Beruflich Dokumente
Kultur Dokumente
And Digits
Anatomy
Principles of Evaluation
General Hand Examination
Anesthesia and Direct Wound
Examination
Radiographs, Consultation,
and Disposition
Tendon Injuries
Flexor / Extensor Tendons
Ligaments And Dislocation
Injuries
Compartment Syndrome
High-Pressure Injection Injury
Hand Anatomy
Hand consist of 27
bones:
14 Phalangeal bones
5 Metacarpal bones
8 Carpal bones
Carpal bones are
made up of two rows of
four bones bridged by
flexor retinaculum
which forms the carpal
tunnel.
Carpal tunnel consist
of the median nerve
and the nine long flexor
of the fingers
Hand Anatomy
Intrinsic muscle of the
hand:
Have their origins and
insertions within the
hand.
Consist the following:
Thenar, Hypothenar,
adductor pollicies, the
interossei and the
lumbricals. (Refer to pg
1665 for anatomical
description)
Hand Anatomy
Extensor Tendons:
Courses over the dorsal side of the forearm,
wrist and hand.
9 extensor tendons pass under the extensor
retinaculum and separate into 6
compartments
Surface anatomy of the hand.
Extensor Tendons:
The extensor tendons gain entrance to
the hand from the forearm through a
series of six canals, five fibroosseous
and one fibrous The communis
tendons are joined distally near the MP
joints by fibrous interconnections
called juncturae tendinum. Beneath
the retinaculum, the extensor tendons
are covered with a synovial sheath.
Hand Anatomy
Extensors digitorum communis are
connected by junctura.
Flexor Tendons:
Flexor carpi
radialis, flexor
carpi ulnaris,
and palmaris
longus primarily
flex the wrist
Hand Anatomy
Hand Anatomy
9 flexor tendons pass through the carpel
tunnel:
1 tendon go to the base of the dist. Phalanx of the
thumb
Flexor digitorum
profundus (FDP) runs
deep to the FDS until
the level of the MP joint
where FDS bifurcates.
Thepatient’soccupation,priorhandinjuries,
and handedness should be documented
Principles of Evaluation
The position of the hand at the time of
injury should be determined.
Tendon testing:
Full ROM of each tendon against resistance
should be assessed and compared with the
uninjured side.
Principles of Evaluation
Tendon testing:
Important to test resistance because up to
90 % of a tendon can be lacerated with
preservation of ROM without resistance.
Usually dorsal
Mechanism:
Hyperextension force causing rupture of the volar
plate.
Ligament and Dislocation injuries
Thumb MP dislocation:
Reduction:
After a radial nerve block.
Bennett's fracture
Avulsion fracture of
the articular surface
of the first
metacarpal with
subluxation at the
CMC jt.
Fractures
Thumb MC
Intraarticular
Rolando fracture
An intraarticular comminuted fracture at the base of the
metacarpal.
Mechanism of injury is similar to the Bennett fracture, but
less common.
Treatment – thumb spica splint and surgery consultation.
COMPARTMENT SYNDROME
May occur in crush injury of the hand with
or without associated fracture.
Involved compartments of the hand
includes:
Thenar
Hypothenar
Adductor pollicis
Four interossei
COMPARTMENT SYNDROME
Cross section
through the palm
showing
compartments of
the hand
COMPARTMENT SYNDROME
Edema of tissues or hemorrhage within
any of these compartments may lead to
elevated pressures that result in tissue
necrosis and subsequent loss of hand
function due to contracture.
Sign and symptoms:
Pain and paresthesias occur early
Paralysis and pulselessness occurring later
COMPARTMENT SYNDROME
Sign and symptoms:
Pain
Most consistent clinical sign
usually described as deep, constant, poorly
localized and disproportionate to clinical findings.
PE findings:
“intrinsicminus”positionatrest(MCP
extended with PIP slightly flexed)
Pain with passive stretch of the involved
compartmental muscle
COMPARTMENT SYNDROME
PE findings:
Pain with passive stretch of the involved
compartmental muscle
Interosseous: performed with MCP extended and
PIP fully flexed with slight radial ulnar deviation
Thenar / Hypothenar: performed by extension of
MCP
Tense swelling of the affected compartment
COMPARTMENT SYNDROME
Diagnosis
Confirmed by compartment pressure
measurement – high rate of false readings.
In the setting of severe crush injury with signs
and symptoms suggestive of compartment
syndrome, emergent hand surgeon
consultation for fasciotomy is mandatory.
High – Pressure Injection Injury
The initial dissipation of kinetic energy
through the soft tissue of the hand
produce tissue edema and resultant
ischemia of the tissue.
Most common injected substances include
grease, paint, hydraulic fluid, diesel fuel,
paint thinner, and water.
High – Pressure Injection Injury
Definitive treatment of high – pressure injection
injuries is early surgical decompression and
debridement of injected areas.
These must be recognized as surgical
emergency and obtain immediate hand surgery
consultation, immobilize and elevate the affected
hand, initiate tetanus prophylaxis, broad-
spectrum antibiotics and provide adequate
analgesia.