Imaging - muh.ie

Document technical information

Format pdf
Size 771.7 kB
First found May 22, 2018

Document content analysis

Category Also themed
Language
English
Type
not defined
Concepts
no text concepts found

Persons

Organizations

Places

Transcript

Article: AENJ-D-12-00023
Date: January 30, 2014
Time: 21:19
Advanced Emergency Nursing Journal
Vol. 36, No. 1, pp. 9–21
C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright Imaging
Column Editor: Denise Ramponi, DNP, NP-C, FAEN, CEN, FAANP
Assessment of Acute Hand Injuries
Part I
Elda G. Ramirez, PhD, RN, FNP-BC, ENP-BC, FAANP, FAEN
K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN
Abstract
More than 140,000 hand injuries occur yearly, and an estimated 5 days of loss of work per patient
occurs (Bureau of Labor Statistics, 2012). Advanced practice registered nurses (APRNs) are responsible for managing many of these injuries in primary and emergency care settings. Hand injuries
are responsible for approximately 10% of all emergency department visits annually (P. Shayne, S.
H. Plantz, & F. Talavera, 2012). This article reviews approaches to the assessment of the patient
with a hand injury and establishes a process for basic identification of the hand structures and
function. Approaches to history taking and specific evaluations for the hand will be discussed and
examples of the assessments will be provided. Diagnostic approaches to support physical findings
will be discussed, and methods of radiologic assessment will support the audience in making appropriate diagnosis in relation to hand injuries. This is Part I of a three-part series that will validate
the approaches to hand assessment for adults and children and identify specific injuries and their
management for the APRN. Key words: acute hand injuries, advanced practice registered nurse,
emergency, hand assessment, hand injury
A
DVANCED PRACTICE registered
nurses (APRNs) are rapidly becoming
frontline providers in emergency
and ambulatory care settings that manage
and treat hand injuries. These settings are
frequented by patients of all ages with hand
injuries. More than 140,000 hand injuries
occur yearly, and an estimated 5 days of
loss of work per patient occurs (Bureau of
Labor Statistics, 2012). Hand injuries are
responsible for approximately 10% of all
emergency department (ED) visits annually
(Shayne, Plantz, & Talavera, 2012).
In this three-part series, Part I of this article
reviews approaches to the assessment of
the patient with a hand injury and establishes a process for basic identification of
the hand structures and function. Part II
discusses the clinical presentations of selected hand injuries including clinical presentation, diagnosis, medical decision making,
and management on the basis of physical examination (PE) and radiographic findings. Part
III discusses pediatric hand injuries. Finally,
Author Affiliations: Emergency/Trauma NP Specialty,
The University of Texas Health Science Center at
Houston (Dr Ramirez) and St. Mary Medical Center,
Long Beach, California (Dr Sue Hoyt).
Disclosure: The author reports no conflicts of interest.
Corresponding Author: Elda G. Ramirez, PhD, RN,
FNP-BC, ENP-BC, FAANP, FAEN, Emergency/Trauma
NP Specialty, The University of Texas Health Science
Center at Houston, 7000 Fannin, Ste 1200, Houston,
TX 77030 ([email protected]).
DOI: 10.1097/TME.0000000000000001
9
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
Date: January 30, 2014
10
a dictation/documentation template will be
provided.
PATIENT PRESENTATION AND LEVEL OF
ACUITY
Patients with hand injuries present with a history of blunt and/or penetrating trauma. Patients with blunt trauma comprise up to 50%
of presentations with hand injuries. These patients may present to the ED with a crush
injury, smashing finger in a door or might be
trying to hammer a nail and injures their finger instead with a hammer (Shayne, Plantz, &
Talavera, 2013).
Patients with a penetrating injury make
up 25% of hand injuries. These injuries include knife lacerations and puncture wounds
with ice picks to name a few. The classifications of common hand injuries include lacerations, puncture wounds, avulsions, crush
injuries, high pressure injuries, fractures,
dislocations, soft tissue injuries/amputations,
nail injuries, foreign bodies, burns, bites, and
infections (Shayne et al., 2012).
