History of Raynaud’s predisposes the patient to necrosis of the fingers
often better to leave open and use 1 or 2 stitches to cover cartilage and tendon. Use interrupted vertical mattress.
Number fingers c roman numerals, use radial, ulnar, palmar, volar
Lines through the fingernails should all intersect at the scaphoid
X-Rays: AP, Lat, Oblique and Laterals of each finger
Transverse/longitudinal/comminuted-splint, drain subungal, refer
Open/Nail bed Lac-remove nail, suture, irrigate, replace nail, ABX 7-10 days
Extension=Mallet Finger-dorsal splint and f/u
Pain/Swelling at volar aspect of distal phalange c palmar pain=ruptured FDP
aka baseball finger, rupture of the extensor tendon that attached to the dorsal side of the distal phalanx of the finger. Caused by forced flexion of a fully extended finger. Treat with splinting in neutral or hyperextension for 6-8 weeks. Can use a paperclip wrapped in tape, froggie, or Stax extension splint. If removed even once in the 6 weeks, you must start over.
tear of the FDP forced extension of a flexed finger. Needs operative management within two weeks of the injury.
Middle and Proximal Phalyngeal
Hand consult or splint and refer
Named after an injury caused by twisting the heads off of rabbits. Now more common as skier’s thumb.
Avulsion of the ulnar collateral ligament of the thumb’s metacarpal phalangeal joint. On exam, there is pain over the ulnar side of the thumb, weakness of pinch. Test by valgus stress with the thumb in full extension and 30 of flexion. Get X-ray then thumb spica splint and referral.
Pain c axial compression of the digit
Head-splint or bulky dressing
Neck-usually c volar displacement, ortho consult
Bennett-fracture c dislocation or oblique fracture through base 1st MCP, thumb spica consult
Rolando-T or Y fracture c extension to joint space, consult
Boxers-MC neck Fracture, reduce in ER then Volar Splint
Order of frequency-scaphoid, triquetrum, lunate
Snuffbox is made of extensor pollicis longis on ulna side and extensor pollicis brevis/abductor pollicis longus
Axial Load all fingers
(Insert Fig 8-5)
From Listers tubercle to lunate to capitate to third metacarpal is a straight line on volar surface of palm
Triquetrum is just distal to the ulna
X-rays: AP/Lat/Oblique, also possibly: AP c max radial/ulna deviation, Lat c max flex/ext
Spaces between the carpals >=3mm is abnormal
Usually from Fall on Outstretched Hand (FOOSH) injuries
Blood supply is tenuous, coming only from distal portion leading to fracture complications like non-union and avascular necrosis
Test the snuffbox, axial loading of the thumb and pain c radial deviation of the wrist.
Splint in long/short arm thumb spica.
Consult if displaced
Dorsal chip-splint c f/u
Transverse-splint c f/u
CHECK ULNA Nerve
Thumb Spica c F/u
Test by pain in dorsum of the hand, axial load 3rd metacarpal
Axial Load 5thMetacarpal
Suspect if tenderness s radiographic signs of fracture
Mechanism of swinging golf club and hitting ground, bat against wall or fall on outstretched hand
Pain c flexion of V against resistance, c slight palmar flexion and ulnar deviation as this loads tendons over hook
Can get carpal x-ray view
Splint volar and refer
Check ulnar nerve
Hand and Wrist
Use bp cuff c padding to control bleeding, inflate to 100 over systolic
FDP/Flexor Pollicis Longus-hold proximal joints extended, flex at DIP, not reliable at V, test IV, V together
FDS-hold all joints in extension at DIP, flex at PIP. Not reliable at index finger
Abductor Pollicis Longus/Extensor Pollicis Brevis-located around snuff-box, forcefully spread hand
Extensor Carpi Radialis Longus/Brevis-make fist, extend wrist
Extensor Pollicis Longus-extend DIP of thumb
Extensor Digitorum Communis-extend II/V at MCP c III/IV flexed
Intrinsics-dorsal interossei: spread hand, volar: paper between fingers
Paper clip calibrated to 2 mm is accurate for 2PD (Academic Emergency Medicine Volume 11, Number 6 710-714,)
Always safe to irrigate, loosely approximate, dress, splint, elevate, antibiotics, and arrange f/u in 72 hrs.
