Hand Assessment

7/27/2019 Hand Assessment

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History taking

L H Tan, V. Rajaratnam

COMFORT AND ANALGESIA

Ensure that the patient is as comfortable as possible and thatadequate analgesia has been given even before the history -taking

and full evaluation.

Patients concerns:

What effect will his injury have on his/her everyday life, bothimmediately and in the long term, and

What treatment options are available?

You must also be aware that the patient requires sufficientinformation, assurance and confidence to be in the surgeonshands.

HISTORY

The following information must be obtained in any hand injurypatients:

1. Name2. Gender3. Age4. Dominant-hand5. Occupation6. Hobbies/recreational activities7. Smoker / non-smoker

Other general points in history:The patients current health status, past medical history, previousanaesthetic experiences, bleeding disorders, current medications,allergies, tetanus immunisation status and time of last meal shouldall be recorded.


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Understanding Hand Surgery2

Date, time and type of injury

It can potentially have medico-legal implications.

The time of injury should be noted as certain injuries requireurgent management and should be treated as soon as they arerecognized; in order of urgency:

1. Uncontrolled haemorrhage secondary to vascular injury2. Complicated fracture or dislocation compromising major

vascular injury or producing doubtful viability3. Compartment syndrome4. Macro-replantation, that is when the amputated part

contains significant muscle bulk5. Hydrofluoric acid burns6. Pressure gas injuries

If left untreated, the hand will undergo certain changes, which willinfluence its eventual recovery of function:

Necrosis and contractures may result from vessel occlusionsecondary to unstable fractures. (Due to irreversiblepermanent intimal changes or irreversible ischemia in the areaof blood supply)

Contamination of the tissue causing infection.

Progressive edema, leading to:a) Compartment syndromeb) Joint contracturec) Friability of tissues, which may complicate tendon, nerve,

and vessel repairsd) Difficulty in skin closure, to the point of compromising

skin circulation

Place of injury

Home

Work


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Understanding Hand Surgery 3

Outdoor

Mode of injury

Accident

RTA (Are there other injuries which may takeprecedence?)

Self-inflicted (Is the patient likely to re-injure / be non-compliant?)

Assault

Mechanism of injury

1. What happened to your hand?2. Which part of your hand is injured?3. How was it injured?

Roller

Punch Pressure

Saw

Laceration

Penetrating

Blunt

Pressure gun

Gunshot wound

Others e.g. lawn mower

Roller injuries

Does it have a roller?

Roller injuries commonly produce avulsion flaps, whereby thedistal part may not be viable and hence amputation would be theonly treatment option.

What is the size of the gap?

If the gap is small, distal crush may be so severe thatrevascularisation may not be successful.


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What are the rollers surfaced with?

What normally passes through the rollers?

There may be some foreign bodies in the wound which may ormay not cause increased risk of wound contamination and willtherefore

Fig: Extensive roller injury to hand and forearm

Fig: Punch press injury

need adequate irrigation in A&E or a formal washout and

debridement in theatre.

Are they hot?


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The viability may be compromised by burns or heat from thefriction of rollers, especially the ones that do not have anautomatic release or arrest.

Do they have an automatic release mechanism?

How quickly were they stopped once your hand wascaught? As prolong pressure necrosis can result.

Punch pressure

What is (roughly) the area and shape of the punch press?

What is the narrowest space in which your hand wascompressed?

Depending on what the punch pressure produces, it can inflictmoderate to severe injuries. A large area of injury can causecomminuted fractures, carpal disruption and soft tissue injuries.In a smaller area of injury, division of tendons and nerves at twolevels is more likely compared to roller injuries.

How long was your hand under the punch?Again bear in mind that blood vessels may be compromised

causing significant necrosis.

Saw

Saw (esp. electrically driven circular saw) injuries fromcarpentry/DIY accidents is very common.

What kind of saw? e.g. Circular saw or high speed metal

saw

What were you cutting?


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(a) (b) (c)Fig: a) Laceration caused by a saw injury. (b) Laceration caused bya sharp instrument (c) Avulsion injury of thumb

This will give you an idea of risks of contamination or possibilitiesof foreign bodies.

