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Objectives to direct the training of emergency medicine residents on off-service rotations: Hand surgery
Printed in the USA. Copyright 0 1990 Pergamon Press plc
The Journal of Emergency Medicine, Vol. 8, pp. 655-658, 1990
OBJECTIVES
Mark A. Eilers,
TO DIRECT THE TRAINING OF EMERGENCY MEDICINE ON OFF-SERVICE ROTATIONS: HAND SURGERY MD, FACEP,* Jeffrey Chapman, MD,t Jon Krohmer, MD, FACEP,* David Carter, MD,II Janet Shapter, MD,~I and Glenn Hamilton,
RESiDENTS
Clifton A. Sheets, MD, FACEP,
MD, FACEP,~
FACP*
*Emergency Medicine, and tDepartment of Surgery, §Wright State University School of Medicine, Dayton, Ohio; *Department Emergency Medicine, Butterworth Hospital, Grand Rapids, Michigan; IISpringfield, and l/East Liverpool, Ohio Reprint address: Mark Eilers, MD, FACEP, Wright State University School of Medicine, P.O. Box 927, Dayton, OH 45401-0927
of
knowledge and skill during their hand surgery rotation. The goal of this series of articles is to provide meaningful objectives for use in directing, providing greater control, and coordinating resident training on off-service rotations.
0 Abstract - This is the fiih article in a continuing series on objectives to direct the training of emergency medicine residents. The emergency physician frequently must deal with hand injuries. Often these may appear innocuous; recognition of these iqjuries requires certain technical skills and a working knowledge of these entities. Specific objectives presented provide guidance for the didactic content as well as skill mastery for the resident experience.
CONTENTS 0 Keywords - objectives; training; hand surgery; emergency medicine
EVALUATIVE 1.1 Triage - recognition of life or limb threat COGNITIVE 12.1 Presentations 1. Anatomy 2. Physical Examination 3. Nerve testing 4. Allen’s test 5. Tendon function exam 12.2 General Considerations 12.2.2 Infectious or inflammatory 12.2.2.1 Arthritis 12.2.2.2 Tenosynovitis 12.2.2.3 Infections 12.2.2.4 Other soft tissue 12.2.6 Soft Tissue or Muscle Injury 12.2.6.1 Amputation or Avulsion 12.2.6.2 Compartment syndrome 12.2.6.3 High pressure injection injury 12.4.2 Upper Extremity 12.4.2.2.1 Bony Injury 12.4.2.2.1 Fractures
INTRODUCTION This is the fifth article in a continuing series on objectives to direct the training of emergency medicine residents. Contents and list of objectives are included along with specific behaviorally based objectives and a list of references. In the residency training program at Wright State University School of Medicine, Department of Emergency Medicine, these materials are placed in a briefcase and “checked out” to each resident during their hand surgery rotation. Each resident is provided a list of the expected behaviorally based objectives, and references to aid in their mastery of these objectives and skills. Many hand disorders are easily overlooked unless the emergency physician has a good working knowledge of common hand injuries and is able to perform an adequate examination. These objectives and references are intended to direct the resident in obtaining the necessary
~ =
Education-Features articles focusing on the training of emergency physicians and the administration of residency programs. This section of JEM is coordinated by Mary Ann Cooper, MD, Mercy Hospital and Medical Center, Division of Emergency Medicine, University of Illinois, Chicago.