Lunate and Perilunate Dislocations
Volar splint, wrist in neutral, refer
from ischemia, remove cast or dressing immediately, may need fasciotomy
Remove proximal aspect of nail, place xeroform into matrix space
Modified Thumb Spica Splint
(A J Emerg Med 2005;23(6):709-822)
Can Follow-Up Radiography for Acute Scaphoid Fracture Still be Considered a Valid Investigation?
Low G, et al
The most common method of managing patients with a clinically suspected scaphoid fracture but negative or equivocal initial x-rays is immobilization, followed by repeat x-rays after 10 to 14 days. While imbedded in clinical practice, some authors have challenged the utility of this practice. The sensitivity and specificity of MRI for the identification of occult scaphoid fracture is felt to be close to 100%. In this British study, four specialists from radiology, emergency medicine, and hand surgery independently read the initial and follow-up plain x-rays (done 10-50 days after presentation) that were taken in 50 patients aged 13 to 54 (mean, 29) who had clinical suspicion of a scaphoid fracture but negative or equivocal initial x-rays.
Figure. All traumatic hip pain is not a hip fracture, and a pelvic ramus fracture (arrows) is a common alternate break when a hip fracture is suspected. This patient fell and had a dislocated hip prosthesis. The hoopla surrounding a successful ED reduction clouded the picture, so these obvious pelvic fractures were initially missed. An MRI will also uncloak a clandestine sacral or acetabular fracture that easily eludes the plain film. As a general rule, do not initially look for the suspected pathology on the x-ray; rather first look for other bony and soft tissue problems. In other words, the last area scrutinized with hip pain should be the hip.
All of the patients underwent MRI (considered the gold standard) a mean of 16 days after presentation. MRI identified a fracture in 35 of 50 patients. Paired inter-observer reliability coefficients ranged from 18 percent to 53 percent (overall, 33%). Sensitivities of the four individual readers were 9% to 49%, while specificities ranged between 80% and 93%. The positive predictive value was about 80%, but the negative predictive value was only about 30% to 40%.
Only two of the 35 fractures seen on MRI were correctly identified by all four observers, and all observers agreed there was no fracture on plain films in 13 patients with an MRI-proven fracture. The authors concluded that follow-up x-rays are a poor method of identifying an occult scaphoid fracture in patients with initially negative or equivocal plain films.
Comment: This report is a condemnation of prior dogma stating that the best route for suspected scaphoid fracture is pre-emptive immobilization and repeating the x-ray. This meek approach has always baffled me, but in the old days, the MRI had not been invented. Numerous studies have now debunked this myth, and such practice seems rather archaic by today’s standards. Of course, the best way to diagnose a scaphoid fracture is to suspect it initially. Other studies have demonstrated in retrospect that the fracture is actually often present on the first plain radiograph, but it was overlooked.
Initial and follow-up x-rays were blindly reversed and shown to a radiologist, and statistics are all over the board for accuracy of plain film diagnosis. Most agree that the prognosis of a scaphoid fracture, with regard to the inevitable and troublesome aseptic necrosis that occurs in five to eight percent is set at the time of injury. You could fracture your scaphoid on the office steps of a hand surgeon, and have a cast 10 minutes later, yet still be saddled with the need for a bone graft. Trying to explain that to a patient who has just been told that you missed his scaphoid fracture 14 days before is a tough sell, even if you splinted according to the book. A scaphoid fracture is bad news whenever it happens, even when the diagnosis is spot-on in the ED.
Clues to a scaphoid fracture in the absence of an obvious fracture line on plain films isolating the bone itself include persistent throbbing pain, soft tissue swelling, snuff box tenderness, and pain on axial load of the thumb. Suffice it to say that a sprained wrist is an unusual diagnosis, one that should be made only by someone cognizant of the clandestine nature of scaphoid fractures. If you fall on your outstretched hand and your wrist hurts for more than a few days, I wouldn’t take a negative plain film as evidence of a simple sprain. It’s not your money, so get the MRI in an expeditious fashion.