Whats the set on the blade (amount of deflection in thesaws teeth from a straight line)

A high speed metal saw with a narrow set will approximate to aknife cut. On the other hand a wide set saw avulses as well ascutting, producing damage distant from the skin wound. This

would make re-vascularisation and replantation difficult.

Laceration

Show me the position of your hand when it slipped on theknife?

The relationship of the distal cut end of the long flexor tendons ofthe fingers to the wound skin varies according to the posture ofthe hand at the time of injury. The distal tendon ends may be atthe wound itself when the finger is extended. If the finger wasfully flexed then the distal tendon ends will be as far removed(proximally) from the skin laceration. This would be important forsurgeon when carrying out primary tendon repair.

Penetrating

Show me how it happened?

Saw blade injury

vulsion of


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Penetrating injuries of the hand carry the same sinister implicationas penetrating injuries to the abdomen or neck. An unimpressivewound may hide a remarkable amount of damage to deepstructures.

In what direction was it pointing?

The damage to deep structures in stab wounds may be remotefrom the skin wound.

What stuck into your hand?

Short puncture lacerations over the knuckles should raisesuspicion as they are most likely inflicted by the human teeth, eventhough the patient may deny it. This injury is prone to infection,which can be more resistant than infections related to dog biteinjuries. Immediate copious irrigation can significantly decreasethis risk. Hence exploration and washout in theatre is essential.Broad spectrum antibiotics are essential in the management of

human and dog bite injuries. For example, intravenous co-amoxiclav and flucloxacillin for human bite wounds andintravenous co-amoxiclav for dog bite wounds.

Pressure gun

Penetrating gun injuries need to be treated with urgencydepending on what agent has been injected. The most common

substances are paint, grease, hydraulic fluid or molten plastic.Patients may not have pain immediately. They should haveimmediate exploration and removal of all foreign material. If notimmediate, may result in infection, gangrene and amputation. Thelong term outcome includes fibrosis, and discharging sinuses fromgranulomas which can cripple the hand

Gunshot

1. Type of gun?2. Range and calibre?


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High-energy injury is associated with comminution, bone loss,significant skin defects and a high incidence of vascular and nerveinjury. Low-energy wounds, however, often present as a foreignbody in the tissues.

Blunt injury

Blunt injury including falls. Very heavy falls on an outstretchedhand are commonly associated with supracondylar fractures inchildren, carpal injuries in young and middle aged adults andColles fractures in the elderly.

1. What height did you fall from?2. Did you have to stop what you were doing?

Patients may be able to continue doing what they were doing withthe initial sustained hair line fracture, which can subsequentlyprogress into a complete fracture following further insult, thuscausing severe pain and not allowing them to continue.

Previous injury

Previous injury to the part, primary treatment and subsequentprogress and therapy may be relevant.Other relevant points in history include:

Current health status/ Relevant past medical historyApart form obtaining associated injuries, a brief general medicalhistory should be obtained. This is to elicit any cardio-respiratoryproblems, which may influence the choice of anaesthesia.

Psychiatric disorderPsychiatric disorders which may severely limit postoperative co-operation.

Medication / AllergiesSome medication may interfere with adequate healing.Uncontrolled diabetes, certain skin conditions, and steroid intakeare associated with increase sepsis rate. Drug allergies shouldalways be recorded.


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Social historyPatients occupation is very important in choosing the appropriateoperation procedure. This is especially important in reconstructive

surgery, which aims to restore maximum function to the hand andto do that in the shortest time. For instance, a self employedmanual worker would want to get back to work as soon aspossible, therefore a long lengthy rehabilitation period isunsuitable for patients needs.

1. What exactly do you do?2. How long have you been doing that kind of work with the

current employer?3. Are you self-employed or is your employer holding your

job?4. Do you hope to go back to the same job?5. Are you the only person working at home?6. How many people are you supporting?

Smoking is also well known to affect tissue healing and a high

alcohol abuser may indicate a non-compliant patient.

Recreational

Do you play any musical instruments? E.g. Guitar, piano,violin

TAKING REFERRALS FOR REPLANTATION

When taking a referral for replantation, the following questionsand statements should be presented to the caller. (Also seeChapter 13)

1. What is your name, that of your facility and the contactnumber?

2. How did the amputation happen?3. Are there any injuries else where in the body?4. How old is the patient and is he generally healthy?5. Does the patient smoke?6. Is that limb otherwise intact?


