(A study guide for Year Level VI and VII students)
Jose Ma. D Bautista, M.D.
Department of Orthopedics
College of Medicine
University of the Philippines – Manila
A complete clinical history and a focused physical examination is the primary method in determining the nature and extent of injuries of the hand. Subsequent examinations (with the exception of radiographs for fractures and dislocations) are often just confirmatory.
The treatment of these hand injuries will depend on modifiable and non-modifiable factors (patient, injury, facilities…), often with no single correct answer. The physician must be able to gather all appropriate data and review all feasible options before making a treatment recommendation.
Please review the anatomy of the hand before you start. Aside from this study guide, you should have access to your previous references (Basic Sciences, Surgery, Orthopedics). It’s also strongly recommended to go over Hoppenfeld’s “Physical Examination of the Spine & Extremities.”
CLINICAL HISTORY TAKING
Information obtained while taking a patient’s clinical history not only is useful to determine the scope and extent of injury, but will also guide us in determining the appropriate treatment. The appropriate treatment for similar injuries may differ depending on patient factors
General Information
1. Patient’s Age
The potential to heal changes as one grows older. In growing children, not only does the proliferative phase occur faster, remodeling is also more complete. As such, repairing injured structures leads to better results in children than in adults. Because of the more extensive remodeling, fractures (except those involving articular surfaces) often are treated non-surgically.
KEY STUDY POINT:
Describe the different phases of healing (both of bone and of soft tissue).
Young and middle-aged adults are usually in the work force and have families to take care of and usually need their hands to perform more functions as compared to those who are older. When deciding which treatment option to recommend a patient for his/her injured hand, the difference in functional demand between an elderly patient and one who is younger should be considered. The goal of treatment is to restore the hand to its pre-injury function. For example, fractures may need to be more accurately reduced and rigidly fixed in younger patients to better restore the hand’s motion and strength.
KEY STUDY POINT:
Differentiate (as regards indications and outcomes) the ff. general methods of treating injuries of the hand:
i. observation
ii. repair
iii. reconstruction
iv. replacement
v. amputation
As elderly patients will more often have other co-morbidities, the chosen treatment for their injured hands will usually be that which requires shorter procedures or less surgery.
KEY STUDY POINT:
For an 80 year-old patient with a comminuted open fracture of the non-dominant little finger with a significant skin loss, explain why amputation may be the best option.
2. Gender
A patient’s gender will not usually affect decision-making as regards treating hand injuries as functional demand is not dictated by being male or female. Concern for cosmetic outcomes is not exclusive to females.
KEY STUDY POINTS:
Suggest a donor site when a wound of the hand needs to be covered with a skin graft.
Describe the different treatment options for wounds.
3. Occupation
A hand’s functional requirement is best determined by what we most often use it for. A neurosurgeon will probably need his hand in a different manner than a stevedore who will also need it differently from a full-time homemaker. Knowing what the hand is frequently used for will guide us in choosing the most appropriate treatment option.
One’s occupation (or that of the spouse or parent) will often determine the available options for treatment (as regards capacity to comply with treatment and tolerance for time off work).
KEY STUDY POINTS:
You are presented with two 40-year old patients, one a physician and the other a PUJ driver, with a comminuted open fracture of the non-dominant little finger with a significant skin loss. Describe the similarities and differences between the treatment of the 2 patients.
How are fractures of the hand treated?
4. Hand Dominance
Most patients will more often use their dominant hand. The functional requirement of that hand is thus higher than the non-dominant one. When deciding, the treatment may differ for similar injuries of the dominant and non-dominant hand.
KEY STUDY POINT:
Describe the function of the hand.
How is the functional loss resulting from loss from the whole, or part of the, hand measured
History of Present Illness
1. Mechanism of Injury
As injuries are often the result of a transfer of energy which the body cannot withstand (Haddon, JTrauma 1973), the idiom of “what you see is what you get” frequently does not hold. Higher-energy injuries, such as in motorcycle accidents, will result in more severe injuries that may not all be obvious on initial evaluation. They may also result in injuries which progress over time.
