GENERAL MANAGEMENT PRINCIPLES
Specific issues relative to wounds and lacerations of the arm and hand include potential injury to the arteries, nerves, and tendons that lie close to the skin and the impact of these injuries on the use of the hands in daily and occupational life. Injuries may be classified as either isolated or combinations of closed crush, simple lacerations, open crush, partial amputation, and complete amputation.
Specific considerations in the history include patient age, occupation, mechanism of injury, and hand dominance. Age is important because the potential for bony injury increases with decreasing bone density, and the likelihood for healing and functional recovery decrease because of loss of elasticity. Mechanism of injury identifies wounds that are more prone to infections. Note the time from injury to repair. There is no distinct threshold for infection from time from injury to closure, but wounds sutured >12 hours after injury could be more prone to infection.1,2
Examination of arm and hand injuries begins with inspection and continues with evaluation of motor and sensory nerve function, tendon/ligament integrity, and assessment of perfusion. During inspection, observe the position and stance of the arm, hand, and digits. Identify exposed tendon or bone, and note the location of the wound relative to major arteries, nerves, and tendons. Explore the wound carefully for possible foreign body, debris, or other visible contaminants. Note significant soft tissue avulsion or loss of length of the injured part, as these findings may be indications for operative repair.
Active and Passive Movement
Examine active motion and resistance to passive movement. Patients with a painful injury may be unwilling to move the affected extremity. After checking sensory function, local anesthesia may be required to obtain an adequate motor exam. The long-held belief that a local anesthetic with epinephrine should not be used for digital nerve blocks has been disproven, and agents containing epinephrine are acceptable for digital nerve blocks.3,4,5
Because there are several muscles with cross innervations, the most distal pure motor function of each major nerve should be tested against resistance (Table 43-1).
TABLE 43-1Motor Testing of the Peripheral Nerves of the Upper Extremity |Favorite Table|Download (.pdf) TABLE 43-1 Motor Testing of the Peripheral Nerves of the Upper Extremity
|Nerve ||Motor Exam |
|Radial ||Dorsiflexion of wrist |
|Median || |
Thumb abduction away from the palm
Thumb interphalangeal joint flexion
|Ulnar ||Adduction/abduction of digits |
Individually assess each tendon in, and adjacent to, the injured area. For injuries to the hand and fingers individually examine the extensor digitorum, flexor digitorum profundus, and the flexor digitorum superficialis of each digit. The flexor digitorum superficialis, which splits and inserts at the proximal interphalangeal joint, can be examined by holding all other digits ...