Extensor tendons. Extensor tendon examination is also critical to perform. To assess abductor pollicis longus and extensor pollicis brevis, the patient must be able to abduct thumb from other fingers. For extensor carpi radialis longus and extensor carpi radialis brevis, the patient must be able to make fist and extend hand at the wrist. For extensor pollicis longus with the palm down, the patient should be able to raise the thumb. For extensor carpi ulnaris, there should be ulnar deviation and intact extension of digits against resistance. There should also be adequate movement of the ulnar collateral ligament of thumb with strong opposition (see Figure 4, Wolfson et al., 2005).
Nerves. The ability to identify the potential for motor and/or nerve and/or sensory function of the hand is imperative (see Figure 5 Wolfson et al., 2005) to depict the specific motor and sensory nerve distribution of the median, radial, and ulnar nerves. The ulnar, median, and radial nerves innervate the hand and support its many functions. Each digit has two neurovascular bundles close to the palmer surface of the hand that include the digital artery, dorsal and palmar digital nerves, and vein (Bickley, 2009; Daniels et al., 2004). A thorough assessment of the hand will include inspection, palpation, and range of motion. The patient should be able to perform the following functions.
Ulnar nerve: abduct fingers against resistance, sensation on ulnar surface little finger.
Median nerve: oppose thumb and little finger, sensation enervates palmar surface of thumb, index, middle, and half of the ring finger
Radial nerve: extend wrist and fingers against resistance, sensation on dorsal web space between thumb and index finger
Nails and their structures/function. It is also important to check the nails for nail avulsions. Check for tissue avulsion, partial/complete amputation, and subungual hematoma. Assess for local erythema, exudate, diffuse soft tissue swelling, fingertip swelling, bony step-off, crepitus, deformity, normal cascade of fingers, and any irregular angulation of the digits. Evaluation of the nail bed, eponychium, and distal interphalangeal joint is critical due to edema and pain masking hidden injuries (see Figure 6; Wolfson et al., 2005). Consider flexor tendon involvement in any trauma to forearm, palm, or digits.
The examination of the proximal extremity and its joints is standard of care: head, neck, shoulder, elbow, and wrist.
Neck. For a C6 involved injury, there will be decreased use of the palmar surface of thumb, index, and half of the third finger. If C7 is involved, there is decreased use of the palmar surface of the third finger, and for a C8, there will be decreased use of the palmar surface of the fourth and fifth fingers.
A step-by-step examination of the hand can be found in Table 2 of this document. The following pneumonic is also a support to providers when completing a thorough hand examination.
8 P MNEMONIC
Inspection of the hand involves evaluating in resting position and through range of motion. Both the dorsal and palmar surfaces and each individual joint must be inspected, put through range of motion, and palpated. (Bickley, 2009).
Palpation may be limited because of pain; yet, having a painful joint or tender area anywhere on the hand is what leads the APRN to the differential diagnosis. Range of motion and altered sensation are the final components of the examination. The following pneumonic has been developed for the APRN to have a customized process in evaluation of the hand so that components of the examination are not overlooked:
Pain: Tenderness to palpation
Position: Obvious deformity/crepitus, hand position
Pallor: Color, temperature, moisture, surface trauma, ecchymosis, open wound/bleeding, erythema, warmth
Pulse: Quality of pulses; distal neurovascular status, cap refill digits
Paralysis: Range of motion of all five digits
Paresthesia: Sensation to light touch
Puffiness: Soft tissue swelling, mass
Pressure: Tenseness, compartment syndrome (Shea & Hoyt, 2012)
RADIOGRAPHIC EVALUATION OF THE HAND
Ordering Plain Films
It is important for the APRN to order the appropriate radiograph of the patient's hand. Bandages and splints must be completely removed with appropriate support so that the injury can be examined properly.
An APRN responsible for management of hand injuries should identify the need for radiographic assessment of the injured hand. Intuitively, a provider assessing a hand or wrist that has tenderness, even without acute injury, should use radiography as form of assessment. In EDs across the nation due to overcrowding, many radiographic orders for extremity injuries are carried out prior to the patient being evaluated by a provider. Triage nurses follow a protocol for hand injuries that should include primary radiography.
There should be three views performed: anterior–posterior, lateral, and oblique of the hand, and each digit should be visible when performing basic radiography. The positioning of the hand and the quality of the radiograph are the role of the technician. Each provider must be able to identify whether a film does not elicit a clear representation of the extremity to reach a definitive diagnosis.