The low velocity injuries, particularly those from sharp instruments (stab wound) usually present with non-progressive injuries.
KEY STUDY POINTS:
Differentiate the injuries that a hand may sustain and the possible treatment options associated with a gunshot wound from a “paltik” and that from an assault rifle.
Describe the “blast effect” and its significance as regards deciding the treatment for hand injuries.
2. Duration from Injury
Determining the actual date and time of injury is important to ascertain so as to be able to know how long since the injury before the patient is seen. In the acute stage of injury, this is particularly important in open injuries as well as injuries which have affected an extremity’s vascular supply.
For open injuries, treatment beyond the “golden period” increases the infection rate.
For extremities whose vascular supply is cut-off, the longer the ischemia time, the lower the chance of its survival.
KEY STUDY POINTS:
Describe the “golden period” for wounds. Differentiate the treatment of similar injuries (such as an open fracture) which differ in whether they are within or beyond this period.
Describe what happens to ischemic tissues. Differentiate cold vs warm ischemia time.
3. Place of Injury
The exact location where the patient was injured will guide our initial treatment. A wound sustained in the kitchen may be managed differently from one that happened in the office.
When we send our patients home after treatment we have to ask where he/she will live. We must be aware of the local resources available to the patient. Not all patients will be able to continue to follow-up with their initial physician.
KEY STUDY POINT:
Describe the different stages of treatment of injuries.
Why should a kitchen wound be managed differently than that sustained in the office?
4. Previous Treatment
What has already been done for the injury may affect your own management. Some initial remedies (such as applying traditional salves to wounds) may increase the chance of infection, whereas others (washing wounds with running water) may improve outcome.
KEY STUDY POINT:
While at an urgent care center a 40-year old laborer whose dominant hand got caught in a steel door was brought in. He had a gaping wound at the back of the hand with bone sticking out. What would be your initial management?
Past and Family Medical History
The patient’s medical conditions will affect the body’s response to the injury as well as how he/she is to be managed.
Knowing a patient’s medical history will inform us as to the need to consult with other specialists regarding the safest way to proceed with treatment (i.e. pre-operative evaluation) as well as to have them treat the existing conditions.
KEY STUDY POINT:
Describe how the ff. conditions may affect management of injuries to the hand:
i. DM
ii. Ischemic Heart Disease
iii. Metastatic CA
iv. AIDS
Personal and Social History
Cigarette smoking, especially if chronic, would lead to multi-system damage affecting the patient’s general health. It would also affect the wound’s capacity to heal. It is important to have smoking cessation as part of the management.
Drug abuse and excessive alcohol intake will lead to chronic diseases, which must be considered when determining treatment. These two are likewise indicative of poor compliance with treatment, especially important during Rehabilitation of the hand, especially after surgery
KEY STUDY POINT:
A 55-year old executive chef at a 5-star hotel, with a 30 pack-year history of cigarette smoking, accidentally cut off his non-dominant thumb 30 minutes prior to his consult at our ER. Describe how you would treat this patient.
PHYSICAL EXAMINATION OF THE HAND
P.E. of the hand follows the same process as other parts of the musculo-skeletal system: Inspection, Palpation, Range of Motion and Special tests. As with other instances when we are doing P.E. of the extremities, we are able to determine whether our finding is normal by comparing with the contralateral or even to the examiner’s own.
Let us consider the hand to be an organ consisting of five tissues. These are:
Integument
Blood vessels
Nerves
Muscles and Tendons
Bones and Joints.
We examine these tissues separately, and come up with a “composite” diagnosis
INTEGUMENT
KEY STUDY POINTS:
Describe the normal integument of the hand.
Differentiate between the palmar and dorsal skin.
Describe the perionychium.
Examination of injuries to the integument is often limited to determining their nature, size and location. These can usually be determined by inspection alone
We first identify the type of wound, whether it’s an abrasion, puncture wound, laceration or avulsion.
KEY STUDY POINTS:
Describe and differentiate these wounds.
Describe wound healing and the factors which affect it.