RECEIVED:
19 April 1990; ACCERED: 2 May 1990
0736-4679&Q 655
$3.00 + .OO
M. A. Eilers et al
656
12.4.2.2.2 Dislocations 12.4.2.2.2 Soft Tissue Injury 12.4.2.2.1 Bite Injuries 12.4.2.2.2 Nerve Injuries 12.4.2.2.3 Nail Bed Injury 12.4.2.2.4 Burns 12.4.2.2.3 Tendon or Ligament Injuries 12.4.2.2.3.1 Tendon Injuries 12.4.2.2.3.2 Ligamentous Injuries PROCEDURES 20.1 Anesthesia 20.1.2 Regional Nerve Blocks 20.1.2.2 Nerve Blocks in the Hand 20.3 Diagnostic Procedures 20.3.13 Compartment Syndromes 20.3.13.1 Measurement of Compartment Pressures 20.5 Skeletal Procedures 205.3 Fracture or Dislocation Immobilization Techniques 20.5.3.1 Splints 20.9 Other Procedures 20.9.3 Suture Techniques 20.9.3.1 Extensor Tendon Repair 20.9.4 Incision and Drainage 20.9.4.1 Incision and Drainage of Hand Infections ROTATIONAL GOALS AND OBJECTIVES: HAND SURGERY EVALUATIVE 1.1 Triage - Recognition of life or limb threat 1. Given a patient with life threatening, traumatic injuries, be able to outline a prioritized evaluative and treatment protocol. Reference: ATLS Manual Chapter 1 and Rosen Chapters 3 and 8 COGNITIVE 12.1 Presentations 1. Using surface landmarks be able to identify the following on physical exam. Pisiform Motor branch of ulnar nerve Hook of the hamate Superficial palmer arch e. Deep palmer arch f. Motor branch of median nerve Metacarpal heads :: Median and ulnar nerves 1. Radial and ulnar artery Palmaris longus tendon j. k. Flexor carpi radialis and ulnaris tendon 1. Extensor hallucis longus and abductor pollicus longus tendon Reference: The Hand - Examination and Diagnosis,
L: i:
pages 347; Treatment of hand emergencies (EMCNA), pages 197-220; and Carter, chapter 2. 2. Be able to draw or identify the sensory distribution of the ulnar, median, and radial nerves. 3. Be able to demonstrate the technique of 2-point discrimination nerve testing. Reference: EMCNA, pages 351-362. 4. Be able to perform and describe the significance of the Allen’s test. Reference: EMCNA, page 201. 5. Describe testing of the following muscles and tendons: Flexor pollicis longus Flexor digitorum profundus Flexor digitorum superficialis Flexor carpi ulnaris and radialis e. Palmaris longus f. Extensor pollicis longus g. Abductor pollicis longus h. Extensor carpi radialis longus i. Extensor pollicis longus j. Extensor digitorum communis k. Extensor indicis proprius 1. Extensor digiti minimi m. Extensor carpi ulnaris n. Flexor pollicis brevis 0. Opponens pollicis p. Abductor pollicis q. Abductor pollicis brevis r. Abductor digiti minimi s. Opponens digiti minimi Reference: The Hand - Examination and Diagnosis, pages 347; Carter, chapter 2. 12.2 General Considerations 12.2.2 Infectious or Inflammatory Disorders 1. List the two most common types of arthritis of the hand and describe two characteristic clinical and radiographic findings associated with each. Reference: The Hand - Primary Care of Common Problems, pages 137-140; Rosen, chapter 44 and 91. 2. Describe a boutonniere and a swan neck deformity Reference: The Hand - Primary Care of Common Problems, page 138; The Hand - Examination and Diagnosis, pages 66-68. 3. Give three signs of flexor tenosynovitis and discuss its complications and treatment. Reference: Carter, pages 220-22 1. 4. Describe the presentation and treatment of DeQuervain’s tenosynovitis. Reference: The Hand - Primary Care of Common Problems, pages 127-128; EMCNA, pages 277278.
