History taking

L H Tan, V. Rajaratnam
COMFORT AND ANALGESIA

Ensure that the patient is as comfortable as possible and that adequate analgesia has been given even before the history -taking and full evaluation. Patients concerns: What effect will his injury have on his/her everyday life, both immediately and in the long term, and What treatment options are available? You must also be aware that the patient requires sufficient information, assurance and confidence to be in the surgeons hands.
HISTORY

The following information must be obtained in any hand injury patients: 1. Name 2. Gender 3. Age 4. Dominant-hand 5. Occupation 6. Hobbies/recreational activities 7. Smoker / non-smoker Other general points in history: The patients current health status, past medical history, previous anaesthetic experiences, bleeding disorders, current medications, allergies, tetanus immunisation status and time of last meal should all be recorded.

Understanding Hand Surgery

Date, time and type of injury

It can potentially have medico-legal implications. The time of injury should be noted as certain injuries require urgent management and should be treated as soon as they are recognized; in order of urgency: 1. Uncontrolled haemorrhage secondary to vascular injury 2. Complicated fracture or dislocation compromising major vascular injury or producing doubtful viability 3. Compartment syndrome 4. Macro-replantation, that is when the amputated part contains significant muscle bulk 5. Hydrofluoric acid burns 6. Pressure gas injuries If left untreated, the hand will undergo certain changes, which will influence its eventual recovery of function: Necrosis and contractures may result from vessel occlusion secondary to unstable fractures. (Due to irreversible permanent intimal changes or irreversible ischemia in the area of blood supply) Contamination of the tissue causing infection. Progressive edema, leading to: a) Compartment syndrome b) Joint contracture c) Friability of tissues, which may complicate tendon, nerve, and vessel repairs d) Difficulty in skin closure, to the point of compromising skin circulation

Place of injury
Home Work

Understanding Hand Surgery

Outdoor

Mode of injury
Accident RTA (Are there other injuries which may take precedence?) Self-inflicted (Is the patient likely to re-injure / be noncompliant?) Assault

Mechanism of injury
1. What happened to your hand? 2. Which part of your hand is injured? 3. How was it injured? Roller Punch Pressure Saw Laceration Penetrating Blunt Pressure gun Gunshot wound Others e.g. lawn mower

Roller injuries
Does it have a roller?

Roller injuries commonly produce avulsion flaps, whereby the distal part may not be viable and hence amputation would be the only treatment option. What is the size of the gap?

If the gap is small, distal crush may be so severe that revascularisation may not be successful.

Understanding Hand Surgery

What are the rollers surfaced with? What normally passes through the rollers?

There may be some foreign bodies in the wound which may or may not cause increased risk of wound contamination and will therefore

Fig: Extensive roller injury to hand and forearm

Fig: Punch press injury need adequate irrigation in A&E or a formal washout and debridement in theatre. Are they hot?

Understanding Hand Surgery

The viability may be compromised by burns or heat from the friction of rollers, especially the ones that do not have an automatic release or arrest. Do they have an automatic release mechanism? How quickly were they stopped once your hand was caught? As prolong pressure necrosis can result.

Punch pressure
What is (roughly) the area and shape of the punch press? What is the narrowest space in which your hand was compressed?

Depending on what the punch pressure produces, it can inflict moderate to severe injuries. A large area of injury can cause comminuted fractures, carpal disruption and soft tissue injuries. In a smaller area of injury, division of tendons and nerves at two levels is more likely compared to roller injuries. How long was your hand under the punch? Again bear in mind that blood vessels may be compromised causing significant necrosis.

Saw
Saw (esp. electrically driven circular saw) injuries from carpentry/DIY accidents is very common. What kind of saw? e.g. Circular saw or high speed metal saw What were you cutting?

Understanding Hand Surgery

(a) (b) (c) Fig: a) Laceration caused by a saw injury. (b) Laceration caused by a sharp instrument (c) Avulsion injury of thumb This will give you an idea of risks of contamination or possibilities of foreign bodies. Whats the set on the blade (amount of deflection in the saws teeth from a straight line)

A high speed metal saw with a narrow set will approximate to a knife cut. On the other hand a wide set saw avulses as well as cutting, producing damage distant from the skin wound. This would make re-vascularisation and replantation difficult.

Laceration
Show me the position of your hand when it slipped on the knife?

