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1
EVALUATING PATIENT S WITH URGENT
HAND INJURIES
Performing a history and physical examination on a patient who
presents with an acute hand injury is a skill that is refined with
experience. It takes many years of training to be an expert in this
area, so do not feel discouraged if you find yourself in unfamiliar
territory. What follows are some basic principles to help keep you on
the right track.
Ask the Important Questions. The first 3 things you want to
know about anyone presenting with a hand injury are age, hand
dominance, and occupation. These significant characteristics are
important factors that affect treatment options and outcomes.
l Age can work for or against a patient in terms of recovery. For
example, we know that nerve repairs tend to be more successful
in younger patients than older patients. However, we also know
that joint surfaces affected by fractures can go on to develop
arthritis over time; this might not lead to problems in the wrist
of an 82 year old, but certainly might in a 28 year old.
l Hand dominance will give you and the patient an idea of how
much this will affect him or her acutely and in the future.
Even the simplest daily activities, such as brushing one’s teeth,
become more difficult when using the nondominant hand.
l Occupation also is important in determining what effect an
injury will have on this patient’s future. For example, a bad
wrist fracture in a massage therapist might result in more significant impairment than the same fracture in someone who
works primarily at a desk. A laborer who has a digital amputation might be better served with a revision and closure of the
amputation stump than by replantation of the digit because he
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or she likely would be less symptomatic and be able to return
to work sooner.
l Medical comorbidities can be causative or contributing factors.
Diabetes can be associated with hand conditions ranging from
trigger finger to cellulitis; gout often is not recognized when it
presents in the hand and wrist. Smoking (which we will call
a “comorbidity”) impairs blood flow and can inhibit healing
of bone and soft tissues. Knowing that such conditions can be
associated with hand complaints will help you diagnose and
treat.
Get the Details. It sometimes is difficult to listen to the stories
of hand injuries, but it is extremely important to find out what happened, where, when, and why. A laceration by a clean kitchen knife
is not as concerning as one by a dirty lawnmower blade; a puncture
wound by a thorn is not as emergent as one by a tooth (see Chapter
30). An infection that has developed over a few days is different from
one that becomes raging within hours. Ask the patient or witnesses
for the details and make sure that you have a clear understanding of
what happened.
Do a Thorough Evaluation. It is very important to perform
an accurate assessment of the extremity. Use the basic principles:
inspection, palpation, range of motion, sensory examination, vascular examination, strength testing. It helps to draw a diagram of the
injured area and label any lacerations, deformities, deficits, etc. so
that you can remember and document the status at that time. Draw
and label both dorsal and volar (palmar) views, and label the side
(right versus left) and the digit, if applicable. A diagram template
can be found in Appendix I. Also, remember to check for other
injuries; often the most apparent is the one that is diagnosed, but
pay close attention to injuries that can be missed (Figure 1-1). The
examination will be covered in more detail in the next chapter.
Get the Right Studies
do not suspect a fracture. A full set of radiographs (usually 3 views)
is necessary in the hand and wrist. In addition to showing fractures
and dislocations, radiographs can show foreign bodies, air, soft tissue swelling, and other important characteristics that are helpful for
treatment now and later. Make sure you look at all studies that you
order, rather than relying on someone’s reading; you might pick up
something that he or she missed.
.
Always get a set of radiographs even if you
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Figure 1-1. This 17-year-old
right-hand dominant quarterback fell during a game and
sustained an injury to his index
metacarpal. The initial provider
did not see the scaphoid fracture
at the edge of the film, a fracture that likely had been missed
by another provider whom the
patient had seen 3 years before
the recent injury.
Manage Expectations. Patients often will ask you what they can
expect in the near and far future. Each chapter of this book includes
an anticipated definitive treatment plan to help guide you in answering these questions. However, it is helpful to explain to patients that
every person and every injury has a different healing potential, so
much of what happens next will depend on those differences. It is
acceptable to tell them that you are not the hand specialist and that
you do not know all the answers; after all, your hand specialist likely
would not answer the questions about most of the non-hand conditions you treat, and honesty is always best.
Ask for Help. If you are uncertain about how to manage something, ask. Ask a colleague, a supervisor, a consultant, someone who
has more experience than you. It is a good idea to establish a relationship with one or more hand specialists in your area whom you
feel comfortable contacting for advice. In the hospital setting, there
usually is a hand surgeon on call who might be able to help you by
phone or in person. It is better for everyone if you ask for help before
you do something about which you are unsure.