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7. How about the x-ray?8. How will you prepare the limb for transport?

With respect to the amputated part:

1. Are there other injuries?2. When you wash off the wound, are there structures

dangling from the part?3. Tell me about the xray of the part?4. How will you transport it?5. Is there a good/fair/poor chance of replantation?6. We will be glad to see the patient but please emphasize to

him/her and the family that the decision to try

replantation can only be made here and, of course successcannot be guaranteed.

7. How will patient be transported?8. Can you give me an estimated time of arrival?


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Evaluation of hand injuries

M Brewster & V Rajaratnam

Before addressing this topic there are 3 crucial rules for success.

Assess for life threatening injuries first, as per ATLS guidelines.

Meticulously document the examination (it is often helpful to use accurate drawings).

Compare the injured with non-injured hand.

INSPECTION

Whilst inspecting a hand, remember the surface anatomy to aid with accurate diagnosis (see

Chapter 1).

Attitude

The position or Attitude of the resting hand can reveal many underlying pathologies.

In a normal relaxed hand a smooth cascade is created by the fingers.

A break in this cascade can signify underlying bone, tendon or nerve injuries.When flexed at the MCP + PIPJs the fingers should all point towards the scaphoid tubercle.The finger nails should be roughly aligned.

Rotational deformities in finger fractures may be exaggerated with the fingers flexed in thisposition.

Fig: Note the normal finger cascade is broken

Fig: Nomally, flexed fingers converge towards the scaphoid


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Fig: Note rotational deformity of the index finger

Fig: Cellulitis (and possible deep infection)


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Discolouration and Swelling/Altered Contours

1. Coloura. Pink: adequate perfusion

b. Red: cellulitis/infectionc. Focal bruising: underlying injuryd. Bruising at a site away from an area of impact: such as dorsal wrist bruising after a

FOOSH, strongly suggests underlying skeletal injury, even with normal x-rays.e. white or blackened wounds - full thickness burns or charred tissues.f. exposed tissues e.g. yellow fat, white nerves or tendons.g. Green (+/- mal-odorous): push. Black: necrotic

2. Swelling - relate to anatomical location.a. fluids e.g. blood, oedema

b. muscle and other soft tissues after injury e.g. muscle rupturec. bones e.g. fracture and/or dislocationd. foreign bodiese. infection/inflammation

N.B. - As the palm and its skin are tightly contained greater amounts of swelling can occur in thedorsum of the hand even with palmar pathology.

COMPARTMENT SYNDROME is suggested by an increase in pain which is out ofproportion with the injury during movement of contained muscles. Compartment pressures mayneed to be measured (using a manometer) in the unconscious patients if there is a high index of

suspicion.

(a) (b)Fig: (a) A simulated laceration in a partially flexed finger. (b) When the finger is extended, theinjured tendon (shown by the green line) moves away from the skin laceration


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REMEMBER Compartment syndrome does not only occur following fractures and crushinjuries but also with circumferential burns, injection injuries and tight dressings too.

3. Contours - displaced fractures e.g. distal radius, metacarpal neck and proximal phalanx.

4. Dislocations e.g. MCP, PIPJ, DIPJ, lunate - alter flexor / extensor tendon tension balanceand may present as unusual posture or joint position due to proximal injury.

Wounds and Scars

Wounds should be examined and explored. Document - site, size, depth and mode of injury.

TRAPSoft tissues move beneath the skin, therefore damage deep structure can lie at a distancefrom the skin wound e.g. a laceration to a tendon in a flexed finger will lead to tendon injuriesdistal to the wound in an extended finger.

Contamination

The level of wound contamination should be noted and in combination with the history willassist in decisions on treatment e.g. antibiotics and tetanus vaccination.

Even if not contaminated this could be a good time to update an overdue tetanus vaccination.

Puncture wound from fight bite punched teeth of another person can cause extensortendon injury and open MP joint.

Nails

Subungual haematomas can herald a nail bed injury and potentially an open fracture of the distalphalanx.