The relationship of the distal cut end of the long flexor tendons of the fingers to the wound skin varies according to the posture of the hand at the time of injury. The distal tendon ends may be at the wound itself when the finger is extended. If the finger was fully flexed then the distal tendon ends will be as far removed (proximally) from the skin laceration. This would beSaw important blade for injury surgeon when carrying out primary tendon repair.

Penetrating
Show me how it happened?

Avulsion of t

Understanding Hand Surgery

Penetrating injuries of the hand carry the same sinister implication as penetrating injuries to the abdomen or neck. An unimpressive wound may hide a remarkable amount of damage to deep structures. In what direction was it pointing?

The damage to deep structures in stab wounds may be remote from the skin wound. What stuck into your hand?

Short puncture lacerations over the knuckles should raise suspicion as they are most likely inflicted by the human teeth, even though the patient may deny it. This injury is prone to infection, which can be more resistant than infections related to dog bite injuries. Immediate copious irrigation can significantly decrease this risk. Hence exploration and washout in theatre is essential. Broad spectrum antibiotics are essential in the management of human and dog bite injuries. For example, intravenous coamoxiclav and flucloxacillin for human bite wounds and intravenous co-amoxiclav for dog bite wounds.

Pressure gun
Penetrating gun injuries need to be treated with urgency depending on what agent has been injected. The most common substances are paint, grease, hydraulic fluid or molten plastic. Patients may not have pain immediately. They should have immediate exploration and removal of all foreign material. If not immediate, may result in infection, gangrene and amputation. The long term outcome includes fibrosis, and discharging sinuses from granulomas which can cripple the hand

Gunshot
1. 2. Type of gun? Range and calibre?

Understanding Hand Surgery

High-energy injury is associated with comminution, bone loss, significant skin defects and a high incidence of vascular and nerve injury. Low-energy wounds, however, often present as a foreign body in the tissues.

Blunt injury
Blunt injury including falls. Very heavy falls on an outstretched hand are commonly associated with supracondylar fractures in children, carpal injuries in young and middle aged adults and Colles fractures in the elderly. 1. 2. What height did you fall from? Did you have to stop what you were doing?

Patients may be able to continue doing what they were doing with the initial sustained hair line fracture, which can subsequently progress into a complete fracture following further insult, thus causing severe pain and not allowing them to continue.

Previous injury
Previous injury to the part, primary treatment and subsequent progress and therapy may be relevant. Other relevant points in history include:

Current health status/ Relevant past medical history

Apart form obtaining associated injuries, a brief general medical history should be obtained. This is to elicit any cardio-respiratory problems, which may influence the choice of anaesthesia.

Psychiatric disorder

Psychiatric disorders which may severely limit postoperative cooperation.

Medication / Allergies

Some medication may interfere with adequate healing. Uncontrolled diabetes, certain skin conditions, and steroid intake are associated with increase sepsis rate. Drug allergies should always be recorded.

Understanding Hand Surgery

Social history

Patients occupation is very important in choosing the appropriate operation procedure. This is especially important in reconstructive surgery, which aims to restore maximum function to the hand and to do that in the shortest time. For instance, a self employed manual worker would want to get back to work as soon as possible, therefore a long lengthy rehabilitation period is unsuitable for patients needs. 1. What exactly do you do? 2. How long have you been doing that kind of work with the current employer? 3. Are you self-employed or is your employer holding your job? 4. Do you hope to go back to the same job? 5. Are you the only person working at home? 6. How many people are you supporting? Smoking is also well known to affect tissue healing and a high alcohol abuser may indicate a non-compliant patient.

Recreational
Do you play any musical instruments? E.g. Guitar, piano, violin

TAKING REFERRALS FOR REPLANTATION

When taking a referral for replantation, the following questions and statements should be presented to the caller. (Also see Chapter 13) 1. What is your name, that of your facility and the contact number? 2. How did the amputation happen? 3. Are there any injuries else where in the body? 4. How old is the patient and is he generally healthy? 5. Does the patient smoke? 6. Is that limb otherwise intact?

