Good CatchDetecting and Managing Upper Extremity Problems in the Emergency Department

David Jones, MDHand and Upper Extremity Surgery

Orthopedic Institute

Objective

To review common, or potentially serious, hand pathology presenting to the Emergency

Department to optimize the recognition and management of these conditions to improve

ultimate patient outcomes and function

Outline• Infections

– Penetrating contaminated wounds– Bite wounds– Infectious flexor tenosynovitis– Necrotizing fasciitis

• Blunt Trauma– Finger injuries – Thumb injuries – Wrist injuries – Compartment syndrome

• Penetrating Trauma– Lacerations – Local anesthesia

Outline• Infections

– Penetrating contaminated wounds– Bite wounds– Infectious flexor tenosynovitis– Necrotizing fasciitis

• Blunt Trauma– Finger injuries – Thumb injuries – Wrist injuries – Compartment syndrome

• Penetrating Trauma– Lacerations – Local anesthesia

Outline• Infections

– Penetrating contaminated wounds– Bite wounds– Infectious flexor tenosynovitis– Necrotizing fasciitis

• Blunt Trauma– Finger injuries – Thumb injuries – Wrist injuries – Compartment syndrome

• Penetrating Trauma– Lacerations – Local anesthesia

Hand Infections

• Penetrating wounds– History/Symptoms

• Deep inoculation event• +/- systemic symptoms• Immunocompromised state?

– Exam• Skin wound may be subtle, fluctuance, warmth,

erythema, TTP, +/- purulent drainage

– Imaging/Tests• Radiographs (foreign body, gas, osteo)• Labs (CBC, lytes, CRP, ESR)

– Plan• I&D pack open• Mark erythema, splint, elevation• IV/PO antibiotics cover MRSA• 24-48 hr follow-up, urgent consult if concern for

septic arthritis

Hand Infections• Bite wounds

– History/Symptoms• Known vs unknown animal• Dog bites 90% of all animal bites, cats 5%• Cat bites 76% of all infected bites

– Exam• Swelling, warmth, erythema, TTP, +/- purulent

drainage• Location over joint/tendon – fight bite

– Imaging/Tests• Radiographs (foreign body, gas, osteo)• Labs (CBC, lytes, CRP, ESR)

– Plan• I&D pack open, open cat bites• Mark erythema, splint, elevation, maceration

dressing• IV/PO antibiotics cover anaerobes, +/- rabies • Surgery consult if concern for septic arthritis or

pyogenic tenosynovitis• Admit vs 24-48 hr follow-up

Hand Infections

• Pyogenic flexor tenosynovitis– History/Symptoms

• Penetrating injury volarly, if not consider gonnorhea

• Immunocompromised state?

– Exam• +/- puncture wound• Knavel signs

– Semi-flexed position of finger– Fusiform swelling– Excessive TTP along course of tendon– Pain with passive finger extension

– Imaging/Tests• Radiographs (foreign body, gas, osteo)• Labs (CBC, lytes, CRP, ESR)

– Plan• Admit and surgery consult• Surgical urgency: purulence + pressure tissue

necrosis and tendon adhesions• Hold antibiotics pending surgical plan

Hand Infections• Necrotizing fasciitis

– History/Symptoms• +/- penetrating injury• Systemically ill, rapidly progressing• +/- sense of impending doom• Immunocompromised, IV drug use

– Exam• Early: cellulitis, exquisite TTP, edema extending

beyond cellulitis, hypotension• Late: dusky, purple skin, sloughing/necrosis,

anesthetic, septic/critically ill

– Imaging/Tests• Radiographs (foreign body, gas, osteo)• Labs (CBC, lytes, CRP, ESR)

– Plan• Broad spectrum IV abx• Admit, consider ICU• Surgical emergency for fascial biopsy and radical

I&D vs amputation, delay in surgical treatment increased mortality

Outline• Infections

– Penetrating contaminated wounds– Bite wounds– Infectious flexor tenosynovitis– Necrotizing fasciitis

• Blunt Trauma– Finger injuries – Thumb injuries – Wrist injuries – Compartment syndrome

• Penetrating Trauma– Lacerations – Local anesthesia

Blunt Trauma

• Mallet finger– History/Symptoms

• Hyperflexion injury - jammed finger• Pain, inability to straighten DIP joint

– Exam• Closed vs open injury?• TTP over DIP joint• Extensor lag/inability to straighten finger

– Imaging/Tests• Radiographs • +/- fracture, >50% articular surface or

volar subluxation surgery

– Plan• Stack splint continuously x6-8 weeks• Consider hand surgery referral (1-2 weeks)

especially if larger fracture fragment

Blunt Trauma

• Seymour fracture– History/Symptoms

• Crush or forced hyperflexion• Bleeding initially?

