Hand SGD

July 25, 2011Block 10a

PATIENT PROFILE

• Patient is Pedro R. Anonuevo, 42 year-old male, married with 4 children, Filipino, Roman Catholic, farmer, left-handed, but uses right hand for writing, from Luciana, Laguna who was first seen by our institution at the OPD last June 1, 2011 due numbing of the left hand.

HISTORY OF PRESENT ILLNESS: • 4 mo. PTA: Patient sustained hacking wounds on his

left wrist and upper arm from an unknown drunk assailant. Said wrist wound produced profuse bleeding and laceration of wrist tendons. He was brought to a local hospital in Santa Cruz, Laguna where his vitals were stabilized and open wounds sutured. He was then sent home well, given pain and prophylactic antibiotic medications, and advised to come back immediately M/W/F which he complied to. Allegedly, there was already note of loss of sensation on fingers and decreased finger mobility. Upon follow-up within that week and note of healing of wound, he was advised to have PT mgt after a month.

HISTORY OF PRESENT ILLNESS: • 3 mo. PTA: Patient complied with physician's advise for

PT for 1 mo. There was relative improvement in range of motion of the left digits, however, there was still note of decrease sensation on the entire left hand.

• 1 mo. and 3 wks PTA: After a month of PT and no improvement in sensation, and starting to have difficulty extending the wrist, patient opted to consult at PGH-OPD Ortho Dept. where x-ray done on left wrist showed unremarkable findings. EMG was done but result unrecalled. Patient was advised for surgery and was advised to wait for admission. During the waiting period, patient discontinued PT mgt.

REVIEW OF SYSTEMS:

• (-) cough, colds, fever, headache • (-) dizziness (-) BOV (-) dysphagia• (-) nausea (-) vomiting• (-) DOB, palpitations • (-) bladder and bowel changes • (-) joint pain• (+) LOM Left shoulder elevation, wrist flexion, fingers

flexion and extension• (+) loss of L palmar sensation• (+) pins and needle pain radiating towards the fingers

PAST MEDICAL HISTORY

• (+) s/p amputation of distal phalanx, 4th finger of the left hand in 1990s due to firecracker explosion (allegedly return of function upon healing of wound and no loss of sensation)

• (-) DM, HPN, PTB, BA, CA, liver/kidney disease, CVD

• (-) food/drug allergies

FAMILY MEDICAL HISTORY

• (-) HPN, DM, PTB, BA, CA, liver/kidney disease, CVD, allergy

PERSONAL AND SOCIAL HISTORY

• (+) smoker• (+)alcoholic drinker• (-) illicit drug use• Works as a farmer, mostly coconuts and rice

Physical Examination

• Awake, coherent, ambulatory, NICRD.• BP 120/80 HR 88 RR 16 T: 37.4• Pink conjunctivae, anicteric sclerae, (-) CLAD,

NVE, ANM, trachea midline• ECE, CBS, (-) ABS• AP, NRRR, DHS, (-) murmurs, heaves, thrills• round abdomen, NABS, (-) masses/tenderness• (-) cyanosis, edemaa

Wrist

Left Right

Inspection (-) swelling, deviation(+) 10 cm linear, hypopigmented scar(+) 6x2 cm, slightly erythematous patch

(-) swelling, deformity, deviation

Palpation (+) weak pulse(-) swelling, tenderness

Full pulse(-) swelling, tendernesss

Movement (+) limited active and passive extension, flexion, ulnar and radial deviation

(-) limitation in both active and passive mov’t

Hand

Left Right

Inspection (+) hypothenar and thenar eminence atrophy(+) surgically absent distal phalanx, 3rd digit(-) swelling, palmar erythema and squaring, guttering(-) swan neck, boutonniere deformity(-) pitting, onycholysis

(-) swelling, erythema, swelling, guttering, deformities(-) atrophy(-) pitting, onycholysis