PALPATION

Tenderness

This suggests underlying injury or infection/inflammation. Specific injuries are:

1. Scaphoid #a) Anatomical snuff box (wrist in ulnar deviation)b) Scaphoid tubercle (wrist in radial deviation)c) Through line of thumb metacarpal.

2. Lunate dislocation - Mid palm at level of distal wrist crease

3. Game Keepers Thumb - Pain and instability if applying radial force to thumb MCPJ.

Temperature

hot: infectionwarm: perfused


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cold: environmental factors or poor perfusion.

Sweating

Require some nervous innervation.

MOVEMENT

Test ACTIVE then PASSIVE movement.

A passive range of motion can be used to assess crepitation (joint surface injury), resistance(swelling, subluxation, dislocation) and instability (ligament injury).

Test proximal to distal to facilitate diagnosis of nerve/tendon injury level.

(a) (b)Fig: Location of tenderness in (a) Scaphoid injury, (b) TFCC injury (in sulcus distal to the ulnarstyloid, with wrist in radial deviation).


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Act ion Joint Muscle Nerve

Finger. Ext. DIPJ +PIPJlumbricals / interossei(mainly palmar)

M+U / U

MCPJ ED, EI, EDM R

Finger. Flex. DIPJ FDP M+U

PIPJ FDS MMCPJ lumbricals / interossei M+U/U

Finger. Add./Abd.

MCPJpalmar/dorsalinterossei (PAD +DAB)

U

Thumb Ext. IPJ EPL R

MCPJ EPB R

Thumb Flex. IPJFPL (ant.Interosseous)

M

MCPJ FPB M

Thumb Abd./Add.

MCP+CMCJAPL+APB/AddP, 1

STD

Interosseous,R+M/MU

Thumb Opp. MCP+CMCJ OP MWrist. UlnarDevi.

Radio carpal FCU / ECU U/R

Wrist RadialDevi.

Radio carpal FCR / ECRL/B M/R

W. Extension Radio carpal ECU / ECRL/B R

W. Flexion Radio carpal FCU / FCR U/M

Range of movement can vary, therefore, compare to uninjured hand.

Normal ROM

MP 090PIP 0100DIP 070

W. Ulna Dev 0-35W. Rad. Dev 0-15W. Ext. 0-55W. Flex 0-65


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Fig: Normal range of motion in wrist, MCPJ and IP joints

Fig: Tenodesis effect


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REMEMBER - Median innervated intrinsics

Lumbricals (lateral 2)

Opponens pollicis

Abductor pollicis brevis

Flexor pollicis longus

TenodesisAn adjunct to active and passive movement is tenodesis. This describes the change in posturingof the hand distal to a moving joint e.g.

Wrist extension active/passive causes finger flexion and thumb adduction to the key pinchposition. The reverse is true for wrist flexion.

SPECIAL

Tendon Zones

Zones are used to describe Flexor and Extensor tendon injuries.There are 5 flexor and 7 extensor zones in the hand/wrist (see below).

Flexor Zones

1. Zone I consists of the profundus tendon only and is bounded proximally by the insertion ofthe superficialis tendons and distally by the insertion of the profundus tendon into the distalphalanx.

2. Zone II is often referred to as Bunnell's no man's land, indicating the frequent occurrenceof restrictive adhesion bands around lacerations in this area. Proximal to zone II, thesuperficialis tendons lie superficial to the profundus tendons. Within zone II and at the levelof the proximal third of the proximal phalanx, the superficialis tendons split into 2 slips.

These slips then divide around the profundus tendon and reunite on the dorsal aspect of theprofundus, inserting into the distal end of the middle phalanx. This split of the superficialistendon is known as Camper chiasma.

3. Zone III extends from the distal edge of the carpal ligament to the proximal edge of the A1pulley. Within zone III, the lumbrical muscles originate from the profundus tendons. Thedistal palmar crease superficially marks the termination of zone III and the beginning of zoneII.

4. Zone IV includes the carpal tunnel and its contents (ie, the 9 digital flexors and the mediannerve).

5. Zone V extends from the origin of the flexor tendons at their respective muscle bellies to theproximal edge of the carpal tunnel.

