II. Indication

III. Observation: Hand Position of Function

  1. Inability to assume position of function is a red flag
  2. Position of Function Image
    1. OrthoHandPositionOfFunction.jpg

IV. 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

V. 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

VI. 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

VII. 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

VIII. Exam: Brief Neurologic Examination

  1. Ulnar Nerve
    1. Finger abduction against resistance
    2. Sensation to ulnar 1.5 fingers on palmar aspect (e.g. tip of pinky finger)
  2. Median Nerve
    1. Sensation to radial 3.5 fingers and dorsal tips (e.g. tip of index finger)
    2. Oppose thumb to index finger against resistance
      1. NeuroMedianNerve.jpg
  3. Radial Nerve
    1. Wrist extension (dorsiflexion) against resistance
    2. Sensation to dorsal first 3.5 fingers (e.g. dorsal first web space)
      1. NeuroRadialNerve.jpg

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