good catch detecting and managing upper extremity problems in the emergency department david jones,...
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![Page 1: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/1.jpg)
Good CatchDetecting and Managing Upper Extremity Problems in the Emergency Department
David Jones, MDHand and Upper Extremity Surgery
Orthopedic Institute
![Page 2: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/2.jpg)
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
![Page 3: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/3.jpg)
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
![Page 4: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/4.jpg)
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
![Page 5: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/5.jpg)
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
![Page 6: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/6.jpg)
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
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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
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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
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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
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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
![Page 11: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/11.jpg)
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
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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
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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
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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
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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
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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
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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 -
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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
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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
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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
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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
![Page 22: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/22.jpg)
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
![Page 23: Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute](https://reader035.vdocument.in/reader035/viewer/2022062515/56649cc55503460f9498edcd/html5/thumbnails/23.jpg)
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
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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