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Specific issues relative to wounds and lacerations of the arm and hand include: (1) the potential injury to the arteries, nerves, and tendons that lie close to the skin, and (2) the importance of hand function in daily and occupational life. Injuries may be classified as either isolated or combinations of closed crush, simple lacerations, open crush, partial amputation, and complete amputation. The approach to treatment depends on multiple factors: the mechanism of injury; location of the injury; injury to adjacent arteries, nerves, and tendons; patient’s age, gender, handedness, occupation, and concurrent medical problems; presence of exposed bone; and anticipated future use of the hand.

History and Examination

Specific considerations in the history include patient age (as there is increased potential for bony injury due to decreasing bone density and decreased likelihood for healing and functional recovery due to loss of elasticity associated with aging), occupation, and hand dominance. Examination of arm and hand injuries begins with inspection and continues with evaluation of motor and sensory nerve function, tendon/ligament integrity, and assessment of perfusion. During inspection, note the position and stance of the arm, hand, and digits. The location of the wound relative to major arteries, nerves, and tendons should be documented, as should the presence of exposed tendon or bone. The wound should be carefully explored for possible foreign body, debris, or other visible contaminants. Significant soft tissue avulsion or loss of length of the injured part should be noted, as these findings may be indications for operative repair.

Examine active motion and resistance to passive movement to assess motor function. Patients with a painful injury may be unwilling to move the affected extremity. After checking sensory function, anesthesia may be required to obtain an adequate motor exam.

As there are several muscles with cross innervations, the most distal pure motor function of each major nerve should be tested against resistance (Table 47-1).

Table 47-1 Motor Testing of the Peripheral Nerves of the Upper Extremity

Each tendon in and adjacent to the injured area should be individually assessed. For injuries to the hand and fingers, the extensor digitorum, flexor digitorum profundus (FDP), and the flexor digitorum superficialis (FDS) of each digit is examined individually. The FDS, which splits and inserts at the proximal interphalangeal (PIP) joint, can be examined by holding all other digits in extension and flexing the PIP joint against resistance. The FDP, which runs below the FDS past the split to attach at the distal interphalangeal (DIP) joint, can be examined by holding the PIP joint in extension and flexing the DIP joint against resistance. The extensor ...

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