10

Understanding Hand Surgery

7. How about the x-ray? 8. How will you prepare the limb for transport? With respect to the amputated part: 1. Are there other injuries? 2. When you wash off the wound, are there structures dangling from the part? 3. Tell me about the xray of the part? 4. How will you transport it? 5. Is there a good/fair/poor chance of replantation? 6. We will be glad to see the patient but please emphasize to him/her and the family that the decision to try replantation can only be made here and, of course success cannot be guaranteed. 7. How will patient be transported? 8. Can you give me an estimated time of arrival?

Understanding Hand Surgery

11

Evaluation of hand injur ies

M Brewster & V Rajaratnam Before addressing this topic there are 3 crucial rules for success. Assess for life threatening injuries first, as per ATLS guidelines. Meticulously document the examination (it is often helpful to use accurate drawings). Compare the injured with non-injured hand.

INSPECTION

Whilst inspecting a hand, remember the surface anatomy to aid with accurate diagnosis (see Chapter 1).

Attitude
The position or Attitude of the resting hand can reveal many underlying pathologies. In a normal relaxed hand a smooth cascade is created by the fingers. A break in this cascade can signify underlying bone, tendon or nerve injuries. When flexed at the MCP + PIPJs the fingers should all point towards the scaphoid tubercle. The finger nails should be roughly aligned. Rotational deformities in finger fractures may be exaggerated with the fingers flexed in this position.

Fig: Note the normal finger cascade is broken

Fig: Nomally, flexed fingers converge towards the scaphoid

12

Understanding Hand Surgery

Fig: Note rotational deformity of the index finger

Fig: Cellulitis (and possible deep infection)

Understanding Hand Surgery

13

Discolouration and Swelling/Altered Contours

1. Colour a. Pink: adequate perfusion b. Red: cellulitis/infection c. Focal bruising: underlying injury d. Bruising at a site away from an area of impact: such as dorsal wrist bruising after a FOOSH, strongly suggests underlying skeletal injury, even with normal x-rays. e. white or blackened wounds - full thickness burns or charred tissues. f. exposed tissues e.g. yellow fat, white nerves or tendons. g. Green (+/- mal-odorous): pus h. Black: necrotic 2. Swelling - relate to anatomical location. a. fluids e.g. blood, oedema b. muscle and other soft tissues after injury e.g. muscle rupture c. bones e.g. fracture and/or dislocation d. foreign bodies e. infection/inflammation N.B. - As the palm and its skin are tightly contained greater amounts of swelling can occur in the dorsum of the hand even with palmar pathology. COMPARTMENT SYNDROME is suggested by an increase in pain which is out of proportion with the injury during movement of contained muscles. Compartment pressures may need to be measured (using a manometer) in the unconscious patients if there is a high index of suspicion.

(a) (b) Fig: (a) A simulated laceration in a partially flexed finger. (b) When the finger is extended, the injured tendon (shown by the green line) moves away from the skin laceration

14

Understanding Hand Surgery

REMEMBER Compartment syndrome does not only occur following fractures and crush injuries but also with circumferential burns, injection injuries and tight dressings too. 3. Contours - displaced fractures e.g. distal radius, metacarpal neck and proximal phalanx. 4. Dislocations e.g. MCP, PIPJ, DIPJ, lunate - alter flexor / extensor tendon tension balance and may present as unusual posture or joint position due to proximal injury.

Wounds and Scars

Wounds should be examined and explored. Document - site, size, depth and mode of injury. TRAP Soft tissues move beneath the skin, therefore damage deep structure can lie at a distance from the skin wound e.g. a laceration to a tendon in a flexed finger will lead to tendon injuries distal to the wound in an extended finger.

Contamination
The level of wound contamination should be noted and in combination with the history will assist in decisions on treatment e.g. antibiotics and tetanus vaccination. Even if not contaminated this could be a good time to update an overdue tetanus vaccination. Puncture wound from fight bite punched teeth of another person can cause extensor tendon injury and open MP joint.

Nails
Subungual haematomas can herald a nail bed injury and potentially an open fracture of the distal phalanx.
PALPATION

Tenderness
This suggests underlying injury or infection/inflammation. Specific injuries are: 1. Scaphoid # a) Anatomical snuff box (wrist in ulnar deviation) b) Scaphoid tubercle (wrist in radial deviation) c) Through line of thumb metacarpal. 2. Lunate dislocation - Mid palm at level of distal wrist crease 3. Game Keepers Thumb - Pain and instability if applying radial force to thumb MCPJ.

