For vascular injuries to the hand requiring tourniquet, the maximum time the tourniquet should be applied to prevent tissue necrosis is:
Initial treatment for an actively bleeding wound should be direct local pressure for not less than 10 continuous minutes. If this is unsuccessful, an upper extremity tourniquet inflated to 100 mm Hg above the systolic pressure should be used. One should keep this tourniquet time to less than 2 hours to avoid tissue necrosis. Once bleeding is controlled well enough to evaluate the wound, it may be cautiously explored to evaluate for bleeding points. One must be very cautious if attempting to ligate these to ensure that adjacent structures, such as nerves, are not included in the ligature.
Anesthetic agents with epinephrine should NOT be used in:
A commonly held axiom is that epinephrine is unacceptable to be used in the hand. Several recent large series have dispelled this myth. Epinephrine should not be used in the fingertip and not in concentrations higher than 1:100,000 (ie, what is present in commercially available local anesthetic with epinephrine). Beyond that, its use is acceptable and may be useful in an emergency room (ER) where tourniquet control may not be available. Also, because most ER procedures are done under pure local anesthesia, many patients will not tolerate the discomfort of the tourniquet beyond 30 minutes. Epinephrine will provide hemostasis and also prolong the effect of the local anesthetic.
Most nondisplaced fractures do NOT require surgical treatment EXCEPT:
Most nondisplaced fractures do not require surgical treatment. The scaphoid bone of the wrist is a notable exception to this rule. Due to peculiarities in its vascular supply, particularly vulnerable at its proximal end, nondisplaced scaphoid fractures can fail to unite in up to 20% of patients even with appropriate immobilization. Recent developments in hardware and surgical technique have allowed stabilization of the fracture with minimal surgical exposure. One prospective randomized series of scaphoid wrist fractures demonstrated shortening of time to union by up to 6 weeks in the surgically treated group, but no difference in rate of union. Surgery may be useful in the younger, more active patient who would benefit from an earlier return to full activity.
A patient shown to have wasting at the interdigital web spaces, experiences numbness of the ring finger and exhibits Wartenberg sign on physical examination most likely is suffering from:
The ulnar nerve also innervates the dorsal surface of the small finger and ulnar side of the ring finger, so numbness in these areas can be explained by cubital tunnel syndrome. The patient may also report weakness in grip due to effects on the flexor digitorum profundus (FDP) tendons to the ring and small fingers and the intrinsic hand muscles. Patients with advanced disease may complain of inability to fully extend the ring and small finger interphalangeal (IP) joints. Physical examination for cubital tunnel syndrome begins with inspection. Look for wasting in the hypothenar eminence and the interdigital web spaces. When the hand rests flat on the table, the small finger may rest in abduction with respect to the other fingers; this is called Wartenberg sign. Tinel sign is often present at the cubital tunnel. Elbow flexion test will often be positive. Grip strength and finger abduction strength should be compared to the unaffected side. Froment sign can be tested by placing a sheet of paper between the thumb and index finger and instructing the patient to hold on to the paper while the examiner pulls it away without flexing the finger or thumb (this tests the strength of the adductor pollicis and first dorsal interosseous muscles). If the patient must flex the index finger and/or thumb (FDP-index and flexor pollicis longus [FPL] , both median nerve supplied) to maintain traction on the paper, this is a positive response.
The most common primary malignant tumor of the hand is:
Squamous cell carcinoma (SCC) is the most common primary malignant tumor of the hand, accounting for 75 to 90% of all malignancies of the hand. Eleven percent of all cutaneous sec occurs in the hand. It is the most common malignancy of the nail bed. Risk factors include sun exposure, radiation exposure, chronic ulcers, immunosuppression, xeroderma pigmentosa, and actinic keratosis.
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