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Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute.

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Presentation on theme: "Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute."— Presentation transcript:

1 Good Catch Detecting and Managing Upper Extremity Problems in the Emergency Department David Jones, MD Hand and Upper Extremity Surgery Orthopedic Institute

2 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

3 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

4 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

5 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

6 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 hr follow-up, urgent consult if concern for septic arthritis

7 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 hr follow-up

8 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

9 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

10 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

11 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

12 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

13 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

14 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

15 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

16 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

17 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 days if -

18 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

19 Blunt Trauma 4 th /5 th CMC fracture dislocation – History/Symptoms Punch/high energy trauma Pain over ulnar aspect of hand – Exam Swelling, +/- ecchymosis Most TTP over base of 4 th /5 th 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

20 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

21 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

22 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

23 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

24 Penetrating Trauma Local anesthesia – Lidocaine with epinephrine safe in fingers Let set for 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


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