Palpation (+) cold to touch(+) tenderness, MCP joints(-) swelling, H&B nodes, crepiti(+) decreased sensation

Warm to touch(-) tenderness, swelling, H&B nodes, crepiti

Movement Cannot fully extend fingers, abduct thumb, make a tight fist, pinch grip(+) LOM, passive extension

Can fully extend fingers, abduct thumb, make a tight fist, pinch grip w/o difficulty

Shoulder

Left Right

Inspection Symmetric scapulae, (-) swelling, deformity, atrophy

Palpation (-) warmth, tenderness

Movement Active abduction and flexion up to 90° only

(-) LOM, active and passive(-) crepiti

Manual Muscle Testing

Left Right

C5 (Elbow flexor) 5/5 5/5

C6 (Wrist extensor) 1/5 5/5

C7 (elbow extensor) 5/5 5/5

C8(long finger flexor) 1/5 5/5

T1 (small finger abductors)

1/5 5/5

Diagnostics

Assessment

Multiple Tendon TransectionMedian and Ulnar Nerve Transection

Musculature

• Extrinsic muscles of the wrist and hand originate on the medial and lateral humeral condyles and the proximal radius and ulna:

• The extrinsic extensor tendons cross the wrist and are surrounded by tendon sheaths in six compartments bounded by the extensor retinacular ligament.

• The extrinsic finger and thumb flexor tendons and the median nerve enter the hand through the carpal canal.

Musculature

• Intrinsic musculature includes thenar, hypothenar, and interosseous muscles .

• Thenar muscles: abductor pollicis brevis, the opponens pollicis, and the superficial head of the flexor pollicis brevis.

• Hypothenar muscles: abductor digiti quinti, the opponens digiti quinti, and the flexor digiti quinti.

• The dorsal interossei, commonly referred to as dorsal intrinsics, abduct the fingers; the palmar interossei (palmar intrinsics) adduct the fingers.

ASSESSMENT

Loss of Median Nerve Function Results In:

• - loss of palmar sensation along the volar aspect of the thumb, index, long, and radial border of the ring finger

• - causes weak wrist flexion, and an “ape hand” with thenar atrophy and weakness of thumb opposition.

• - motor strength deficits include loss of thumb opposition (loss of abductor pollicis brevis), loss of thumb interphalangeal (IP) joint flexion (loss of flexor pollicis longus muscle function), and loss of index distal interphalangeal joint flexion (flexor digitorum profundus function).

Loss of Median Nerve Function

• - Restoration:• - Restoration of thumb IP joint flexion can be

restored using a transferred brachioradialis muscle (radial nerve innervated) to the FPL tendon.

• - Restoration of FDP function of the index finger can be accomplished using the extensor carpi radialis longus (radial nerve innervated) tendon rerouted to the index FDP tendon in the mid forearm.

• - Lastly, thumb opposition can be restored with transfer of the abductor digiti minimi muscle (ulnar nerve innervated).

Loss of Ulnar Nerve Function:• “Clawhand” of ulnar nerve palsy is known as

Duchenne's sign. • Wartenberg's sign is the inability to pull in (adduct) the

small finger against the ring finger. • Froment's sign is the hyperflexion of the thumb IP joint

to substitute for the lack of thumb-pinch power against the index finger. Weakness of DIP joint flexion due to loss of FDP function of the ring and small finger is known as Pollock's sign.

• The flattening of the natural metacarpal arch of the hand seen in association with hand muscle wasting is known as Masse's sign.

Loss of Ulnar Nerve Function:

• Reconstruction– Tendon transfers for ulnar nerve palsy are limited in

their ability to restore hand strength. – The ECRB tendon can be transferred to the thumb

proximal phalanx to provide thumb pinch (adduction) while the extensor pollicis brevis (EPB) tendon is transferred to the index interosseous muscle.

– Additionally, the thumb MCP joint may be fused to prevent thumb hyperextension and instability. The combination of these surgeries has been reported to restore approximately 50% of the lost pinch strength.