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Why must hand wounds be fully explored and function assessed
To identify full or partial tendon lacerations
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When should hand tendons NOT be assessed through movement
- Glass thought to be in wound
- High suspicion of a partial tendon tear
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How must any suspected tendon injury be managed
Refer
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How would a hand injury with normal X-ray but lack of full function be managed
Follow up
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What discharge advice should be given following a hand injury
Come straight back if your finger gets droopy or twisted
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What must be done BEFORE giving a local anaesthetic for a hand injury
- Assessment of sensory nerves
- Resisted tests of muscles for pain and weakness
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When do finger fractures through the joint need referring
Greater than 1/3 of the joint surface
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What additional treatment do compound distal phalanx fractures need
- Antibiotics
- ED or ENP review
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What is the management of partial amputation of digits, inc distal phalanx
Refer to plastics
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What is the management of displaced or angulated finger fractures
Refer to plastics
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What is the general management of uncomplicated finger fractures
- Neighbour strap
- Elevate
- Fracture clinic
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When do metacarpal fractures need referral
- Rotational deformity
- Volar angulation
- Open fracture
- Displaced fracture
- Multiple metacarpals involved
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What sort of X-ray needs requesting for base of metacarpal fractures
- True lateral
- Fractures and dislocations are difficult to see on oblique
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What injuries are associated with finger hyperextension
- Sprain at the PIPJ
- avulsion fracture of the volar plate
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When must flake fractures of the finger be referred to fracture clinic
If flake is >2mm from the bone
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Which finger fractures need fracture clinic follow up?
- Flakes over 2mm from bone
- Avulsion fractures involving over 1/3 articular surface
- Shaft fractures
- Any fractures needing manipulation in the department
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Which finger fractures should be referred to orthos
Displaced fractures involving the articular surface
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If it is not possible to assess finger function fully, what is the management
5-7 day review
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What is mallet finger commonly caused by
Avulsion of the extensor tendon from the base of the distal phalanx
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How does mallet finger present
Inability to extend at the DIPJ
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Why should mallet fingers be xrayed
To check for dorsal avulsion fracture from the distal phalanx
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What is the treatment for mallet finger
- Mallet splint
- Keep extended at all times
- ENP review at 3 and 6 weeks
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What advice should be given for mallet finger
- Keep extended at all times
- Keep skin clean and dry
- A residual deformity may remain
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What is the management of a mallet finger associated with a small avulsion fracture
- Mallet splint
- Next fracture clinic
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What is a swan neck deformity caused by
- Disease
- Injury to the volar plate of the PIPJ
- long standing mallet injury
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What is the management of mallet finger with a large avulsion involving >1/3 of the articular surface
Refer to plastics
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What takes place at the 3 week mallet finger review
- Remove splint - maintain extension
- Check skin integrity
- Change splint for a smaller size if needed
- Re emphasise cleaning and maintaining splint at all times
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What is the 6 week mallet finger review for
- Remove splint
- Check finger function
- Advise that residual deformity may be permanent
- Use splint for 2 weeks at night
- Use splint for 2 weeks if heavy work or sport
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What is the mechanism of injury for boutonnieres
Sharp blow to dorsum of the PIPJ
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How does the patient with boutonnieres present
Inability to flex the DIPJ
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What is the management for a boutonnière
- Splint in extension
- Refer to ED, discuss with plastics
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What ruptures to cause a boutonnière
- The central slip of the extensor tendon
- Puts the PIPJ into flexion
- DIPJ into extension
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Why may a boutonnieres be missed initially
- The lateral bands of the extensor mechanism disguise the injury
- They then slip towards the palm causing fixed flexion deformity at the PIPJ, hyperextension at the DIPJ
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Which joints of the hand are most commonly dislocated
IPJs of the fingers
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After reduction, what's the management of finger dislocations
- Xray
- Neighbour strap
- Fracture clinic
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What is the management for MCPJ dislocations if unable to reduce
- Refer immediately to ED or plastics
- Neighbour strapping
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When may metacarpal neck fractures be managed by the ED
- Involves 1 metacarpal
- Not thumb MC
- buckle or green stick
- No rotational deformity or finger
- Minimal loss of extension
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What is the finger position with a boutonnière
- Fixed flexion at PIPJ
- hyperextension at DIPJ