The wound’s location is best described as regards its orientation (volar, dorsal, radial or ulnar) or relationship to the landmarks, such as the ray and skin creases (Fig. 1: proximal palmar crease, along the 3rd metacarpal).
For example, a puncture wound can be described to be at the volar side, along the distal palmar crease, in line with the ring finger or 4th ray. In parts of the hand where there is no crease (the dorsum), a wound’s location can be described as regards the underlying bone and segment. For example, a wound can be located at the hand’s dorsum, at the mid-third of the second metacarpal area.
KEY STUDY POINT:
Describe the hand’s surface anatomy.
A wound’s size is described as to its length, width, depth and area.
BLOOD VESSELS
Unlike when we examine the other tissues of the hand, when we examine the blood vessels, the first question is not whether there’s any damage, but whether the hand is still adequately perfused. It is not unusual to see a well-perfused hand even when a major blood vessel (such as the radial artery) has been injured.
1. Inspection
We look at the color of the volar skin of the finger/s and the nail beds to see whether it’s the usual pink or whether the part is pale or cyanotic.
2. Palpation
We first palpate for the temperature, which can best be done using the dorsum (or back) of our hand. A cold, injured hand or finger may indicate vascular insufficiency.
Pulp turgor (Video 1: pulp turgor)
and the capillary refill time, or CRT (Video 2: capillary refill time)
are more reliable tests to determine for adequate perfusion. We should compare our results with that of the uninjured parts as different results may indicate either inadequate arterial flow or venous congestion.
When we need to determine whether there is an injury to a blood vessel even if the hand is well perfused, we can do the Allen test (Video3: Allen test).
A Digital Allen Test has also been described to determine injuries to the digital arteries, but is not recommended due to the discomfort to the patient and the blood vessel’s proximity to the adjacent digital nerve. Because it’s common that the digital artery is injured whenever an adjacent digital nerve is cut, only the digital nerve needs to be examined for.
KEY STUDY POINT:
A 20-year old medical student with a non-accidental knife wound over the volar aspect of the non-dominant wrist was brought to the ER. On inspection, blood was spurting from the wound. Please describe your diagnostic approach.
NERVES
It is useful to remember that peripheral nerves serve three functions in the hand: sensory, motor and autonomic. Sensory and motor functions are usually examined when we have an awake and cooperative patient. Otherwise we may have to rely on testing for the nerve’s autonomic function.
The Autonomic system controls the sweat in our palms, which we need in order to hold onto objects more efficiently. We can check for the presence of sweat by gently rubbing the back of our hand against the volar surface of the injured part and comparing the friction at this part with the hand’s normal area. The tactile adherence test (Video 4: Tactile Adherence Test) has also been described (Lister).
Of the various ways sensation can be tested for, the tests for light touch are the most sensitive for detecting the presence of a nerve injury. Using cotton balls, the cover of a ballpen or even the examiner’s own finger are the most practical ways of performing this at the Emergency Room. The more sensitive methods, such as the Two-point Discrimination Tests and the use of mono-filaments, are better reserved when examining in a more quiet environment, with patients more relaxed than when they are at the E.R. Nonetheless, we should compare the findings of the injured parts or sides to those of the uninjured parts or sides.
Where sensation is to be tested for in the hand depends on the location of the injury. When a wound is proximal to the wrist, the nerve probably injured is still a major nerve (Median, Ulnar or Superficial Radial Nerve). As such, it suffices to evaluate sensation sensation at the autonomous zones. For the median nerve, this at the radial half of the index finger’s pulp (Fig. 2: autonomous zone for Median Nerve),
the ulnar nerve’s autonomous zone is at the ulnar half of the little finger’s pulp (Fig. 3: autonomous zone for Ulnar Nerve),
while the superficial radial nerve’s zone is at the dorsum of the 1st web (Fig. 4: autonomous zone for Superficial Radial Nerve).
If a palmar sided wound is distal to the wrist crease, the sensory nerves which could be injured would already be either a common or a proper digital nerve. Sensory testing for this nerve should be done at the radial and ulnar halves of the pulps of the thumb and fingers.