Extensor tendon Zones

I. DIPj: (Mallet Injury )II. Central slip to DIPjIII. PIP jIV. MCPj to PIPj

V. MCPjVI. CMCj to MCPjVII. Wrist and proximal


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NB - Pain on move can be related to swelling, fracture, foreign body, sot tissue injury. Intact butpainful movement can also signify partial rupture/division of tendons.

Nerves

Neurological examination is divided into Sensory and Motor. An accurate history to assess pre-injury neurology is ESSENTIAL and can prevent unneeded operation.

a) SensoryThe sensory distribution of the upper limb can be described and examined in a number of ways:

(a) (b)

(c)

Fig: Testing for individualmuscles (a) FDS to ring finger(b) FDP to ring finger, (c) FPL

Fig: Quick tests for nerves (a) Median nerve (b) Radial nerve


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1. Individual NervesDigital Nerves Ulna and radial digital nerves to each digit : palmar finger laceration injuringdigital artery very likely to have damaged the nerve.

2.Dermatomes

C4-T3 used for brachial plexus and more proximal injuries. See section on nerves3.Proximal to Distal(as per neuropathy in glove and stocking distribution)

b) MotorMany of the movements tested in examinations can not be exclusively attributed to a singlenerve. Recognised tests for single nerves are:

Quick TestsFor median nervepinchFor radial nerveextend thumb, wrist and fingers

1. Radial - Posterior interosseous nerveIsolated extensor pollicis longus(EPL) : Palm face down and lift thumb away from table.2. Median - Recurrent motor branchIsolated adbuctor pollicis brevis(APB) : Palm face up and abduct thumb towards ceiling.3. MedianAnterior interosseous nerveKiloh-Nevin signflexion at thumb IPJ and Index DIPJ to create the OK sign is used for supra-condylar or forearm fractures in children as easy to copy (innervation of FPL and FDP to indexamongst others).4. Ulnar NerveFroments signtests adductor pollicis. : Place paper perpendicular to the palm along radial border

of index finger. Grip the paper by adducting the thumb. If grip against resistance is onlypossible by flexing at IPJ and not by simple adduction, then test is positive and adductor pollicisis denervated or injured.Ulnar ParadoxThe phenomenon in which a proximal ulna nerve lesion produces a less clawed hand than a more distal ulna nerveinjury.

This occurs as a distal ulna nerve lesion disables the lumbricals and interossei but the FDP is stillactive and flexing the finger from the distal phalanx. Loss off the ulna half of the FDPinnervation in proximal ulna nerve lesions allows unresisted extension of the fingers andtherefore less clawing.c) Sympathetic Nerves

Tactile AdherenceWith nerve injury comes the loss of sympathetic input and the ability to sweat,thus reducing tactile adherence.

To examine this, simply rest a pen along the line of the radial/ulna border of a digit and slide italong distally. Compared to the normal side there will be less resistance.Loss of sweating in the nerve damaged area causes smooth movement of plastic pen overaffected skin. Normal sweating skin produces resistance and the digit will move with the pen.

Wrinkle testSkin with absent nervous innovation will not wrinkle in water. 5-10mins is sufficient.

Vessels

The hand has a collateral circulation - Radial and ulna arteries. Important notes duringexamination are:


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Capillary refill of all digits


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Modified digital Allens testExsanguinate digit with repeated flexion tension while applying pressure over both digitalarteries. Relese one side and note time to reperfuse. Do similarly for other side.

INVESTIGATIONS

X-Rays

In the acute setting only Xrays are used to image the hand views include:

Standard AP, lateral and oblique hand/wrist and digital viewsObserve for fractures, dislocations (including lunate) soft tissue swellings, periosteal elevation,increased joint space (scapholunate dissociations)

Scaphoid views1. AP (fist mildly clenched and the wrist in ulnar deviation.)2. oblique (45 from horizontal)3. lateral (wrist in neutral position)4. scaphoid view (wrist is ulnarly deviated and extended while the film is shot from a dorsal-

volar angle)

Initial radiographs are 80 percent sensitive for scaphoid #.MRI will diagnose the remaining cases.

Carpal tunnel/Hook of hamate Views

Individual joint and stress views - to diagnose fractures and ligament injuries

Fig: Scapholunate dissociation

ons

Documents

Hand Assessment