Refer Early. Patients never complain that they wish they had not
seen a hand specialist so early, and they never are upset when a hand
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specialist gives them good news (eg, “it is unlikely that this is a fracture”). The bad news—when it has to come—is unavoidable, but it is
the late bad news that is a problem. Most acute conditions should be
referred as soon as possible (within a few days) so that the diagnosis
can be confirmed, and a definitive treatment plan can be made.
These are just a few pearls to keep in mind as you treat patients
with acute hand complaints. Helping these people can be very gratifying; you truly are a part of each patient’s road to recovery.
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2
EXAMINATION OF THE HAND
The complex anatomy of the hand is beyond the focus of this book,
but understanding the anatomy is key to performing a thorough,
accurate examination, and facilitating a proper diagnosis and course
of management. Documentation and communication of examination
findings are easier when descriptive terms referring to surface anatomy (Figure 2-1) and underlying bone and joint architecture are used.
Inspect the hand for skin lacerations, edema, ecchymosis, and
deformity. These often are indicative of a serious injury.
Palpate for tenderness, crepitation, fluctuant areas, and instability.
Assess the range of motion of the elbow—flexion/extension;
the forearm—pronation/supination; the wrist—flexion/extension
and radial/ulnar deviation; and the digits—flexion/extension of the
metacarpophalangeal joints (MPJ), the proximal interphalangeal
joints (PIPJ), the distal interphalangeal joints (DIPJ), and adduction/
abduction of thumb at the carpal metacarpal joints (CMCJ).
Examine the function and motor strength of muscles and tendons
(Figures 2-2A-E, 2-3A-E, 2-4A-E). For communication and comparison
purposes, motor strength can be graded on a scale from 0 to 5:
0/5 No detectable muscle function
1/5 Muscle visibly contracts or “flickers”
2/5 Muscle functions with gravity eliminated
3/5 Muscle functions against gravity, but not against
any other resistance
4/5 Muscle functions against examiner’s resistance,
but not at full strength
5/5 Muscle functions against examiner’s full resistance
(“normal”).
Evaluate sensation using a 2-point discrimination. This can be
performed using a caliper (Figure 2-5) or a paper clip. A sensory
deficit is indicated by the inability to discriminate 2 points as little
as 6 mm apart. This should be documented in all nerve distributions:
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Figure 2-1. Surface anatomy can be used to describe locations of tenderness, swelling,
lacerations, and deformities.
median, ulnar, and radial (Figure 2-6), and in the radial and ulnar
digital nerve distributions of each digit.
Assess perfusion using skin color, nail bed blanching, digital
Doppler examination, and Allen’s test. To perform Allen’s test at
the wrist:
l Place slight manual pressure on the patient’s radial and ulnar
arteries at the wrist.
l Ask the patient to make a fist and extend the digit multiple
times to exsanguinate (remove blood from) the hand, then
occlude the radial and ulnar arteries.
l Release pressure on the radial artery while maintaining occlu-
sion of the ulnar artery; perfusion of the hand within 5 seconds
indicates a patent radial artery and circulation through the arch
to the hand.
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l Repeat the examination, releasing the ulnar artery occlusion
and maintaining pressure on the radial artery to assess patency
of the ulnar artery and perfusion through the arch.
B
E
“extrinsic flexors” of the hand
and wrist. (A) Flexor pollicis
longus (IPJ flexion). (B) Flexor
digitorum profundus (DIPJ
flexion). (C) Flexor digitorum
superficialis (isolated PIPJ
flexion). (D) Flexor carpi
Figures 2-2A-E. Testing of the
radialis (radial wrist flexion).
(E) Flexor carpi ulnaris (ulnar
D
A
C
wrist flexion/ulnar wrist devia-
tion).
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B
Figures 2-3A-C. Testing of the “extrin-
sic extensors” of the hand and wrist.
(A) Abductor pollicis longus (abducts
thumb away from plane of palm). (B)
Extensor carpi radialis brevis and longus
(radial wrist extensors). (C) Extensor
pollicis longus (thumb extension).
C
A
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E
proprius (isolated index digit extension),
extensor digiti minimi (isolated small
digit extension), and extensor digitorum
communis (tandem index, long, ring, and
small digit extension). (E) Extensor carpi
Figures 2-3D-E. (D) Extensor indices
ulnaris (ulnar wrist extension/deviation).
D
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