The initial approach to any patient with a
hand injury is to first assess for level of acuity. A patient with a hand injury involving a
life-threatening injury (e.g., injury with severe
blood loss, sepsis) or a patient with neurovascular compromise (e.g., crush injury, compartment syndrome) requires immediate attention.
Time: 21:19
Advanced Emergency Nursing Journal
quet should be visible at all times, and the
patients must be transported to a medical facility immediately for definitive management
(White, 2011). Splint all fractures for hemorrhage and pain control. Dress all wounds with
saline gauze. Major disabilities such as neurological injuries (e.g., nerve injury of the hand)
must all be addressed during this phase of
care.
Compartment Syndrome
Patients with suspected compartment syndrome need immediate assessment for increased compartment pressure. The hand
has 10 compartments, and the pressures
in the compartments should not exceed
within 20 mmHg of a patient’s diastolic pressure or within 30 mmHg of the mean arterial pressure. Anything in theses ranges
of elevated pressure should be considered
for emergent surgical intervention (Olson &
Glasgow, 2005). Obtain vital signs including
pulse oximetry. Once the APRN has established the immediate acuity of the injury and
it is not life or limb threatening, the provider
may proceed with the examination. Check
the pulses and capillary refill in the affected
extremity and compare with opposite noninjured extremity.
Then, the history of present illness (HPI),
medical history, and PE of the patient are simultaneously important considerations in the
overall care of a patient with a hand injury.
A-B-C-Ds
It is the responsibility of the APRN to perform a thorough PE. Begin with general resuscitation as needed: airway, breathing, and
circulation (ABCs). If there is excessive bleeding (e.g., amputation), provide hemorrhage
control with blood pressure cuff or tourniquet use in life-saving situations, which is
now recognized as appropriate care if performed properly (Kragh et al., 2009). Extensive bleeding should be controlled with a
tourniquet that is approximately 2–3 in. above
the bleeding extremity and should occlude
the arterial pulse (White, 2011). The tourni-
HISTORY OF PRESENT ILLNESS
History of present illness includes a chief complaint stated in the patient’s own words and
an HPI primarily to identify the level of care
the patient needs. The patients’ medical history is important in relation to comorbidities
that may affect healing of injuries and can potentiate infection. A thorough history of hand
injury would include some of the following
questions identified in Table 1.
Advanced practice registered nurses
may receive patients with hand injuries
from triage with concurrent environmental
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
January–March 2014
Date: January 30, 2014
r Vol. 36, No. 1
Table 1. History questions
Hand dominance
Occupation: Work injury? Sports injury?
Onset and duration of injury? Delayed
presentation?
Mechanism of injury?
Hyperextension/flexion?
Fracture? Dislocation? Tendon injury?
Nerve injury?
Crush injury?
Laceration, abrasion
Nail injury, avulsion?
Animal/human bite?
High-pressure injury (e.g., paint gun)?
Puncture wound?
Foreign body
Burn? Infection?
Pain/function/sensation:
Pain (e.g., severe, throbbing, dull)
Pallor (e.g., pale, ecchymosis, delayed
capillary refill)
Pulselessness
Paresthesias
Position of limb (when patient arrives)
Paralysis: Movement limitations (e.g.,
previous movement limitations)
Puffiness: Feeling of fullness (e.g., swelling
of hand, digit, compartment swelling,
pus, blood?)
Associated: Fever, chills, tender swollen
bumps (any location)
situations such as nonaccidental trauma (e.g.,
child maltreatment) and domestic violence.
These conditions may alter the management
plan for the patient. Performing a thorough
HPI along with family, social, allergy, and
medication history is obligatory. The through
history will prepare the APRN to approach
the injury with knowledge that will enhance
the PE and direct differential diagnosis.
MEDICAL HISTORY
Hand Dominance
Comorbidities: Does the patient have any
comorbidities including but not limited to
Time: 21:19
Assessment of the Acute Hand Injury
11
diabetes, cancer, human immunodeficiency
virus (HIV), and/or hepatitis?
Social history: Does the patient use substances such as alcohol, tobacco, or recreational drugs?
Past surgeries: Has the patient had a previous upper extremity injury, previous surgical
intervention, or previous illness?
Family history: Is there a hand anomaly?
Medications: Is the patient taking
Coumadin (warfarin), or is the patient
currently on any antibiotics for another infection?
