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ANATOMY AND EXAMINATION ANATOMY AND EXAMINATION OF THE HAND AND WRISTOF THE HAND AND WRIST
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OBJECTIVESOBJECTIVESBony structure
Nerve supply
Blood supply
History
Examination technique
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1. Radial styloid
2. Scaphoid
3. Lunate
4. Triquetral
5. Pisiform
6. Trapezium
7. Trapezioid
8. Capitate
9. Hamate
10. Metacarpal
11. Proximal phalanx
12. Middle phalanx
13. Distal phalanx
14. ulna styloid
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BONY STRUCTUREBONY STRUCTURE
• Carpal bones:scaphoid (some)lunate (lovers)Triquetral (try)Pisiform (positions)Trapezium (that)Trapeziod (they)Capitate (can’t)Hamate (handle)
(right hand dorsum)
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1. 1st metacarpal2. Metacarpals II-V3. Trapezium4. Tubercle of scaphoid5. Lunate6. Triquetrum7. Radiocarpal joint8. Distal end of radius9. Distal end of ulna
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Nerve supply Nerve supply -- SensorySensorySensory
Digital nerves: Each finger has two which run on the volaraspect of each digit laterally. Each supplies half of the finger.
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Nerve Supply Nerve Supply -- MotorMotor
Median nerve: passes through the carpal tunnel. It supplies the thenar muscles of the thumb.
Ulna nerve: Passes through ulna side of wrist. It supplies all the interossei , 2-3 lumbricals and hypothenar muscles .
Radial : No motor function in hand
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Blood supplyBlood supplyRadial artery: Lies on radial side of wrist. Main branch passes within the anatomical snuff box, then forming the palmer branch on volar aspect of the hand.
Ulna artery: Lies on ulna side of wrist then joining the radial artery to form the palmer branch.
Digital arteries: Each finger has two that run along the borders.
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HistoryHistory
MechanismTime since injuryHand dominanceOccupationTetanus status if wound
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Mechanism of InjuryMechanism of Injury
Definition
Pattern of Injury
Examination
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Mechanism of InjuryMechanism of Injury
Transfer of energy from environment to patientGives an idea of what injury to expect
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Mechanism of InjuryMechanism of Injury
Patterns of injury– Blunt
Fall on outstetched handFall on flexed handThumb “sprain”Punch injuryTwisting of fingers
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Mechanism of InjuryMechanism of Injury
Patterns of injury– Penetrating
LacerationIncised woundPunctureBite
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ExaminationExamination
Look– Swelling– Bruising – Deformity– Wound
Feel– Where tender esp Scaphoid– Palpable deformity
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ExaminationExamination
Move– Range of movement
ReducedAbnormal
– Any pain– Rotation
X-Ray
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ExaminationExamination
Flexor tendons– Deep– Superficial
Thumb
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ExaminationExamination
Sensation– Ulnar– Radial– Median
Motor– Medial– Ulnar
Wrist RadiologyWrist Radiology
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Who to XWho to X--RayRay
Consistent mechanism and – Clinical Scaphoid– Young children– Old ladies– Bony tenderness– Significant bruising or swelling– Any glass injury
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The Normal WristThe Normal Wrist
AP and Lateral are the standard views
AP Radial Styloidshould be more distal than Ulnar styloid
Lateral Radial articularsurface should have 50 of palmar angulationDistal radius, Lunateand Capitate should be in alignment
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ChildrensChildrens WristsWrists
The Epiphysis should be exactly centred on the metaphysis in all viewsThe epiphyseal plate should be uniformly wide in all viewsAny sudden change in curvature is abnormal
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Wrist AP and Lat Trans Wrist AP and Lat Trans scaphoidscaphoid perper--lunatelunate
dislocationdislocation
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Hand XHand X--RaysRays
Normal views– AP– Oblique
True lateral
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Metacarpal fracture: transverseMetacarpal fracture: transverse
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Metacarpal fracture: obliqueMetacarpal fracture: oblique
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BoxerBoxer’’s fractures fracture
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BennettsBennetts FractureFracture
Fracture dislocation of thumb matacarpal/carpal jointFollows forced extension of thumb
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The The ScaphoidScaphoid
Clinical diagnosis initiallyTypical mechanismTender anatomical snuffbox or anterior scaphoidInitial X-Ray may be normalFollow up in 10 daysIf missed may undergo avascular necrosis
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Inter Inter articulararticular FractureFracture
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Blade Plate Fixation Phalanx Blade Plate Fixation Phalanx
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BennettBennett’’s fractures fracture
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ScaphoidScaphoid waist fracturewaist fracture
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Unstable scaphoid nonUnstable scaphoid non--unionunion
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LunateLunate dislocationdislocation
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ScapholunateScapholunate dissociationdissociation
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UCL sprainUCL sprain
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UCL ruptureUCL rupture
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‘‘BonyBony’’ UCLUCL