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What is the MOI for a Bennets fracture
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What is a bennets fracture
- Fracture of base of thumb metacarpal
- Divides base from bone
- Force of the APL dislocates the rest of the bone proximally
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What is the management for a bennets fracture
- Bennets style backslab
- Fracture clinic
- If displaced, refer for MUA
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What is a boxers fracture
- Angulated fracture of the 5 th MC
- close to the head of the bone
- Definition of the knuckle is lost
- Exyension of the MCPJ is lost
- Swelling over the ulna side of the dorsal hand
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What must be remembered when examining a boxer type fracture
Inspect any wounds for teeth
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What overuse injury is common in the wrist and thumb
- Tenosynovitis
- In the combinedpassage of the APL and EPL
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What are the symptoms of tenosynovitis
- Pain on movement
- Crepitations
- Pain on the finkelsteins test
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What is the finkelsteins test and what does it show
- Patient makes a fist with the thumb inside
- Apply passive ulna deviation
- Painindicates tenosynovitis
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What is the treatment for tenosynovitis
- Rest
- Thumb extension splint may help
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What is the management for a 5th metacarpal fracture
- Manipulation if needed
- Neighbour strapping
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What is the mechanism of injury for ulna collateral ligament rupture
- Hypeextension or abduction
- Gamekeepers thumb
- Skiing
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What is the treatment for UCL injury with ligament stability
- 1/52 thumb spica
- Then mobilise
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What is the treatment if UCL is too painful to assess
- Thumb spica
- Review in 1/52
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What is the management if the UCL is completely ruptured
Refer to plastics
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How is UCL rupture ascertained
Painfree and marked laxity on stress
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what should be part of the assessment of human and animal bites to hands
- Xray if bony tenderness
- Explore wounds for tendon damage
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Why should bites over the MCPJ be reviewed in 48 hours
Increased risk of infection
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What is the management of all animal bites
Antibiotic
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When should hand bites be referred or discussed with plastics
- Tendon damage
- Nerve damage
- Infection
- Open fracture
- Wounds needing closure
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How do tendon sheath infections present
- Red hot swollen hand
- Ascending lymphangitis
- Extreme pain on tendon movement ESP passive extension
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What is the management of tendon sheath infection
Refer to plastics
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What should be tested when assessing hand wounds
- Resisted tendon function
- Nerves
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What should hand wounds be explored for
-
What is the management of hand wounds if tendons intact but visible
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Which hand wounds should be sutured
- Lacerations palmer aspect
- Deep wounds over joints
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Which hand wounds should be steri stripped
- Superficial
- Distal phalanx crush injuries
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Which hand wounds should have a 2 day review
- Sutured wounds
- Deep steri stripped wounds
- Any possible nerve damage
- Nerve involvement at the distal phalanx
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When should hand wounds be referred to plastics
- Tendon damage
- Functional weakness
- Nerve involvement
- Longitudinal lacs over PIPJ and DIPJ
- skin loss over 1cm x 1cm
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How do early stage paronychia present
-
What is the treatment for early stage paronychia
- Flucloxacillin or erythromycin 250mg QDS for 5 days
- Warm saline soaks
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How do late stage paronychia present
Visible or palpable pus
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What it the treatment for late stage paronychia
- I and D
- Clean nail fold
- Cold spray
- Scalpel sweep the nail edge
- Express pus
- Irrigate wound
- Dry dressing
- DO NOT close
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What may chronic paronychia be caused by
- Fungal
- Dont drain
- Refer to GP
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How do herpetic paronychia present
- Erythaema
- Clear blisters of fluid
- Refer to the GP
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What is the management of infection under the nail
- Trim nail
- Drain pus
- ABS flucloxacillin or erythromycin 250mg QDS for 5 days
- GP review
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What is the management of a splinter under the nail
- Digital nerve block
- Remove FB with forceps
- Dry dressing
- Xray if possible glass or metal
- Refer if unable to remove
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What is the management of deep splinter in finger nail
- Digital nerve block
- Trim 'V' shaped wedge in nail
- Remove FB
- dry dressing
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what is the mechanism if injury for subungual haematoma
Crush
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What is the management of subungual haematoma
- Assess
- Trephine
- Xray if needed
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What is the management of subungual haematoma without a fracture
- Trephine
- Neighbour strap
- Elevate
- Mobilise
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What is the management of a subungual haematoma with a fracture
- If distal phalanx fracture - ED review
- If joint involving >1/3 articular surface - fracture clinic
- ABS - flucloxacillin or erythromycin 250mg QDS for 3 days
- Elevate
- Analgesia
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