It seems rather silly to immobilize a patient for 10 to 14 days, burden him with referral forms, arrange a complicated follow-up with a hard-to-find hand specialist, or bring the patient back in two weeks for a repeat plain films when an MRI will expeditiously settle the issue. Interestingly, MRI, not CT scan, is the modality of choice. The incidence of a scaphoid fracture in the presence of positive physical findings and a truly negative x-ray ranges from five to 10 percent. It’s simply not there until necrosis is apparent. Of course, you have to read the x-ray correctly, and you can always ask for another set of eyes on the film.
Brydie (Brit J Radiol 2003,76:296) found a 19 percent incidence of MRI-proven scaphoid fracture and a 17 percent incidence of nonscaphoid acute fracture when an MRI was performed on patients with clinically significant findings and a suspected scaphoid fracture. This was a selected population, and not all sprained wrists require an MRI, but MRI is probably the new gold standard. Bottom line: Significant or persistent wrist pain that congers up the thought of a possible scaphoid fracture is not a sprain until the MRI says so. Note also that many significant hand injuries, not just scaphoid fractures, have normal x-rays.
CommentsStudies vary widely in diagnostic values for a variety of tests. Only one study used MR imaging as the gold standard. There is no consensus as to the best clinical test for a scaphoid fracture. ASB tenderness in all studies gave 100% sensitivity (ie, if ASB tenderness is absent, then a fracture is highly unlikely). Specificity ranged from high, at 98% (ie, if ASB tenderness is present then a fracture is likely) to low, at 19% (ie, if ASB tenderness is present then a fracture is less likely). There is some evidence that a combination of tests (pain on ASB+AC+ST) will give perfect sensitivity and high specificity. Most clinical tests had higher sensitivity than specificity, which means that a fracture is unlikely to be missed but they will give a high number of false positives. Clinical bottom lineA combination of clinical tests seems to give the best diagnostic values for a scaphoid fracture. (EMJ 2011;28(4):332)
Soft Tissue Problems
Flexor tendon infection
Kordavels four signs:
- Pain c passive extension
- Digit held in slightly flexed posture
- severe tenderness to tendon palpation
- Symmetric swelling (fusiform swelling/sausage digit)
jamming of partially extended finger. Painful swollen PIP joint. Tender over dorsum of middle phalanx. Test by flexing finger over straight edge to 90 at PIP. Have patient extend against resistance, they will not have strength, may be able to hyperextend distal phalanx b/c of laterals. Splint PIP in extension. DIP should be left unsplinted.
Carpal Tunnel Syndrome
most sensitive (76%) and specific (80%) test is Phalen’s: flex wrist while forearms are vertical for 1 minute.
After removal of nail, glue it back on with dermabond
Can use absorbable sutures if pt may not come back (JEM 15:5)
loose gauze pack
24 hour wound check
soak 4 times a day for 10 minutes in warm water. Coincide with keflex if antibiotics were given
Do not need to remove the nail if there is no underlying fracture. (Emerg Med J 20:65, Jan 2003) (Am J Emerg Med 1991; 9(3):209) (J Hand Surg 1999,24(6):1166)
EVALUATION OF THE HANDLeonard Gordon, MD, Associate Clinical Professor of Orthopedic Surgery, University of California, San Francisco, School of Medicine, and Chief, Hand Surgery, California Pacific Medical Center, San Francisco
History: medications; immunosuppressive problems; tetanus prophylaxis status; determine need for antibiotics by asking when, how, and where injury occurred; previous injuries and treatment
Examination: supine position prevents injuries from falling if patient faints; easier to keep hand elevated while clinician examines hand; decreases bleeding
Bleeding that does not stop: in elderly patients with arteriosclerosis, vessel cannot contract and constrict; also caused by partial laceration of vessel (again, vessel cannot constrict); to stop bleedingclamp vessel; place suture around vessel; place tourniquet proximally (must be able to monitor amount of pressure and time); apply pressure (recommended approach; does not damage nerves associated with vessel)
Local anesthetics: examine for nerve injuries before giving local anesthetics
Distal examination: generally, you can tell everything about an injury from examining distal to the injury; by examining distal to laceration across palm, eg, possible to determine if tendon cut; no further examination required if tendon cut because patient must go to operating room (OR) and will be further evaluated there (saves time and patient discomfort); if everything intact, explore wound in emergency department (ED)