Allergies: Are there known allergies to medications, foods, or latex?
Immunizations: Tetanus status. Inquire
about recent tetanus status. These guidelines
will be discussed in depth in Part II of this
series.
Finally, inquire about recent food intake in
the event that the patient will need operative
intervention.
PHYSICAL EXAMINATION
Bones. It is important to appreciate the
anatomy of the hand. Describing the palmar (volar) surface anatomy (see Figure 1;
Wolfson et al., 2005) is important to describe
direction and imagery of the hand when describing either in documentation or on consultation. There are 27 bones in the hand: five
metacarpals, five proximal phalanges, four
middle phalanges, five distal phalanges, and
the eight carpal bones. These bones work together with 12 extensor and 12 flexor tendons
that make up the hand and allow it the ability
to oppose and grip (Daniels, Zook, & Lynch,
2004).
Flexor tendons. Flexor tendon examination is critical to perform. To assess flexor
digitorum profundus, hold middle phalanx in
complete extension and evaluate strength of
flexion of the distal phalanx (see Figure 2).
Repeat for each digit. To assess flexor digitorum superficialis, hold nonaffected digits
in complete extension and evaluate strength
of flexion of the midphalanx (proximal
interphalangeal (PIP) joint; see Figure 3). It is
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
Date: January 30, 2014
12
Time: 21:19
Advanced Emergency Nursing Journal
Figure 1. Volar (palmer) surface of the hand. From “Hand Injuries ” by K. Jackimczyk of Harwood-Nuss’
Clinical Practice of Emergency Medicine (4th ed.), by A. B., Wolfson, G. W., Hendey, P. L., Hendry, C.
H., Linden, C. L., Rosen, J. J., Schaider, J., Schaider, G. Q., Sharieff, and J. R., Suchard, 2005, Philadelphia,
PA: Lippincott Williams & Wilkins. Reprinted with permission.
important to eliminate use of intrinsic palmar
muscles in order to isolate the flexor tendon.
Extensor tendons. Extensor tendon examination is also critical to perform. To assess
abductor pollicis longus and extensor pollicis brevis, the patient must be able to abduct
thumb from other fingers. For extensor carpi
radialis longus and extensor carpi radialis bre-
vis, the patient must be able to make fist and
extend hand at the wrist. For extensor pollicis longus with the palm down, the patient
should be able to raise the thumb. For extensor carpi ulnaris, there should be ulnar deviation and intact extension of digits against
resistance. There should also be adequate
movement of the ulnar collateral ligament of
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
January–March 2014
r Vol. 36, No. 1
Date: January 30, 2014
Time: 21:19
Assessment of the Acute Hand Injury
13
Figure 2. Assessment of flexor digitorum profundus. Hold the middle phalanx in complete extention and
evaluate strength of flexion of the distal phalanx (DIP). Repeat for each digit.
Figure 3. Assessment of flexor digitorum superficialis. Hold the non affected digits in complete extension
and evaluate strength of flexion of the mid-phalanx (PIP). It is important to eliminate use of intrinsic
palmar muscles in order to isolate the flexor tendon.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
Date: January 30, 2014
14
thumb with strong opposition (see Figure 4,
Wolfson et al., 2005).
Nerves. The ability to identify the potential
for motor and/or nerve and/or sensory function of the hand is imperative (see Figure 5
Wolfson et al., 2005) to depict the specific
motor and sensory nerve distribution of the
median, radial, and ulnar nerves. The ulnar,
median, and radial nerves innervate the hand
and support its many functions. Each digit
has two neurovascular bundles close to the
palmer surface of the hand that include the
digital artery, dorsal and palmar digital nerves,
and vein (Bickley, 2009; Daniels et al., 2004).
A thorough assessment of the hand will include inspection, palpation, and range of motion. The patient should be able to perform
the following functions.
Ulnar nerve: abduct fingers against resistance, sensation on ulnar surface little finger.