L: i:
Objectives-Hand
Surgery
5. Identify the signs, complications, and treatment of the following: a. Paronychia b. Felon c. Herpetic felon d. Septic arthritis e. Deep palmar space abscess Reference: Carter, chapter 17; EMCNA, pages 263-274. 6. Identify and discuss the etiology, potential complications, and treatment of ganglion and mucous cysts. Reference: The Hand - Examination and Diagnosis, pages 89-92; Rosen, chapter 44. 7. Give a typical history and physical exam and describe the treatment of the following: a. Carpal tunnel syndrome b. Claw hand c. Dupuytren’s contracture d. Trigger finger Reference: EMCNA, pages 275-281; The Hand - Examination and Diagnosis, chapter 5. 12.2.6 Soft Tissue or Muscle Injuries 1. For a near or complete amputation/avulsion injury discuss appropriate care of the limb or amputated parts and indications/contraindications for replantation. Reference: Carter, chapter 14; EMCNA, pages 365-372. 2. Describe the findings and treatment for a compartment syndrome involving the hand. Reference: Carter,, pages 185-187; The Hand - Primary Care of Common Problems, pages 56-69. 3. Discuss possible complications and treatment of a high pressure injection injury. Reference: Carter, chapter 15; EMCNA, pages 373-38 1. 12.4.2 Upper Extremity: Hand 12.4.2.2.1 Bony Injury 1. Be able to describe normal radiographic anatomy of the hand Reference: EMCNA, pages 221-233; Carter, chapters 9 and 10. 2. Discuss mechanism of injury, clinical findings, and treatment for fractures of the following location or description: a. Phalangeal b. Volar plate c . Bennett’s d. Boxer’s e. Navicular f. Colle’s g. Smith’s Reference: Carter, chapter 8; Rosen,chapter 44. 3. Describe clinical and radiographic findings and treatment of the following dislocations: a. Distal interphalangeal joint
657
b. Proximal interphalangeal joint c. Metacarpal phalangeal joint d. Lunate dislocation e . Perilunate dislocation f. Carpal, metacarpal dislocations g. Scapho-lunate dissociation Reference: Carter, chapters 9 and 10. 4. Be able to classify a fracture of bones of the hand and wrist into the proper Salter-Harris category and describe treatment implications. Reference: Carter, pages 98-99. 12.2.2.2 Soft Tissue Injury 1. Describe pathogens, potential complications, and treatment of a bite to the hand. Reference: Carter, chapter 16; EMCNA, pages 271-173. 2. For the following nerve injuries, identify the expected deficit: a. Digital b. Median c. Radial d. Ulnar Reference: Carter, pages 29-34; EMCNA, pages 351363. 3. For a nail bed injury, describe proper management. Reference: Carter, page 195; EMCNA, pages 255-261. 4. Describe proper treatment and assessment of fingertip injuries. Reference: EMCNA, pages 245-254. 5. Describe assessment and care for a burn of the hand. Reference: EMCNA, pages 391-403. 12.2.2.3 Tendon or Ligament Injuries 1. Discuss clinical findings, mechanism of injury, and treatment for the following injuries: a. Mallet finger b. Shirt grasp injury (profundus tendon rupture) c. Trigger finger d. Extensor tendon laceration e . Boutonniere Reference: Carter, chapter 11; EMCNA, pages 341-349. 2. Describe the five flexor tendon zones and their implications. Reference: EMCNA, pages 341-349. 3. Describe the following injuries and their treatment: a. Hyperextension sprain b. Collateral ligament sprain c . Gamekeeper’s thumb Reference: Carter,chapter 7. PROCEDURAL 20.0 Manipulative Skills 20.1 Anesthesia 20.1.2 Regional Nerve Blocks 1. Describe the technique and anesthetics for the following nerve blocks: a. Digital block
658
M. A. Eilers et al
b. Metacarpal block c. Wrist block of the radial, median, and ulnar nerves. Reference: Roberts and Hedges, chapter 32. 20.3 Diagnostic Procedures 20.3.13 Compartment Pressure monitoring 1. Describe the technique of measuring compartment pressures. Reference: Roberts and Hedges, chapter 75. 20.5 Skeletal Procedures 20.5.3 Fracture or Dislocation Immobilization Techniques 1. Describe the application of the following:
a. Finger aluminum splintb. Volar and ulnar splint c. Thumb spica splint Reference: Roberts and Hedges, chapter 45. 20.9 Other Techniques 20.9.3 Suture Techniques 1. Discuss repair of an extensor tendon laceration. Reference: Roberts and Hedges, chapter 44. 20.9.4 Incision and Drainage 1. Describe the proper technique of incision and drainage of the following: a. Felon b. Paronychial infection. Reference: Carter, chapter 17.