Skin and vasculature
Color and turgor: in evaluating circulation, carefully observe appearance of digit
Pulses: palpate pulses at wrist (sometimes possible to palpate pulse at base of finger on both sides); perform Allens test if laceration in wrist area
Allens test: apply firm pressure to radial and ulnar arteries to obliterate flow; have patient empty blood from hand; release one artery, measure length of time to restoration of color to hand (should take <6 sec; indicates whether released artery intact); repeat test with other artery; in some circumstances one artery supplies portion of hand; sometimes single artery takes over to supply entire hand (repair of injured artery still recommended)
Venous congestion: circumferential lacerations may allow arterial inflow, but inadequate venous drainage can result in loss of digit
Compartment syndrome: pulse may be normal; increased pressure reduces venous drainage which further increases pressure; pressure must be extremely high before abnormal pulse develops; high pressure causes severe injury to muscles and nerves; so feeling for the pulse is not an adequate test of whether you have a compartment syndrome or not
Forearm: pain on passive stretch and painful tight compartment on palpation are two early diagnostic features
Hand: extend metacarpophalangeal (MCP) joint and flex interphalangeal (IP) joint (this is the intrinsic tightness test; exquisitely painful in compartment syndrome); the patient will not allow you to do that test; if missed, outcome is claw-like hand deformity; patient must be taken to surgery for repair of injury; something you cannot miss
Flexor pollicis longus (FPL; reaches to end of thumb) and flexor digitorum profundus (FDP; goes to end of fingers): stabilize proximal phalanx and ask patient to flex thumb; stabilize middle phalanx and ask patient to flex end of finger; simple test to see whether tendon intact
Flexor digitorum superficialis (FDS): flexes middle joint; must exclude profundus tendon (all profundus tendons connected at wrist; excluding one excludes them all); completely extend distal phalanx of adjacent finger; ask patient to flex finger to be tested; in child or adult who cannot cooperate, rest hand on examination table and apply forearm pressure like you would test for the achille’s tendon
Zone II: from middle of palm to proximal interphalangeal (PIP) joint; dense pulley region; difficult to repair, can cause severe disability; requires treatment by specialist
FDS of index finger: difficult to test because no way to exclude profundus tendon (separate from other fingers); ask patient to flex finger hard against thumb (relative test)
Treatment: OR repair needed within 24-48 hr; zone II injuries require surgery by physician with specific expertise in zone II
Abductor pollicis longus (APL) and extensor pollicis brevis (EPB): ask patient to pull thumb away from palm and extend thumb in plane of palm; palpate; have patient hold both injured and uninjured hands on examination table and lift thumb as much as possible; if either tendon lacerated, injured thumb will lag (fairly obvious)
Extensor pollicis longus (EPL): most commonly missed injury; have patient place hand flat on examination table and lift thumb up; tendon will tent skin if intact
Extensor digitorum communis (EDC): elevate or extend MCP joints; for patient to extend finger at MCP joint, tendon must be intact; extensor tendons united by juncturae tendonae; if patient cannot lift all four fingers equally and fully, look inside wound for lacerated extensor tendon
Median nerve: ask patient to move thumb away (abduct) from palm, then palpate thenar muscles
Ulnar nerve: have patient hold both hands on examination table and lift index finger; apply resistance to see if index finger remains strong against resistance; Froments paper signask patient to firmly pinch; if ulnar nerve intact, patient will pinch with thumb extended; if nerve cut, patient will pinch with thumb flexed
Radial nerve: extend MCP joints or test by extension of wrist
Sensory function: ulnar nerve supplies sensation to small finger and half of ring finger; median nerve supplies thumb, index finger, long finger, and remaining
half of ring finger; test tip of small finger for ulnar nerve, distal phalanx of index finger to test median nerve
How far out can nerve be repaired? nerves should always be repaired with operating microscope 5 mm from base of nail or 2 to 3 mm distal to distal IP joint
Specific problems relating to nerves: nerves can adhere to tendons; penetrating objects can lacerate nerves; important to repair partial lacerations early because healed partial laceration cannot be repaired; nerves should be repaired in OR within 48 hr; grease- or paint-gun injury a very serious situation; injuries that cannot wait until morning include compartment syndrome, paint- or grease-gun injury, devascularizing injury, eg, amputation
