II. Indication

III. Exam: Telemedicine

  1. See Telemedicine
  2. Perform observation (see below) and compare opposite side
  3. Patient points to point of maximal tenderness (e.g. snuffbox)
  4. Patient performs finger range of motion
  5. Test specific Hand Neurovascular Exam (see below)
  6. Patient performs hand strength examination
    1. Make a fist and then fully extend fingers
    2. Patient specifically tests DIP and PIP extension and flexion against their own resistance

IV. Observation: General

  1. General appearance (comparing with opposite side)
    1. Erythema
    2. Deformity
    3. Swelling or joint effusion
    4. Ecchymosis (recent Trauma)
    5. Overlying skin changes
    6. Nail changes
    7. Atrophy
    8. Scars suggesting old Trauma
  2. Hand Position of Function
    1. Inability to assume position of function is a red flag
    2. Position of Function Image
      1. OrthoHandPositionOfFunction.jpg

V. Observation: Fixed digital flexion or extension

  1. Fixed single finger extension: Flexor Tendon Injury
    1. Image
      1. OrthoHandExtensorTendonInjury.jpg
    2. Description: Observe with hand at rest
      1. Affected finger in complete extension
      2. Other fingers PIP and DIP at 10 degrees flexion
    3. Injuries
      1. DIP Flexor Tendon Avulsion
      2. Flexor Tendon Laceration
  2. Fixed single finger flexion: Extensor Tendon Injury
    1. Image
      1. OrthoHandFlexorTendonInjury.jpg
    2. Injuries
      1. Extensor Tendon Laceration
      2. DIP Extensor Tendon Avulsion

VI. Observation: Finger rotational deformity

  1. Image
    1. OrthoHandPositionFistToScaphoid.jpg
  2. Flex finger against palm
  3. Finger tips normally point toward Scaphoid
  4. Malalignment suggests Fracture with rotation

VII. Observation: Skin changes

  1. Vascular compromise signs
    1. Capillary Refill >2 seconds
    2. Also check radial pulse and ulnar pulse
    3. Consider Allen Test for ulnar artery distribution
  2. Digital nerve injury
    1. Two Point Discrimination requires >5 mm apart
    2. Skin Color change
      1. Anhidrosis of finger involved
      2. Blanched or hyperemic Skin Color

VIII. Exam: Brief tendon evaluation

  1. Observe for fixed digital flexion or extension
    1. See above
  2. Extend DIP joint of affected finger
    1. Fails: DIP Extensor Tendon Avulsion (Mallet Finger)
  3. Start with all fingers in extension
    1. Flex PIP joint of affected finger only
      1. Injury
        1. Flexor digitorum profundus injury (Jersey Finger)
      2. Testing
        1. Test with all fingers in extension
        2. Hold affected finger DIP in extension
        3. Patient instructed to flex affected PIP joint
    2. Flex DIP joint of affected finger only
      1. Consider flexor digitorum superficialis injury
      2. Specific test for index finger
        1. Patient pulls a paper between both hands
          1. Paper held by each hand pinching paper
          2. Each hand uses opposed thumb and index finger
        2. Injury of flexor digitorum superficialis signs
          1. DIP hyperflexes
          2. PIP hyperextends

IX. Exam: Neurovascular Exam

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