REFERENCES *The hand - examination and diagnosis. 2nd ed. American Society for Surgery of the Hand. New York: Churchill Livingstone; 1983. *The hand - primary care of common problems. 1st ed. American Society for Surgery of the Hand. New York: Churchill Livingstone; 1985. *Treatment of hand emergencies. Emerg Med Clin North Am. 1985;3. *ATLS Manual, student manual. American College of Surgeons,
Chicago, Illinois; 1985. 5. Rosen P, Baker FJ, Barkin R, Braen R, Dailey R, Levy R. Emergency medicine: concepts and clinical practice. 2nd ed. St. Louis: CV Mosby; 1986. 6. Carter P. Common hand injuries and infection. Philadelphia: WB Saunders; 1983. I. Roberts J, Hedges J. Clinical procedures in emergency medicine. Philadelphia: WB Saunders; 1985.
The Journal of Emergency Medicine, Vol. 8, pp. 655-658, 1990
OBJECTIVES
Mark A. Eilers,
TO DIRECT THE TRAINING OF EMERGENCY MEDICINE ON OFF-SERVICE ROTATIONS: HAND SURGERY MD, FACEP,* Jeffrey Chapman, MD,t Jon Krohmer, MD, FACEP,* David Carter, MD,II Janet Shapter, MD,~I and Glenn Hamilton,
RESiDENTS
Clifton A. Sheets, MD, FACEP,
MD, FACEP,~
FACP*
*Emergency Medicine, and tDepartment of Surgery, §Wright State University School of Medicine, Dayton, Ohio; *Department Emergency Medicine, Butterworth Hospital, Grand Rapids, Michigan; IISpringfield, and l/East Liverpool, Ohio Reprint address: Mark Eilers, MD, FACEP, Wright State University School of Medicine, P.O. Box 927, Dayton, OH 45401-0927
of
knowledge and skill during their hand surgery rotation. The goal of this series of articles is to provide meaningful objectives for use in directing, providing greater control, and coordinating resident training on off-service rotations.
0 Abstract - This is the fiih article in a continuing series on objectives to direct the training of emergency medicine residents. The emergency physician frequently must deal with hand injuries. Often these may appear innocuous; recognition of these iqjuries requires certain technical skills and a working knowledge of these entities. Specific objectives presented provide guidance for the didactic content as well as skill mastery for the resident experience.
CONTENTS 0 Keywords - objectives; training; hand surgery; emergency medicine
EVALUATIVE 1.1 Triage - recognition of life or limb threat COGNITIVE 12.1 Presentations 1. Anatomy 2. Physical Examination 3. Nerve testing 4. Allen’s test 5. Tendon function exam 12.2 General Considerations 12.2.2 Infectious or inflammatory 12.2.2.1 Arthritis 12.2.2.2 Tenosynovitis 12.2.2.3 Infections 12.2.2.4 Other soft tissue 12.2.6 Soft Tissue or Muscle Injury 12.2.6.1 Amputation or Avulsion 12.2.6.2 Compartment syndrome 12.2.6.3 High pressure injection injury 12.4.2 Upper Extremity 12.4.2.2.1 Bony Injury 12.4.2.2.1 Fractures
INTRODUCTION This is the fifth article in a continuing series on objectives to direct the training of emergency medicine residents. Contents and list of objectives are included along with specific behaviorally based objectives and a list of references. In the residency training program at Wright State University School of Medicine, Department of Emergency Medicine, these materials are placed in a briefcase and “checked out” to each resident during their hand surgery rotation. Each resident is provided a list of the expected behaviorally based objectives, and references to aid in their mastery of these objectives and skills. Many hand disorders are easily overlooked unless the emergency physician has a good working knowledge of common hand injuries and is able to perform an adequate examination. These objectives and references are intended to direct the resident in obtaining the necessary
~ =
Education-Features articles focusing on the training of emergency physicians and the administration of residency programs. This section of JEM is coordinated by Mary Ann Cooper, MD, Mercy Hospital and Medical Center, Division of Emergency Medicine, University of Illinois, Chicago.