Median nerve: oppose thumb and little
finger, sensation enervates palmar surface of
thumb, index, middle, and half of the ring
finger
Time: 21:19
Advanced Emergency Nursing Journal
Radial nerve: extend wrist and fingers
against resistance, sensation on dorsal web
space between thumb and index finger
Nails and their structures/function. It
is also important to check the nails for
nail avulsions. Check for tissue avulsion,
partial/complete amputation, and subungual
hematoma. Assess for local erythema, exudate, diffuse soft tissue swelling, fingertip
swelling, bony step-off, crepitus, deformity,
normal cascade of fingers, and any irregular
angulation of the digits. Evaluation of the nail
bed, eponychium, and distal interphalangeal
joint is critical due to edema and pain masking
hidden injuries (see Figure 6; Wolfson et al.,
2005). Consider flexor tendon involvement in
any trauma to forearm, palm, or digits.
The examination of the proximal extremity
and its joints is standard of care: head, neck,
shoulder, elbow, and wrist.
Neck. For a C6 involved injury, there will be
decreased use of the palmar surface of thumb,
index, and half of the third finger. If C7 is
involved, there is decreased use of the palmar
Figure 4. Musculotendinous anatomy of the finger. From page 1060 of Harwood-Nuss’ Clinical Practice
of Emergency Medicine (4th ed.), by A. B., Wolfson, G. W., Hendey, P. L., Hendry, C. H., Linden, C. L.,
Rosen, J. J., Schaider, J., Schaider, G. Q., Sharieff, and J. R., Suchard, 2005, Philadelphia, PA: Lippincott
Williams & Wilkins. Reprinted with permission.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
January–March 2014
r Vol. 36, No. 1
Date: January 30, 2014
Time: 21:19
Assessment of the Acute Hand Injury
15
Figure 5. Sensory innervation of the hand. From page 1060 of Harwood-Nuss’ Clinical Practice of
Emergency Medicine (4th ed.), by A. B., Wolfson, G. W., Hendey, P. L., Hendry, C. H., Linden, C. L.,
Rosen, J. J., Schaider, J., Schaider, G. Q., Sharieff, and J. R., Suchard, 2005, Philadelphia, PA: Lippincott
Williams & Wilkins. Reprinted with permission.
Figure 6. Fingertip and nail bed anatomy. From page 1059 of Harwood-Nuss’ Clinical Practice of Emergency Medicine (4th ed.), by A. B., Wolfson, G. W., Hendey, P. L., Hendry, C. H., Linden, C. L., Rosen, J.
J., Schaider, J., Schaider, G. Q., Sharieff, and J. R., Suchard, 2005, Philadelphia, PA: Lippincott Williams &
Wilkins. Reprinted with permission.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
Date: January 30, 2014
Advanced Emergency Nursing Journal
16
surface of the third finger, and for a C8, there
will be decreased use of the palmar surface of
the fourth and fifth fingers.
A step-by-step examination of the hand can
be found in Table 2 of this document. The
following pneumonic is also a support to
providers when completing a thorough hand
examination.
8 P MNEMONIC
Inspection of the hand involves evaluating in
resting position and through range of motion. Both the dorsal and palmar surfaces
and each individual joint must be inspected,
put through range of motion, and palpated.
(Bickley, 2009).
Palpation may be limited because of pain;
yet, having a painful joint or tender area anywhere on the hand is what leads the APRN
to the differential diagnosis. Range of motion and altered sensation are the final components of the examination. The following
pneumonic has been developed for the APRN
to have a customized process in evaluation of
the hand so that components of the examination are not overlooked:
Pain: Tenderness to palpation
Position: Obvious deformity/crepitus, hand position
Pallor: Color, temperature, moisture, surface
trauma, ecchymosis, open wound/bleeding, erythema, warmth
Pulse: Quality of pulses; distal neurovascular status,
cap refill digits
Paralysis: Range of motion of all five digits
Paresthesia: Sensation to light touch
Puffiness: Soft tissue swelling, mass
Pressure: Tenseness, compartment syndrome
(Shea & Hoyt, 2012)
RADIOGRAPHIC EVALUATION OF THE HAND
Ordering Plain Films
It is important for the APRN to order the appropriate radiograph of the patient’s hand.
Time: 21:19
Bandages and splints must be completely
removed with appropriate support so that the
injury can be examined properly.
An APRN responsible for management of
hand injuries should identify the need for radiographic assessment of the injured hand. Intuitively, a provider assessing a hand or wrist
that has tenderness, even without acute injury, should use radiography as form of assessment. In EDs across the nation due to
overcrowding, many radiographic orders for
extremity injuries are carried out prior to the
patient being evaluated by a provider. Triage
nurses follow a protocol for hand injuries that
should include primary radiography.