Temperature
hot: infection warm: perfused

Understanding Hand Surgery

15

cold: environmental factors or poor perfusion.

Sweating
Require some nervous innervation.
MOVEMENT

Test ACTIVE then PASSIVE movement. A passive range of motion can be used to assess crepitation (joint surface injury), resistance (swelling, subluxation, dislocation) and instability (ligament injury). Test proximal to distal to facilitate diagnosis of nerve/tendon injury level.

(a) (b) Fig: Location of tenderness in (a) Scaphoid injury, (b) TFCC injury (in sulcus distal to the ulnar styloid, with wrist in radial deviation).

16

Understanding Hand Surgery

Action Finger. Ext. Finger. Flex.

Joint DIPJ +PIPJ MCPJ DIPJ PIPJ MCPJ MCPJ IPJ MCPJ IPJ MCPJ

Muscle lumbricals / interossei (mainly palmar) ED, EI, EDM FDP FDS lumbricals / interossei palmar/dorsal interossei (PAD + DAB) EPL EPB FPL (ant. Interosseous) FPB ST APL+APB/AddP, 1 D Interosseous, OP FCU / ECU FCR / ECRL/B ECU / ECRL/B FCU / FCR

Nerve M+U / U R M+U M M+U/U U R R M M R+M/MU M U/R M/R R U/M

Finger. Add./ Abd. Thumb Ext. Thumb Flex. Thumb Abd./ Add. Thumb Opp. Wrist. Ulnar Devi. Wrist Radial Devi. W. Extension W. Flexion

MCP+CMCJ MCP+CMCJ Radio carpal Radio carpal Radio carpal Radio carpal

Range of movement can vary, therefore, compare to uninjured hand.

Normal ROM
MP 0 90 PIP 0 100 DIP 0 70 W. Ulna Dev 0-35 W. Rad. Dev 0-15 W. Ext. 0-55 W. Flex 0-65

Understanding Hand Surgery

17

Fig: Normal range of motion in wrist, MCPJ and IP joints

Fig: Tenodesis effect

18

Understanding Hand Surgery

REMEMBER - Median innervated intrinsics Lumbricals (lateral 2) Opponens pollicis Abductor pollicis brevis Flexor pollicis longus Tenodesis An adjunct to active and passive movement is tenodesis. This describes the change in posturing of the hand distal to a moving joint e.g. Wrist extension active/passive causes finger flexion and thumb adduction to the key pinch position. The reverse is true for wrist flexion.
SPECIAL

Tendon Zones
Zones are used to describe Flexor and Extensor tendon injuries. There are 5 flexor and 7 extensor zones in the hand/wrist (see below).

Flexor Zones
1. Zone I consists of the profundus tendon only and is bounded proximally by the insertion of the superficialis tendons and distally by the insertion of the profundus tendon into the distal phalanx. 2. Zone II is often referred to as Bunnell's no man's land, indicating the frequent occurrence of restrictive adhesion bands around lacerations in this area. Proximal to zone II, the superficialis tendons lie superficial to the profundus tendons. Within zone II and at the level of the proximal third of the proximal phalanx, the superficialis tendons split into 2 slips. These slips then divide around the profundus tendon and reunite on the dorsal aspect of the profundus, inserting into the distal end of the middle phalanx. This split of the superficialis tendon is known as Camper chiasma. 3. Zone III extends from the distal edge of the carpal ligament to the proximal edge of the A1 pulley. Within zone III, the lumbrical muscles originate from the profundus tendons. The distal palmar crease superficially marks the termination of zone III and the beginning of zone II. 4. Zone IV includes the carpal tunnel and its contents (ie, the 9 digital flexors and the median nerve). 5. Zone V extends from the origin of the flexor tendons at their respective muscle bellies to the proximal edge of the carpal tunnel.

Extensor tendon Zones

I. II. III. IV. V. VI. VII. DIPj: (Mallet Injury ) Central slip to DIPj PIP j MCPj to PIPj MCPj CMCj to MCPj Wrist and proximal

Understanding Hand Surgery

19

NB - Pain on move can be related to swelling, fracture, foreign body, sot tissue injury. Intact but painful movement can also signify partial rupture/division of tendons.