Conditions treatable in ED: lacerations of extensors (need good lighting, tourniquet, assistant, correct instruments)
Basic discharge checklist: make sure patient keeps extremity elevated; prescribe tetanus shot, antibiotics and analgesics; appropriate follow-up
Single digit amputation between the PIP and DIP Amputated thumbs Multiple digit amputations Any amputation in a child Mid-palmar amputations
Transthecal Digital Block (Am J of EM 2005;23:340)
use 3cc or until resistance over the sheath is felt. Go down to bone then pull up just a bit
(Emergency Medicine Journal 2007;24:789-790) BEST EVIDENCE TOPIC REPORTS Epinephrine in digital nerve block Report by P P Mohan, Research Fellow, Gastrointestinal Surgery Checked by P T Cherian, Specialist Registrar, Hepatobiliary Surgery Good Hope Hospital NHS Trust, Sutton Coldfield, University Hospital Birmingham, UK. Abstract A short cut review was carried out to establish whether epinephrine (adrenaline) is safe to use in digital nerve blocks. A total of 16 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are presented in table 2. The clinical bottom line is that epinephrine (1:200 000 to 1:100 000) is safe to use in digital blocks. View this table: [in this window] [in a new window] Table 2 Table 2 Three part question In [adult patients with no underlying vascular compromise undergoing digital block] is [local anaesthetic with low dose epinephrine as safe as local anesthetic alone] at [achieving analgesia without causing ischaemic complications]? Clinical scenario A 25-year-old man presents to the emergency department with a traumatic laceration to his left index finger. The wound needs a thorough clean and will require suturing and you decide to do this using a digital nerve block technique. A colleague who has recently worked in plastic surgery suggests you use epinephrine (1:100 000) to help with haemostasis, but you have always been told that this can cause finger necrosis and that it should never be done. You wonder whether in fact this is true and decide to look at the evidence for yourself. Search strategy Medline search using Pubmed “Anesthesia”[MeSH] OR “Anesthesia, Local”[MeSH]) OR “Nerve Block”[MeSH] AND “Epinephrine”[MeSH] AND “Fingers”[MeSH]. Outcome Sixteen papers were retrieved, of which seven were found to be relevant, including two randomised control trials, three observational studies and two reviews (table 2). Comments Two review articles carefully examined the previously reported cases and found that no case had epinephrine as the sole cause of ischaemic complication. Two studies examined the digital perfusion using Doppler flow, and concluded that the blood flow returned to normal by 1 h after epinephrine injection. Other randomised and observational studies showed longer duration of anaesthesia, better analgesia, less need for tourniquets and no ischaemic damage with the use of epinephrine. This is clearly a controversial topic as it has been emergency medicine dogma that vasoconstrictive agents should not be used in digits. However, the evidence does not support this assertion for all patients. Clinicians may decide to use low concentration epinephrine when they feel this may help the procedure and where there is no underlying reason not to do so. Clinical bottom line In the absence of underlying vascular compromise, epinephrine (1:200 000 to 1:100 000) is safe to use in digital blocks along with local anaesthetics. Sylaidis P, Logan A. Digital blocks with adrenaline. An old dogma refuted. J Hand Surg (Br) 1998;23:1719. Wilhelmi BJ, Blackwell SJ, Miller J, et al. Epinephrine in digital blocks: revisited. Ann Plast Surg 1998;41:4104. Wilhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg 2001;107:3937. Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg 2001;108:11424. Altinyazar HC, Ozdemir H, Koca R, et al. Epinephrine in digital block: color Doppler flow imaging. Dermatol Surg 2004;30(4 Pt 1):50811. Krunic AL, Wang LC, Soltani K, et al. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol 2004;51:7559. Andrades PR, Olguin FA, Calderon W. Digital blocks with or without epinephrine. Plast Reconstr Surg 2003;111:176970.
Nail Gun Injuries
nails are linked with glue, if piece breaks off can cause tissue reaction. Nails are often barbed with little hairs (cooper barbs) therefore it must be pushed through wound; not pulled out.
while the rolled glove concept seems clever; it actually generates excessive pressures on the finger tissues rolled glove was 561 mm Hg, we should shoot for 200 and not to exceed 300 mm hg. (EP Monthly – Re: With finger amputations, be aware of excessive tourniquet pressure)