There should be three views performed:
anterior–posterior, lateral, and oblique of the
hand, and each digit should be visible when
performing basic radiography. The positioning of the hand and the quality of the radiograph are the role of the technician. Each
provider must be able to identify whether a
film does not elicit a clear representation of
the extremity to reach a definitive diagnosis.
Imaging
Computed tomography (CT) can be included
by the APRN if there is question of intraarticular injury and magnetic resonance imaging (MRI) can be included if there is ligamentous injury (Hammert Boyer, Bozentka, &
Calfee, 2010). Magnetic resonance imaging is
utilized to identify soft tissue injuries, occult
fractures, osteonecrosis, and ligamentous injuries (Hammert et al., 2010). The practice of
ordering CT or MRI in the ED is not common
for simple, isolated hand and wrist injuries.
If the injury is stable and consultation is initiated with an orthopedist or hand surgeon,
these time-consuming, nonemergent studies
can be done on an outpatient basis managed
by the specialist.
Radiographic Identification
Basic radiographic imaging identifies varying
density of the area being examined. As a refresher, the four basic radiographic classifications include air and fat that are black, water
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
January–March 2014
Date: January 30, 2014
r Vol. 36, No. 1
Time: 21:19
Assessment of the Acute Hand Injury
17
Table 2. Examination of the hand
Examination technique
While the patient’s hand is in the
resting position, look for fingers that
are flexed or extended
While patient flexes fingers toward the
palm, check that tips of fingers point
toward the scaphoid
Check for changes in skin color or
ability to sweat
Check capillary refill after applying
pressure to distal fingertip or nail
bed
Check two-point discrimination in
distal fingertip using blunt calipers
or a paper clip
The patient flexes the proximal IP joint
of the affected finger while the other
fingers are kept extended
The patient extends the distal IP joint
of the affected finger while the other
fingers are kept extended
The patient extends the distal IP joint
of the affected finger
Abnormal result
Flexed finger
Extended finger
Fingers extend normally but
overlap when flexed
Part or all of finger has a
different skin color
(blanched or hyperemic)
or lacks ability to sweat
Blanching lasts more
than 2 s
Possible pathology
Disrupted extensor
tendon
Disrupted flexor tendon
Fracture with rotational
deformity of finger
Digital nerve injury
Microvascular
compromise
Patient cannot distinguish
two points at least 5 mm
apart
Unable to flex joint
Neurological compromise
Patient cannot flex joint
Disrupted flexor
digitorum profundus
(i.e., jersey finger)
Fracture of distal phalanx
or rupture of extensor
tendon (i.e., mallet
finger)
Pathology of distal ulnar
joint or triangular
fibrocartilage complex
(in the absence of
radiographic findings)
Trauma to pisiform
Patient cannot extend joint
or lacks complete joint
extension
The patient shakes hands with the
examiner and then attempts to
pronate and supinate the wrist while
the examiner resists movement
Patient has pain or cannot
complete the movement
Locate the small, bony prominence on
the ulnar aspect of the palm in the
area of the palmar crease
After pisiform is located, the
physician’s thumb IP joint is placed
on the pisiform, and the thumb is
directed toward the patient’s index
finger. When the patient flexes the
wrist, the hook of the hamate can be
felt with the tip of the thumb
Follow the extensor carpi radialis
tendon distally where it intersects
the palmar crease and then palpate
the small protuberance
Tenderness
Disrupted flexor
digitorum superficialis
Tenderness
Fracture of hook of the
hamate
Tenderness
Fracture of scaphoid
tubercle
(continues)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
Date: January 30, 2014
Time: 21:19
Advanced Emergency Nursing Journal
18
Table 2. Examination of the hand (Continued)
Examination technique
Abnormal result
Possible pathology
Locate the extensor pollicis longus and
abductor pollicis longus and then palpate
the depression between them (the
anatomical snuffbox)
Physician’s thumb is placed on scaphoid
tubercle while the wrist is held in ulnar
deviation and then the patient actively
radially deviates the wrist while the
physician exerts pressure on the tubercle
Patient’s wrist is held in flexion while the
physician resists active finger extension
Tenderness
Fracture of distal pole
Pain
Pain with clunk
Fractured scaphoid
Scapholunate instability
Pain
Parascaphoid inflammation,
radiocarpal instability,
midcarpal instability
Note. IP = interphalangeal. From “Hand and Wrist Injuries: Part I. Nonemergent Evaluation,” by J. M., Daniels, E. G.,
Zook, and J. M. Lynch, 2004, American Family Physician, 69, pp. 1941–1948. Copyright 2004 by American Academy
of Family Physicians. All rights reserved. Adapted or reprinted with permission.
