tendon involvement

Fractures of the Distal Phalanx
nailbed injury
Nailbed Injury
  • Nailbed lacerations need to be repaired
    • Use 6-0 absorbable to repair matrix
    • Prevents nail growth problems
  • Reinsert nail and secure
subungual hematoma
Subungual Hematoma
  • Results from blunt trauma to nail
  • Very painful
  • Relieved by
    • Cautery
    • Heated paperclip
    • 18g needle
subungual hematoma1
Subungual Hematoma
  • Clean with alcohol
  • Instrument of choice
  • Pierce nail
  • Gauze for 24 hours
mallet fingers soft tissue and bony
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
mallet fingers soft tissue and bony1
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
mallet fingers soft tissue and bony2
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
mallet fingers soft tissue and bony3
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
flexor tendon avulsion
Flexor Tendon Avulsion
  • Applied Anatomy
    • Flexor digitorum profundus tendon inserts into the base of the distal phalanx
flexor tendon avulsion1
Flexor Tendon Avulsion
  • Mechanism of Injury
    • Hyperextension against a flexed DIP joint
    • Relatively uncommon, but devastating is missed
    • Ring finger most commonly involved
flexor tendon avulsion2
Flexor Tendon Avulsion
  • Associated injuries
    • None
  • History and Physical Exam
    • Pain on volar surface of digit
      • May extend into palm with eccymosis
    • Cannot flex tip
    • Resting hand has extension of DIP joint
    • No active flexion
flexor tendon avulsion3
Flexor Tendon Avulsion
  • Radiographs
    • DIP to look for avulsion, but also hand to look for retracted segment
    • Most are normal
  • Classification
    • Pure tendon avulsion
    • Bony avulsion
flexor tendon avulsion4
Treatment

Should be splinted and referred in a semi-urgent fashion

Surgery is required

Outcomes

Results correlate with delay in treatment

Early do well

Postoperative hand therapy is important

Flexor Tendon Avulsion
middle and proximal phalangeal fractures
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
middle and proximal phalangeal fractures1
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
middle and proximal phalangeal fractures2
Mechanism of Injury

Direct blow to the digit or a twisting injury

Associated Injuries

Open injuries

Lacerations to tendons or neurovascular bundles

Important to evaluate for DIP injuries

History and Physical Exam

Evaluate for malrotation

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

Middle and Proximal Phalangeal Fractures
middle and proximal phalangeal fractures3
Middle and Proximal Phalangeal Fractures
  • Radiographs
    • 3 views
      • Evaluate joint proximal and distal
      • Spiral fracture may appear on only 1 view
  • Classification
middle and proximal phalangeal fractures4
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
boutonniere
Boutonniere
  • Applied Anatomy
    • When the central slip insertion at the base of the middle phalanx is disrupted, active PIP joint extension may be limited
boutonniere1
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
boutonniere2
Mechanism of Injury

Acute flexion force to PIP joint

PIP does not immediately fall into a flexed position

Several weeks after the injury the digit assumes a buttonhole posture.

Other mechanism include PIP dislocation and central slip lacerations

History and Physical Exam

Pain and swelling about PIP

Inability to fully extend PIP

DIP flexion is limited

Longstanding cases

PIP flexion

Passive extension not possible

Boutonniere
boutonniere3
Boutonniere
  • Radiographs
    • Most often negative
    • Occasionally small fragments dorsally off middle phalanx
  • Classifications
    • Acute
    • Chronic
      • Stiff
      • supple
boutonniere4
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
proximal interphalangeal collateral ligament injuries and dislocations
Proximal Interphalangeal Collateral Ligament Injuries and Dislocations
  • Most common orthopedic hand injury that can result in long-term digital stiffness and impairment
proximal interphalangeal collateral ligament injuries and dislocations1
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
proximal interphalangeal collateral ligament injuries and dislocations2
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
proximal interphalangeal collateral ligament injuries and dislocations3
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 Injury

If the skin tears open, it is an open dislocation

History and Physical Exam

Joint swollen and tender

Test collateral ligaments to ascertain partial vs complete

Proximal Interphalangeal Collateral Ligament Injuries and Dislocations
proximal interphalangeal collateral ligament injuries and dislocations4
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
proximal interphalangeal collateral ligament injuries and dislocations5
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
ulnar collateral ligament injuries to the thumb gamekeeper s thumb
Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper’s Thumb)
  • The ulnar collateral ligament of the thumb is important for pinch strength and stability
  • Because of its location, it is particularly vulnerable to injury
ulnar collateral ligament injuries to the thumb gamekeeper s thumb1
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)

History and Physical Exam

Moderate swelling and eccymosis over ulnar side of MP joint

In complete tears stress testing of UCL shows a poor endpoint

Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper’s Thumb)
ulnar collateral ligament injuries to the thumb gamekeeper s thumb2
Ulnar Collateral Ligament Injuries to the Thumb (Gamekeeper’s Thumb)
  • Radiographs
    • Typically negative
    • Possible avulsion fragment off proximal phalanx or metacarpal
  • Treatment
    • Incomplete – non-operatively (splint)
    • Complete - surgically
bennett s fracture dislocation
Bennett\'s Fracture Dislocation
  • Most frequent of all thumb fracture
  • Described in 1882 by Dr. Edward Bennet
  • It is a fracture dislocation, intra-articular fracture at base of carpometacarpal (CMC) joint of the thumb
bennett s fracture dislocation1
Mechanism of Injury

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

History and Physical Exam

Moderate swelling and eccymosis over the CMC joint

Pain with ROM or palpation

Bennett\'s Fracture Dislocation
bennett s fracture dislocation2
Bennett\'s Fracture Dislocation
  • Radiographs
    • Oblique fracture line with a triangluar fragment at ulnar base of metacarpal
    • Triangular fragment remains attached to trapezium w/ proximal displacement of the metacarpal
  • Treatment
    • Immobilization
    • Referral for surgical pinning
conditions that mimic infection
Gout

Pyogenic granuloma

Acute calcification

Foreign body reaction

Herpetic whitlow

Metastatic lesions

Pseudogout

Rheumatoid arthritis

Granuloma annulare

Local reactions

Conditions That Mimic Infection
paronychia
Paronychia
  • Infection localized to the proximal and lateral skin folds of fingers and toes
    • Staph aureus
    • Group A or D Strep
    • Pseudomonas
    • Gram-negative bacteria
    • anerobes
paronychia1
Paronychia
  • Clean area with alcohol or betadine
  • Perform digital nerve block
  • Area of greatest fluctuance
  • Remove pus
  • Debride nail if necessary
  • Antibiotics
  • Dressing
felon
Felon
  • Abscess of distal pulp
  • Results from penetrating trauma
  • Bacteria trough eccine sweat glands
  • Pulp is tense and tender
  • Significant edema
felon1
Felon
  • Fish-mouth incision
  • Hockey-stick/ J-incision
  • Transverse palmar incision
ad