Motor testing of the nerves is more easily done by identifying a muscle which is the sole motor of a particular action and testing that muscle’s strength using the “place and hold” technique. For the ulnar nerve, the Flexor digiti minimi is tested by passively flexing the little finger at the metacarpo-phalangeal joint, asking the patient to hold the position while the examiner tries passively extend the metacarpophalangeal joint by pushing the finger back down (Video 5: MMT for FDM).
The Abductor pollicis brevis is used to test the Median nerve. The thumb is passively palmarly abducted, and the patient is asked to hold that position while the examiner adducts the thumb by pushing it down (Video 6: MMT for APb).
KEY STUDY POINT:
One day after a fight in which he recalls to have been hit in the arm with a bat, a 32-year old male complains of not being able to dorsiflex his wrist. The arm is slightly swollen but has no wound.
Describe how you will proceed.
Describe the different injuries to the nerves.
Differentiate the classification systems of Seddon and Sunderland.
MUSCLES AND TENDONS
The muscles which move the hand and fingers are classified as to their origins. They are extrinsic if their origins are proximal to the wrist, and intrinsic if otherwise. Intrinsic muscles are tested in injured hands as part of the examination for nerve injuries.
Inspection
The hand’s attitude is the position it assumes while at rest. It is the result of the balance of the tension between extensors and flexors. At rest, with the wrist slightly extended, the fingers are slightly flexed at the MCP and IP joints. The little finger is most flexed, and the index finger least flexed. This is called the normal cascade (Fig 5: Normal cascade of the hand).
When all the extrinsic muscles or tendons are transected, the involved joint is more flexed or extended than normal (Fig. 6: a. complete transection of long finger flexors of the ring finger; b. complete transection of extrinsic extensor of the ring finger).
If not all the muscles/tendons moving a joint into flexion or extension are transected, then that joint will still be in its normal attitude. The patient will still be able to fully flex and extend the involved hand.
Palpation/Range of Motion
Test for FDS injury:
In the presence of an intact FDP, the finger will still have a normal attitude, and can still fully flex.
Due to the FDP having a common belly for the three ulnar fingers, keeping the uninvolved fingers passively extended, prevents the FDP from flexing the injured finger. An uninjured FDS will allow the PIP joint to flex.
The test described above is not used for the index finger because its FDP usually has a separate belly. The index finger FDS is tested by having the patient flex the IP joint while the DIP joint is passively extended. Inability to do so is probably due to an injury to the FDS (Video 7: FDS test for index finger).
Partial Injuries
Partial tendon transections must be considered when the patient reports pain on resisted active motion.
KEY STUDY POINT:
Describe the significance of tendon injuries in “no man’s land.”
Describe the differences in treatment between acute and chonic tendon injuries.
BONE AND JOINTS
KEY STUDY POINT:
Describe signs of a fracture and radiologic anatomy of the hand and wrist.
Inspection
Deformities are the most obvious signs of an injury to the hand’s bones and joints. The deformity’s appearance depends on the injury. Deformities can appear as shortening, bending, twisting and step-offs. Shortening usually occurs when there is significant comminution causing the bone to collapse. Bending is due to angular displacement of fractures. Step-offs are due to transverse displacement of fracture fragments or dislocations. Twisting deformities are due to malrotated fragments, and in the fingers this can best be determined by checking for the direction of a finger with the MPJ and IPJ flexed (normally, they should all be pointing towards the scaphoid tubercle) or by comparing the plane of the nailplate of the injured finger with that of the uninjured fingers while the IPJs are in flexion.
Palpation
When there is swelling, but no deformity, we palpate for tenderness. When there is tenderness over the bone itself (as opposed to over ligaments as we see in sprains), we should consider a fracture.
Range of Motion
Do not move hands with fractures!
KEY STUDY POINTS:
Describe the differences in fracture treatment between:
i. children and adults
ii. articular and extra-articular fractures
iii. open and closed fractures
What are the benefits and disadvantages of doing closed treatment compared to open reduction and internal fixation for fractures of the hand.
ADDITIONAL LEARNING ACTIVITY:
After going through this guide, it would be very helpful to have a practice session on the PE of the hand.