is gray, and metal or bone is white (Erkonen
& Wilbur, 2010). In evaluating a hand, initially the provider should systematically begin
with making sure that the image is of the patient who is being evaluated. A common potentially disastrous mistake is to make clinical
decisions on the basis of an examination belonging to another patient. The image is then
evaluated for fracture or abnormality of each
bone, each joint for smoothness, and fracture or dislocation, and soft tissue for swelling
(Erkonen & Wilbur, 2010) and foreign bodies.
Foreign bodies may be present over a bone,
so multiple views are critical to identifying an
object that is camouflaged by the whiteness
of bone. Always consider that the organic foreign body may not be visible in radiograph,
and glass is identified only in some cases on
the basis of the type of glass and size of the
object (see Table 3).
Table 3. Radiologic evaluation—hand: plain
film mandatory dictation/documentation
Fracture or abnormality of each bone
Dislocation
Soft tissue swelling
Foreign body
As identified, there are 27 bones in the
hand: five metacarpals, five proximal phalanges, four middle phalanges, five distal
phalanges, and the eight carpal bones
(Bickley, 2009). The hand radiographs in
Figures 7A and B illustrating oblique and
posterior–anterior (PA) views of the hand
identify the bone and joint anatomical presentations of the hand. Figure 7B illustrates
the lateral view and identifies the lateral hand
bones and distal anatomy of the radius and
the ulna. Figure 7C depicts the PA view of the
hand and clarifies bone anatomically. Figure 8
illustrates the lateral view of the hand
identifying the bones that make up the hand.
Each of these views serves a specific purpose
in allowing clear identification of significant
anatomy of the skeletal presentation. The
providers should approach the visualization
of the image the same way every time they
view a radiographic image. One method is to
begin by following the contour of each bone
to look for deformity, then soft tissue edema,
and finally foreign body. It is common for
providers to glance at an image and quickly
identify a large deformity and yet err by
missing a misalignment or subtle finding that
will potentially affect functionality when
missed. It is imperative that the provider
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
January–March 2014
Date: January 30, 2014
r Vol. 36, No. 1
Time: 21:19
Assessment of the Acute Hand Injury
19
Figures 7. A, Oblique and PA view of bone and joint identification by radiograph. B, Lateral view of
hand identifying hand bones and distal radius and ulna. C, Posterior–anterior view identifying anatomy
of bone structure. PA = posterior–anterior. From Radiology 101: The Basics and Fundamentals of
Imaging (3rd ed.; p. 158–159, 160–161), by E. Erkonen and L. S., Wilbur, 2010, Philadelphia, PA: Wolter
Kluwer Health/Lippincott Williams & Wilkins. Copyright 2010 by Wolters Kluwer Health. Reprinted with
permission.
returns to the patient and reevaluates the
hand physically to correlate with radiographic findings. In some cases, the image
will show no fracture or significant finding,
but the patient is still in significant discomfort
or may have dramatic soft tissue injury. The
provider should treat the injury as if there is a
fracture or underlying injury by appropriately
splinting and following up for occult fracture.
PEDIATRIC HAND INJURIES
In the ED, patients of all ages present with
hand injuries, and it is imperative to identify
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
Date: January 30, 2014
Advanced Emergency Nursing Journal
20
Figure 8. Bone and joint identification by radiograph of the hand bones in lateral view. Posterior–
anterior view identifying anatomy of bone structure. From Radiology 101: The Basics and Fundamentals of Imaging (3rd ed.; pp. 160–161), by
E. Erkonen and L. S., Wilbur, 2010, Philadelphia,
PA: Wolter Kluwer Health/Lippincott Williams
& Wilkins. Copyright 2010 by Wolters Kluwer
Health. Reprinted with permission.
the anatomical findings in children who may
not have fully formed bones. The identification, differentiation, and definition of children’s fractures are beyond the scope of this
basic assessment article but will be discussed
in Part III of this article in an upcoming
issue.