– Exam• Mimics mallet injury• Eponychial fold not clearly visible

– Imaging/Tests• Radiographs – good lateral view• Widening/fracture through distal phalanx

physis

– Plan• Hand surgery f/u (1-2 days) for I&D, open

reduction and perc pinning• Alumafoam splint• Initiate antibiotics • If missed nailbed deformity, osteo/septic

arthritis

Blunt Trauma

• FDP Avulsion “Jersey Finger”– History/Symptoms

• Forceful extension on flexed DIP joint• 75% ring finger involved

– Exam• TTP over distal phalanx• Abnormal resting finger cascade• Inability to flex DIP joint

– Imaging/Tests• Radiographs – possible avulsion fx

– Plan• Dorsal blocking plaster/OneStep splint in

intrinsic plus position• Referral <1 week for open repair

Blunt Trauma

• PIP joint injury– History/Symptoms

• “jammed finger”• Pain/swelling/stiffness

– Exam• TTP over PIP joint, pain with ROM• +/- deformity

– Imaging/Tests• Radiographs • Good lateral view to assess joint

congruency

– Plan• If dislocated, digital block and closed

reduction• Alumafoam splint (if fracture dorsal place in

extension, if fracture volar place in flexion)

• Referral <1 week

Blunt Trauma

• Thumb UCL injury “Skier’s thumb”– History/Symptoms

• Thumb hyperextended or jammed• Pain, swelling, weakness with pinch

– Exam• Swelling, ecchymosis at thumb MP joint• TTP over ulnar aspect• +/- instability to radial deviation stress

– Imaging/Tests• Thumb radiographs – possible avulsion fx,

joint subluxation

– Plan• Thumb spica splint• F/U in 1-2 weeks for possible surgical repair

Blunt Trauma

• Thumb metacarpal base fracture “Bennet fracture”– History/Symptoms

• Jammed thumb

– Exam• Swelling, TTP over CMC joint,

weakness with pinch

– Imaging/Tests• Thumb radiographs

– Plan• Thumb spica splint• Referral <1 week for surgical

treatment

Blunt Trauma

• Scaphoid fracture– History/Symptoms

• FOOSH• Wrist pain, stiffness

– Exam• +/- swelling or ecchymosis• TTP anatomic snuffbox• Pain with wrist ROM

– Imaging/Tests• Wrist radiographs including scaphoid

view (ulnarly deviated PA view)

– Plan• Thumb spica splint• Referral <1 week if x-rays +• Repeat x-rays in 10-14 days if -

Blunt Trauma

• Dorsal triquetral avulsion fracture– History/Symptoms

• FOOSH• Dorsal wrist pain

– Exam• Swelling/ecchymosis over dorsum of wrist• Most TTP over dorsal ulnar wrist > distal

radius• Pain with wrist ROM

– Imaging/Tests• Radiographs – dorsal fleck on lateral view

– Plan• Wrist splint• Referral 1-2 weeks for repeat radiographs, tx

like wrist sprain, wean from splint as tolerated 4-6 weeks

Blunt Trauma

• 4th/5th CMC fracture dislocation– History/Symptoms

• Punch/high energy trauma• Pain over ulnar aspect of hand

– Exam• Swelling, +/- ecchymosis • Most TTP over base of 4th/5th

metacarpals

– Imaging/Tests• Radiographs – joint incongruity,

metacarpals not parallel, fx fragments

– Plan• Ulnar gutter splint• Referall <1 week for closed vs open

reduction and perc pinning

Blunt Trauma

• Perilunate dislocation– History/Symptoms

• High energy injury/FOOSH• Pain, +/- paresthesias

– Exam• Swelling, TTP, pain with ROM• Acute carpal tunnel syndrome

– Imaging/Tests• Wrist radiographs, if in doubt CT

– Plan• Urgent closed reduction• Splint• Referral for ligament repair and pinning

Blunt Trauma

• Compartment syndrome– History/Symptoms

• High energy injury• Crush injury

– Exam• Swelling• 5P’s• Pain – difficult to control or exquisite

PROM

– Imaging/Tests• Radiographs • +/- compartment pressure monitoring

– Plan• Emergent surgical consult for possible

fasciotomies

Outline• Infections

– Penetrating contaminated wounds– Bite wounds– Infectious flexor tenosynovitis– Necrotizing fasciitis

• Blunt Trauma– Finger injuries – Thumb injuries – Wrist injuries – Compartment syndrome

• Penetrating Trauma– Lacerations – Local anesthesia

Penetrating Trauma

• Lacerations– History/Symptoms

• Sharp injury• Bleeding, loss of function

– Exam• Thoroughly assess radial and ulnar sensation in each

digit PRIOR to anesthetizing/exploring wound• Vascular status of each finger• Assess active motion at each joint HIGH index of

suspicion for tendon/nerve injury• Potential for joint injury

– Imaging/Tests• Radiographs – rule out foreign body or bony injury

– Plan• If perfused, I&D, repair lac, splint, tetanus and abx• Refer 1-2 days

Penetrating Trauma

• Local anesthesia– Lidocaine with epinephrine safe in fingers

• Let set for 20-30 min for hemostasis

– Tips for nearly painless anesthesia• Buffer 10 mL lidocaine with 1 mL of 8.4% bicarb• 27 gauge needle• Needle perpendicular to skin• Inject slowly• Keep fluid wave 5 mm ahead of needle tip