History and Physical Examination



History and Physical Examination


Craig M. Rodner

Christian A. Merrill



INTRODUCTION

The aim of this chapter is to provide a systematic guide and template on which to perform a history and physical (H&P) examination in the setting of hand and wrist trauma. For all hand and wrist injuries, obtaining a thorough H&P is essential to establishing the correct diagnosis and making the appropriate treatment decision.




HISTORY

The mechanism of injury can provide insightful knowledge about the type of injury sustained in a hand or wrist trauma patient. It is important to assess whether the injury is blunt or penetrating in nature and whether or not this is high-energy versus a low-energy type of injury. This can provide context to the type and extent of injury sustained and various other structures that may be damaged in the acute trauma patient. The chief complaint, whether it be acute or more chronic in nature or potentially a sequela from a previously sustained trauma, should be investigated. The pain must be carefully examined for location, onset, duration, intensity, character, frequency, aggravating and relieving factors, night or rest pain, and radiating symptoms. Additionally, any associated symptoms such as catching, clicking, locking, weakness, numbness, or temperature sensitivities should be addressed. For both acute and chronic pathologies, the history of prior and current treatments should be examined. Any motor or sensory deficits should be inquired about.


Additionally, the patient’s handedness, occupation, and current work status should be ascertained. This information can add valuable insight into how this injury can affect the patient’s life and livelihood. With regard to past medical history and past surgical history, any history related to the afflicted extremity should be obtained; furthermore, any conditions that may increase the risk for infection, wound healing capacity, or vascular conditions should be documented. Social history should include any smoking, alcohol, or illicit drug use. Allergies and vaccination status, in particular tetanus updates, should be inquired about as well.


PHYSICAL EXAMINATION



  • When performing the physical examination (PE), it is always important to remove all jewelry, clothing, bandages, splints, or other impedances such that the entire extremity could be examined. It is important to take a systematic approach to examining the fingers, hand, and wrist. The contralateral limb can always provide a reference for examination and can be examined first. It is often best to have the patient demonstrate the site of maximum pain by pointing with one finger and then approach this site last during examination.


  • Inspection



    • Traumatic wound



      • Type—laceration, crush, inoculation, penetrating, avulsion, necrotic, caustic, burn


      • Size—estimate/measure (cm)


      • Shape—linear, stellate, complex, poke-hole, injection


      • Location—volar, dorsum, zone of injury (Figure 1.1)


      • What is exposed? Subcutaneous tissue, fat, muscle, tendon, bone, nerves, vessels


    • Swelling—diffuse versus localized


    • Deformity



      • Natural resting position of hand—gentle flexion at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints


      • Natural resting position of wrist—slight extension and ulnar deviation


      • Coronal, sagittal, rotational deformities notable to contralateral


    • Skin—color changes, hair loss, scar, wounds/sinus tracts



    • Atrophy



      • Hand—thenar, hypothenar, interosseous musculature


      • Forearm—flexor and extensor compartments


  • Palpation—assess tenderness, defects, step-offs, fluctuance, wounds



    • Hand—metacarpals, phalanges, MCPs, PIPs, and DIPs (Figures 1.2 and 1.4)


    • Nail—eponychium, paronychium, nail plate, and nail bed (Figure 1.3)



    • Digit—pulp, flexor tendon sheath, flexor tendon pulleys


    • Palm—thenar/hypothenar eminence


    • Dorsal wrist (Figures 1.2 and 1.4)



      • Distal radius—radial styloid, Lister tubercle



        • Distal radioulnar joint (DRUJ)


      • Distal ulna—ulna head, ulnar styloid



        • Triangular fibrocartilage complex


      • Carpal bones—scaphoid (proximal pole and waist), lunate, trapezium, trapezoid, capitate, hamate


      • Carpometacarpal joints—thumb, index, middle, ring, small finger


      • Extensor compartments: (1) abductor pollicis longus (APL) and extensor pollicis brevis (EPB); (2) extensor carpi radialis brevis (ECRB) and longus (ECRL); (3) extensor pollicis longus (EPL); (4) extensor digitorum communis (EDC) and extensor indicis proprius (EIP); (5) extensor digiti minimi (EDM); (6) extensor carpi ulnaris (ECU)



        • Anatomic snuff box—between first and second extensor compartment


    • Volar wrist (Figures 1.2 and 1.4)



      • Carpal bones—scaphoid (tuberosity), trapezial ridge, pisiform, hook of hamate


      • Tendons—flexor carpi radialis (FCR), palmaris longus, flexor carpi ulnaris (FCU)


      • Neurovascular—radial and ulnar artery; median and ulnar nerve



    • Mass—tenderness, consistency, mobility, compressibility, transillumination, pulsatileness, sinus tract


    • Probing—explore wound with cotton tip applicator


  • Range of motion —assess both passive and active; assess smoothness of motion, abnormal movement, lack of movement, rotational deformity, scissoring (Table 1.1)



    • Passive tenodesis—fingers will flex with wrist passively extended and extend with passive flexion of the wrist (assess for tendon laceration) (Figure 1.5)



      • Lack of tenodesis—disruption of tendon or musculotendinous junction




    • Hand—make full fist, open completely



      • All fingertips should touch palm, fingertips point toward scaphoid tubercle (assess rotational deformities)


    • Wrist—move in all planes of motion


  • Muscular examination (Table 1.2)



    • Flexors



      • FCR—make a fist and flex wrist, ulnar deviation of the wrist is indicative of weak or incompetent FCR. Strength against resistance in wrist flexion and radial deviation.


      • FCU—make a fist and flex wrist, radial deviation of the wrist is indicative of weak or incompetent FCU. Strength against resistance in wrist flexion and ulnar deviation.


      • Flexor digitorum superficialis (FDS)—flex PIP joint of each individual digit while all other digits’ MCP joint is stabilized in extension (Figure 1.6)



        • Prevents flexor digitorum profundus (FDP) from flexing because of quadriga effect because FDP tendons are connected to a single unit compared to FDS


      • FDP—flex DIP joint of each individual digit while PIP joint is stabilized in extension (Figure 1.7)


      • Flexor pollicis longus—flex interphalangeal (IP) joint of thumb while stabilizing thumb at proximal phalanx


    • Extensors

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May 7, 2019 | Posted by in ORTHOPEDIC | Comments Off on History and Physical Examination

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