Download Hand SGD

Hand SGD
August 1, 2011
Block 10A
PATIENT PROFILE
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Lope S. Ampalayo,
70 y.o/M, from Paco, Manila
Married, with 2 children
Filipino, Roman Catholic
Baker
Right-handed
Chief Complaint
• Open wound on dorsum of hand with fx of
metacarpal bones
– July 31, 2011
– No prior history of trauma.
HISTORY OF PRESENT ILLNESS:
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DOI: 7/30/11
TOI: 8 PM
POI: Paco, Manila
MOI: Degloving Injury, L
• Left hand caught in mechanical rolling pin 
Ospital ng Maynila  ATS and Teana; x-ray done
showed hand: fx, closed, complete, oblique,
displaced, D3 of 3rd metacarpal, L  PGH
REVIEW OF SYSTEMS:
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(-) cough, colds, fever, headache
(-) dizziness (-) BOV (-) dysphagia
(-) nausea , (-) vomiting
(-) DOB, palpitations
(-) bladder and bowel changes
(-) joint pain
(+) polyphagia, polydipsia, polyuria
PAST MEDICAL HISTORY
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(+) DM (since 2006)– no medications taken
(+) HPN (since 2006)– uncontrolled
PTB, BA, CA, liver/kidney disease, CVDs
(-) food/drug allergies
No other previous hospitalization and
surgeries
FAMILY MEDICAL HISTORY
• (-) HPN, DM, PTB, BA, CA, liver/kidney disease,
CVD, allergy
PERSONAL AND SOCIAL HISTORY
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(-) smoker
(-)alcoholic drinker
(-) illicit drug use
Elementary graduate (Bohol).
Baker since 1980s.
Married but wife lives in Bohol; has 2 children
but one died.
Physical Examination
• Awake, coherent, ambulatory, NICRD.
• BP 120/80 HR 88 RR 20 T: 36.7
• Pink conjunctivae, anicteric sclerae, (-) CLAD,
NVE, ANM, trachea midline
• ECE, CBS, (-) ABS
• AP, NRRR, DHS, (-) murmurs, heaves, thrills
• Round abdomen, NABS, (-) masses/tenderness
• PNB, FEP, (-) cyanosis
Hand and Wrist
Left
Inspection
(+) 10x6 cm avulsed
wound dorsum of left
hand extending to D3
of wrist (dorsal and
volar aspects)
(+) swollen hand
(dorsum) and digits
(-) deviation, muscle
atrophy, swan neck,
boutonniere
deformity, (-) pitting,
onycholysis
Right
(-) swelling, deformity,
deviation, muscle atrophy,
pitting
Hand an d Wrist
Left
Right
Palpation
Full pulses
(-) Sensory deficits
Full pulses
(-) Sensory deficits
Movement
Full ROM on passive
extension, flexion, abduction
and adduction of fingers
(+) Limitation of ROM on
active flexion, extension and
deviation of wrist and fingers
Able to make pinch grip with
difficulty
Unable to make tight fist
Full ROM on both
active and passive
mov’t on all joints
Manual Muscle Testing
Left
Right
C5 (Elbow
flexor)
5/5
5/5
C6 (Wrist
extensor)
0/5
5/5
C7 (Elbow
extensor)
5/5
5/5
C8(Finger
flexor)
4/5
5/5
T1 (Small
finger
abductors)
4/5
5/5
Hand Habitus: Slightly flexed wrist,
slightly flexed 3rd, 4th, 5th digits, extended
2nd digit, and extended thumb
Diagnostics
Assessment
Degloving Injury, Left Hand
Hand:
Fx, closed, complete, oblique,
displaced, 3rd metacarpal, L
Fx, closed, complete, transverse,
displaced, proximal phalanx, base of 5th, L
Musculature
• Extrinsic muscles
• Extrinsic extensor tendons cross the wrist and are
surrounded by tendon sheaths in six
compartments* bounded by the extensor
retinacular ligament.
• Extrinsic finger and thumb flexor tendons and the
median nerve enter the hand through the carpal
canal.
* Compartments and anatomy illustrated next
Musculature
• Intrinsic musculature includes thenar,
hypothenar, and interosseous muscles .
• Thenar muscles: abductor pollicis brevis, the
opponens pollicis, and the superficial head of the
flexor pollicis brevis.
• Hypothenar muscles: abductor digiti quinti, the
opponens digiti quinti, and the flexor digiti quinti.
• The dorsal interossei (4), commonly referred to as
dorsal intrinsics, abduct the fingers; the palmar
interossei (3)(palmar intrinsics) adduct the fingers.
ASSESSMENT
Radial Nerve Palsy
Median Nerve Palsy
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Loss of palmar sensation along the volar
aspect of the thumb, index, long, and radial
border of the ring finger
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Motor strength deficits include loss of
thumb opposition (APB), loss of thumb
interphalangeal (IP) joint flexion (FPL), and
loss of index distal interphalangeal joint
flexion (FDP).
Ulnar Nerve Palsy
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“Clawhand” = Duchenne's sign
Wartenberg's sign
Froment's sign
Pollock's sign.
Masse's sign.
Radial Nerve Palsy
• Extension posturing of the hand is important in
grasping and releasing functions.
• Most often caused by injuries following a spiral
fracture of the humerus
– The sharp bony ends of the fracture can impale the
radial nerve along its course.
• Loss of radial nerve function at this level results in
loss of wrist and finger extension (Wrist Drop)
Degloving Injuries
• Common with crush or shear mechanisms of injury
• Zone of internal injury is often greatly underestimated
by the external appearance of the limb.
– Skin and subcutaneous tissue are separated from the
underlying fascia in an open wound, or without break in
the skin.
• Degloved areas may lead to infected hematomas
• It is generally recommended that the degloving injury
be treated and healed before an incision is made in the
area to treat the fracture.
– Antibiotics and pain meds