SUMMARY
The purpose this article was to review approaches to assessment and examination of
the acute hand and establish a process for basic radiographic identification of the skeletal
anatomy of the hand. Often, the APRN’s early
identification of such an injury can change the
outcome of a patient’s long-term functionality. At times, a patient will present with a
hand injury but fail to inform the APRN of
previous injury or disease to the hand and its
limited function. Any aberrant finding must
Time: 21:19
be evaluated for acuity and relation to presenting injury. Some red flags in hand assessment are tendon injury missed by not placing hand in position during the injury, such
as a fist position. Vascular injuries may seem
to be obvious, but if there is no clot formation, and change in position occurs, the clot
detaches and the arterial injury is identified.
Compartment syndrome can develop in any
compartment and the hand has many fascial
planes; when initially identifying the mechanism of the injury and the present damage,
compartment syndrome may be anticipated
and early intervention may save potential disastrous outcome. High-pressure penetration
is often not considered when taking a history.
Any high-pressure injury classification is considered a potential loss of limb injury until
proven otherwise. Part II of this series will discuss specific hand injuries’ radiologic and laboratory findings, procedures, and treatment
modalities for the injury.
REFERENCES
Bickley, L. S. (2009). Bates guide to physical exam &
history (10th ed.). Philadelphia, PA: Wolter Kluwer
Health/Lippincott Williams & Wilkins.
Daniels, J. M., Zook, E. G., & Lynch, J. M. (2004). Hand
and wrist injuries: Part I. Nonemergent evaluation.
American Family Physician, 15 69(8), 1941–1948.
Erkonen, E. E., & Wilbur, L. S. (2010). Radiology 101:
The basics and fundamentals of imaging (3rd ed.).
Philadelphia, PA: Wolter Kluwer Health/Lippincott
Williams & Wilkins.
Hammert, W. C., Boyer, M. I., Bozentka, D. J., & Calfee, R.
P. (2010). ASSH manual of hand surgery (1st ed.).
Philadelphia, PA: Wolter Kluwer Health/Lippincott
Williams & Wilkins.
Kragh, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C.
E., Salinas, J., . . . Holcomb, J. B. (2009). Survival with
emergency tourniquet use to stop bleeding in major
limb trauma. Annals of Surgery, 249(1), 1–7.
Olson, S. A., & Glasgow, R. R. (2005). Acute compartment syndrome in lower extremity musculoskeletal
trauma. The Journal of the American Academy of
Orthopedic Surgeons, 13, 436.
Shayne, P., Plantz, S. H., & Talavera, F. (2012).
Hand injuries. emedicinehealth WebMD. Retrieved from http://www.emedicinehealth.com/
hand injuries/article em.htm
Shayne, P., Plantz, S. H., & Talavera, F. (2013).
Hand injuries. emedicinehealth. Retrieved from
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-12-00023
January–March 2014
Date: January 30, 2014
r Vol. 36, No. 1
http://www.emedicinehealth.com/hand injuries/
article em.htm
Shea, S. S., & Hoyt, K. S. (2012). Emergency NP/PA
pocket reference guide. San Diego, CA: EmergeEd.
U.S. Department of Labor—Bureau of Labor Statistics.
(2012). Nonfatal occupational injuries and illnesses requiring days away from work. Retrieved
2011,
from
http://www.bls.gov/news.release/
archives/osh2_11082012.pdf
Time: 21:19
Assessment of the Acute Hand Injury
21
White, D. (2011). Tourniquets in EMS: Our EMS systems
learn invaluable lessons from the horrible price our
soldiers pay. Retrieved from http://www.ems1.com/
trauma/articles/1001613-Tourniquets-in-EMS/
Wolfson, A. B., Hendey, G. W., Hendry, P. L., Linden,
C. H., Rosen, C. L., Schaider, J. J., . . . Suchard, J. R.
(2005). Harwood-Nuss’ clinical practice of emergency medicine (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
×

Report this document