Hand Injury Approach

  • WIPE, blah blah 🙂
  • Proper exposure
  • Position: patient’s hands on a pillow

– History –

  • Age
  • Timing and duration
  • Mechanism of injury
  • Sx: pain (SOCRATES), numbness, tingling, weakness
  • Hand dominance
  • Occupation
  • Past medical and surgical, allergies
  • Family Hx
  • Social Hx

– Look –

  • Normal hand cascade
  • Discoloration
  • Scars, skin changes, swelling
  • Muscle atrophy
  • Deformities
  • Nails (pitting, splinter hemorrhage, clubbing)
  • Describe the injury, if any

– Feel –

  • Temperature, dryness\sweating, capillary refill, skin turgor
  • Vascularity:
    • Radial pulse (radial to the FCR tendon)
    • Ulnar (push FCU tendon radially and push down)
    • Allen’s test: pt makes a fist, examiner occludes both arteries, pt releases fist, examiner releases one artery, and observes refill of the palm (normal < 5 sec), repeat for the other artery. “Allen test showed patent vasculature
  • Sensation:
    • Light touch
    • Median: tip of the index finger
    • Ulnar: ulnar aspect of the little finger
    • Radial: 1st web space
    • Two-point discrimination
  • Joints + anatomical snuff box: tenderness or swelling

hand inj 2


– Move –

(go nerve by nerve, start extrinsic, then intrinsic muscles for each)

  • Extrinsic muscles: origin is outside the hand, insertion in the hand -> control crude movements
  • Intrinsic muscles: origin and insertion w\in hand -> control fine movements

hand inj 1

 

A. MEDIAN NERVE:

  • Extrinsic:
    1. Wrist flexion + radial deviation (FCR + PL)
    2. Pronation (pronator teres + quadratus)
    3. Ok sign (FPL + FDP of the index -> by AIN)
    4. All FDS
    5. Radial 2 FDP
  • Intrinsic:
    1. Thumb abduction + opposition (Thenar muscles: APB, FPB, opponens pollicis)
    2. Flexion of MCP + extension of IP (radial 2 lumbricals)

hand inj 3.png

B. ULNAR NERVE:

  • Extrinsic:
    1. Wrist flexion + ulnar deviation (FCU)
    2. Ulnar 2 FDP
  • Intrinsic:
    1. Little finger abduction + opposition (Hypothenar muscles: abductor digiti minimi, flexor digiti minimi, opponens digiti minimi)
    2. Froment’s sign (adductor pollicis)
    3. Fingers adduction + abduction (all interossei; volar + dorsal)
    4. Flexion of MCP + extension of IP (ulnar 2 lumbricals)

hand inju 4.png

C. RADIAL NERVE:

All supplied muscles are extrinsic: 6 compartments of extensor tendons -> from radial to ulnar: [221,211]

  1. APL, EPB -> abduction + extension of thumb
  2. ECRB, ECRL -> wrist extension + radial deviation
  3. EPL -> thumb extension
  4. EDC, EIP -> extension of the MCPs + isolated extension of index
  5. EDM -> isolated extension of the little finger
  6. ECU -> wrist extension + ulnar deviation

hand inj 5.png


– Special Tests –

  • De Quervain’s tenosynovitis
    • Finkelstein’s test
  • Carpal tunnel syndrome
    • Carpal tunnel compression test
    • Phalen’s test
    • Tinel’s sign

 


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