Wrist and Hand Injuries

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Wrist and Hand Injuries
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• Basic Anatomy-eight carpal bones
• The ulnar nerve runs deep to the carpi ulnaris
  tendon.
• Provides sensation to palm and dorsal aspects of
  the ulnar side of hand, 5th digit and ulnar half
  of the 4th digit.
• Test-abduction of fingers against resistance

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• Median nerve-runs through carpal tunnel
• Thenar motor branch
• Common digital branch
• Provides sensation to the palm on the radial side
  of the hand and the palmar aspect of the radial 3
  ½ fingers and the dorsal aspect of the tips of
  the index and middle fingers and the radial half
  of the ring finger.
• Test opposition of the thumb to each finger-watch
  for thenar muscles contractions.

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• Radial nerve-provides sensation to dorsum of
  radial aspect of the hand, the dorsum of thumb
  and the dorsal aspect of the 2nd and 3rd fingers
  and radial half of the 4th finger.
• Motor test-extension of the wrist and fingers
  against resistance
• Sensation-dorsal web space b/t 1st and 2nd
  finger.
• Causes wrist drop with loss of function

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• Regional nerve blocks-useful with finger/hand
  injuries.
• Finger injuries-digital block better than local
• Sensation is by the palmar and dorsal digital
  nerves along the lateral aspect of each finger.
• Digital block
• Dorsal approach
• Palmar approach
• Web space approach

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• High pressure injection injuries- surgical
  injuries. Fluid travels down tendon sheath
• 70 result in amputation-low viscosity and
  corrosive liquids produce more damage
• Velocity and duration of exposure-bad prognosis

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• Carpal injuries
• Scaphoid-most common-FOOSH-snuff box
  tenderness-longitudinal compression of thumb
• Nondisplaced-thumb spica
• Displaced-ORIF
• Avascular necrosis possibility

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• Triquetrum-2nd most common-FOOSH or direct
  blow-tender distal to ulnar styloid on the dorsal
  wrist
• Treatment-volar splint
• Lunate-3rd most common-FOOSH-pain middorsum of
  the wrist worse with axial compression of 3rd
  metacarpal
• Treatment-thumb spica-avascular necrosis is a
  complication

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• Lunate dislocation- loss of flexion with the
  wrist in anatomic position.
• Triangular in shape piece of pie
• Lateral view-spilled teacup sign-lunate volarly
  displaced to the capitate
• Perilunate dislocation-most common wrist
  dislocation-assoc. with fracture/dislocation of
  scaphoid.

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• Scapholunate dislocation-pain with wrist
  hyperextension snap with radial or ulnar
  deviation.
• On AP scaphoid has a dense ring signet ring-
  gt3mm widening between lunate and scaphoid Terry
  Thomas sign
• Radial gutter splint

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• Metacarpal injuries-punch clenched fist
• Metacarpal neck fractures of 4th and 5th up to 20
  and 40 degrees of angulation is acceptable.
• Index and 3rd digit lt16 degrees is acceptable

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• MCP dislocations-thumb is most common
• Bennetts-base of 1st metacarpal
• Rolandos-frx is a comminuted intra-articular frx
  at base of thumb metacarpal
• Gamekeepers-torn ulnar collateral
  ligament-forceful radial deviation of the thumb

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• Distal forearm fractures
• Colles fracture-transverse fx of metaphysis of
  the distal radius with dorsal displacement of the
  distal fragment-FOOSH-dinner fork
  deformity-dorsal displacement
• Hematoma block reduce
• Treat with long arm or sugar tong cast

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• Smiths fracture
• Transverse fracture of the distal radial
  metaphysis with volar displacement of distal
  fragment-FOOSH while in suppination-median nerve
  injury
• Immobilize in long arm splint

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• Tendon injuries-close inspection in anatomic
  position, position of injury, and through ROM
• Must test against resistance-90 tears will still
  have normal range of motion-look for decreased
  strength
• Flexor tendon injuries-repair in OR

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• Extensor tendon injuries
• Mallet finger-unable to extend the DIP
• MOI-sudden forced flexion
• Splint in slight hyperextension if no fracture
  refer to ortho-fracture requires pinning
• Boutonniere deformity-rupture central slip of
  extensor tendon at PIP
• Flexion of PIP and hyperextension of DIP
• MOI direct blow
• Treatment splint the PIP in extension refer to
  ortho

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• DeQuervains tenosynovitis-inflammed extensor
  tendons of the thumb-pain on radial aspect of
  wrist-worse with use
• Finkelstein test-pain on ulnar deviation of the
  wrist while thumb is flexed and held in the palm
  by the other finger
• Treatment-NSAIDs-splint position of function

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• Infections of hand
• Paronychia-nail fold infection-Staph
  Strep-Treat with ID
• Felon-fingertip infection-Staph-Treat with ID
• Incision through the pulp of the finger laterally
  with wick placed though the incision-remove in 72
  hours

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• Herpetic Whitlow-viral infection of distal
  finger-HVS I or II-pain, burn, itching and
  herpetic lesions then form.
• Treatment-splint and analgesics-may give oral
  antivirals
• DO NOT DRAIN

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• Human bite or fight bite-punch to the mouth
  usually
• DO NOT suture over the MCP-heal by secondary
  intention
• Eikenella corrodens
• Treatment-ortho consult-xrays-wound
  cultures-irrigate-IV antibiotics if necessary

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• Tenosynovitis
• Typically from punture wound-staph or strep
• Diagnose-Kanavel four cardinal signs
• Held in slight flexion
• Symmetric swelling of the finger
• Tender along flexor tendon sheath
• Pain with passive extension of the finger

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• Treat with IV antibiotics
• If penetrating trauma penicillinase-resistant
  antistaphylococcal PCN or 1st gen. cephalosporin
• If no history of trauma in a sexually active
  adult, consider GC-treat with ceftriaxone and
  culture-elevate, splint-tetanus

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