Computed tomography (CT) can be included by the APRN if there is question of intra-articular injury and magnetic resonance imaging (MRI) can be included if there is ligamentous injury (Hammert Boyer, Bozentka, & Calfee, 2010). Magnetic resonance imaging is utilized to identify soft tissue injuries, occult fractures, osteonecrosis, and ligamentous injuries (Hammert et al., 2010). The practice of ordering CT or MRI in the ED is not common for simple, isolated hand and wrist injuries. If the injury is stable and consultation is initiated with an orthopedist or hand surgeon, these time-consuming, nonemergent studies can be done on an outpatient basis managed by the specialist.
Basic radiographic imaging identifies varying density of the area being examined. As a refresher, the four basic radiographic classifications include air and fat that are black, water is gray, and metal or bone is white (Erkonen & Wilbur, 2010). In evaluating a hand, initially the provider should systematically begin with making sure that the image is of the patient who is being evaluated. A common potentially disastrous mistake is to make clinical decisions on the basis of an examination belonging to another patient. The image is then evaluated for fracture or abnormality of each bone, each joint for smoothness, and fracture or dislocation, and soft tissue for swelling (Erkonen & Wilbur, 2010) and foreign bodies. Foreign bodies may be present over a bone, so multiple views are critical to identifying an object that is camouflaged by the whiteness of bone. Always consider that the organic foreign body may not be visible in radiograph, and glass is identified only in some cases on the basis of the type of glass and size of the object (see Table 3).
As identified, there are 27 bones in the hand: five metacarpals, five proximal phalanges, four middle phalanges, five distal phalanges, and the eight carpal bones (Bickley, 2009). The hand radiographs in Figures 7A and B illustrating oblique and posterior–anterior (PA) views of the hand identify the bone and joint anatomical presentations of the hand. Figure 7B illustrates the lateral view and identifies the lateral hand bones and distal anatomy of the radius and the ulna. Figure 7C depicts the PA view of the hand and clarifies bone anatomically. Figure 8 illustrates the lateral view of the hand identifying the bones that make up the hand. Each of these views serves a specific purpose in allowing clear identification of significant anatomy of the skeletal presentation. The providers should approach the visualization of the image the same way every time they view a radiographic image. One method is to begin by following the contour of each bone to look for deformity, then soft tissue edema, and finally foreign body. It is common for providers to glance at an image and quickly identify a large deformity and yet err by missing a misalignment or subtle finding that will potentially affect functionality when missed. It is imperative that the provider returns to the patient and reevaluates the hand physically to correlate with radiographic findings. In some cases, the image will show no fracture or significant finding, but the patient is still in significant discomfort or may have dramatic soft tissue injury. The provider should treat the injury as if there is a fracture or underlying injury by appropriately splinting and following up for occult fracture.
PEDIATRIC HAND INJURIES
In the ED, patients of all ages present with hand injuries, and it is imperative to identify the anatomical findings in children who may not have fully formed bones. The identification, differentiation, and definition of children's fractures are beyond the scope of this basic assessment article but will be discussed in Part III of this article in an upcoming issue.
The purpose this article was to review approaches to assessment and examination of the acute hand and establish a process for basic radiographic identification of the skeletal anatomy of the hand. Often, the APRN's early identification of such an injury can change the outcome of a patient's long-term functionality. At times, a patient will present with a hand injury but fail to inform the APRN of previous injury or disease to the hand and its limited function. Any aberrant finding must be evaluated for acuity and relation to presenting injury. Some red flags in hand assessment are tendon injury missed by not placing hand in position during the injury, such as a fist position. Vascular injuries may seem to be obvious, but if there is no clot formation, and change in position occurs, the clot detaches and the arterial injury is identified. Compartment syndrome can develop in any compartment and the hand has many fascial planes; when initially identifying the mechanism of the injury and the present damage, compartment syndrome may be anticipated and early intervention may save potential disastrous outcome. High-pressure penetration is often not considered when taking a history. Any high-pressure injury classification is considered a potential loss of limb injury until proven otherwise. Part II of this series will discuss specific hand injuries' radiologic and laboratory findings, procedures, and treatment modalities for the injury.
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acute hand injuries; advanced practice registered nurse; emergency; hand assessment; hand injuryCopyright © Wolters Kluwer Health, Inc. All rights reserved.