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 24-48 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 24-48 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 10-14 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 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