Nerves
Neurological examination is divided into Sensory and Motor. An accurate history to assess preinjury neurology is ESSENTIAL and can prevent unneeded operation. a) Sensory The sensory distribution of the upper limb can be described and examined in a number of ways:

(a)

(b)

(c)

Fig: Testing for individual muscles (a) FDS to ring finger (b) FDP to ring finger, (c) FPL

Fig: Quick tests for nerves (a) Median nerve (b) Radial nerve

20

Understanding Hand Surgery

1. Individual Nerves Digital Nerves Ulna and radial digital nerves to each digit : palmar finger laceration injuring digital artery very likely to have damaged the nerve. 2.Dermatomes C4-T3 used for brachial plexus and more proximal injuries. See section on nerves 3.Proximal to Distal (as per neuropathy in glove and stocking distribution) b) Motor Many of the movements tested in examinations can not be exclusively attributed to a single nerve. Recognised tests for single nerves are: Quick Tests For median nerve pinch For radial nerve extend thumb, wrist and fingers 1. Radial - Posterior interosseous nerve Isolated extensor pollicis longus (EPL) : Palm face down and lift thumb away from table. 2. Median - Recurrent motor branch Isolated adbuctor pollicis brevis (APB) : Palm face up and abduct thumb towards ceiling. 3. Median Anterior interosseous nerve Kiloh-Nevin sign flexion at thumb IPJ and Index DIPJ to create the OK sign is used for supracondylar or forearm fractures in children as easy to copy (innervation of FPL and FDP to index amongst others). 4. Ulnar Nerve Froments sign tests adductor pollicis. : Place paper perpendicular to the palm along radial border of index finger. Grip the paper by adducting the thumb. If grip against resistance is only possible by flexing at IPJ and not by simple adduction, then test is positive and adductor pollicis is denervated or injured. Ulnar Paradox The phenomenon in which a proximal ulna nerve lesion produces a less clawed hand than a more distal ulna nerve injury. This occurs as a distal ulna nerve lesion disables the lumbricals and interossei but the FDP is still active and flexing the finger from the distal phalanx. Loss off the ulna half of the FDP innervation in proximal ulna nerve lesions allows unresisted extension of the fingers and therefore less clawing. c) Sympathetic Nerves Tactile Adherence With nerve injury comes the loss of sympathetic input and the ability to sweat, thus reducing tactile adherence. To examine this, simply rest a pen along the line of the radial/ulna border of a digit and slide it along distally. Compared to the normal side there will be less resistance. Loss of sweating in the nerve damaged area causes smooth movement of plastic pen over affected skin. Normal sweating skin produces resistance and the digit will move with the pen. Wrinkle test Skin with absent nervous innovation will not wrinkle in water. 5-10mins is sufficient.

Vessels
The hand has a collateral circulation - Radial and ulna arteries. Important notes during examination are:

Understanding Hand Surgery

21

Capillary refill of all digits <2 seconds Arterial bleeds from wound Contralateral hand anomalies Allens Test: The collateral circulation can be examined using: Allens Test. Patient elevates hand and makes a fist for 20 seconds. Pressure applied to occlude radial and ulna arteries. Patient opens hand, which should have blanched white. Release one artery and note time to flush. Normal = hand colour flushes within 5 to 7 seconds.

Fig: Tactile adherence/Biro test (a) (b)

(c)

(d)

Fig: Allens test, and Modified Allens test

22

Understanding Hand Surgery

Modified digital Allens test Exsanguinate digit with repeated flexion tension while applying pressure over both digital arteries. Relese one side and note time to reperfuse. Do similarly for other side.

INVESTIGATIONS

X-Rays
In the acute setting only Xrays are used to image the hand views include: Standard AP, lateral and oblique hand/wrist and digital views Observe for fractures, dislocations (including lunate) soft tissue swellings, periosteal elevation, increased joint space (scapholunate dissociations) Scaphoid views 1. AP (fist mildly clenched and the wrist in ulnar deviation.) 2. oblique (45 from horizontal) 3. lateral (wrist in neutral position) 4. scaphoid view (wrist is ulnarly deviated and extended while the film is shot from a dorsalvolar angle) Initial radiographs are 80 percent sensitive for scaphoid #. MRI will diagnose the remaining cases. Carpal tunnel/Hook of hamate Views Individual joint and stress views - to diagnose fractures and ligament injuries

ciations

Fig: Scapholunate dissociation