RECEIVED:
19 April 1990; ACCERED: 2 May 1990
0736-4679&Q 655
$3.00 + .OO
M. A. Eilers et al
656
12.4.2.2.2 Dislocations 12.4.2.2.2 Soft Tissue Injury 12.4.2.2.1 Bite Injuries 12.4.2.2.2 Nerve Injuries 12.4.2.2.3 Nail Bed Injury 12.4.2.2.4 Burns 12.4.2.2.3 Tendon or Ligament Injuries 12.4.2.2.3.1 Tendon Injuries 12.4.2.2.3.2 Ligamentous Injuries PROCEDURES 20.1 Anesthesia 20.1.2 Regional Nerve Blocks 20.1.2.2 Nerve Blocks in the Hand 20.3 Diagnostic Procedures 20.3.13 Compartment Syndromes 20.3.13.1 Measurement of Compartment Pressures 20.5 Skeletal Procedures 205.3 Fracture or Dislocation Immobilization Techniques 20.5.3.1 Splints 20.9 Other Procedures 20.9.3 Suture Techniques 20.9.3.1 Extensor Tendon Repair 20.9.4 Incision and Drainage 20.9.4.1 Incision and Drainage of Hand Infections ROTATIONAL GOALS AND OBJECTIVES: HAND SURGERY EVALUATIVE 1.1 Triage - Recognition of life or limb threat 1. Given a patient with life threatening, traumatic injuries, be able to outline a prioritized evaluative and treatment protocol. Reference: ATLS Manual Chapter 1 and Rosen Chapters 3 and 8 COGNITIVE 12.1 Presentations 1. Using surface landmarks be able to identify the following on physical exam. Pisiform Motor branch of ulnar nerve Hook of the hamate Superficial palmer arch e. Deep palmer arch f. Motor branch of median nerve Metacarpal heads :: Median and ulnar nerves 1. Radial and ulnar artery Palmaris longus tendon j. k. Flexor carpi radialis and ulnaris tendon 1. Extensor hallucis longus and abductor pollicus longus tendon Reference: The Hand - Examination and Diagnosis,
L: i:
pages 347; Treatment of hand emergencies (EMCNA), pages 197-220; and Carter, chapter 2. 2. Be able to draw or identify the sensory distribution of the ulnar, median, and radial nerves. 3. Be able to demonstrate the technique of 2-point discrimination nerve testing. Reference: EMCNA, pages 351-362. 4. Be able to perform and describe the significance of the Allen’s test. Reference: EMCNA, page 201. 5. Describe testing of the following muscles and tendons: Flexor pollicis longus Flexor digitorum profundus Flexor digitorum superficialis Flexor carpi ulnaris and radialis e. Palmaris longus f. Extensor pollicis longus g. Abductor pollicis longus h. Extensor carpi radialis longus i. Extensor pollicis longus j. Extensor digitorum communis k. Extensor indicis proprius 1. Extensor digiti minimi m. Extensor carpi ulnaris n. Flexor pollicis brevis 0. Opponens pollicis p. Abductor pollicis q. Abductor pollicis brevis r. Abductor digiti minimi s. Opponens digiti minimi Reference: The Hand - Examination and Diagnosis, pages 347; Carter, chapter 2. 12.2 General Considerations 12.2.2 Infectious or Inflammatory Disorders 1. List the two most common types of arthritis of the hand and describe two characteristic clinical and radiographic findings associated with each. Reference: The Hand - Primary Care of Common Problems, pages 137-140; Rosen, chapter 44 and 91. 2. Describe a boutonniere and a swan neck deformity Reference: The Hand - Primary Care of Common Problems, page 138; The Hand - Examination and Diagnosis, pages 66-68. 3. Give three signs of flexor tenosynovitis and discuss its complications and treatment. Reference: Carter, pages 220-22 1. 4. Describe the presentation and treatment of DeQuervain’s tenosynovitis. Reference: The Hand - Primary Care of Common Problems, pages 127-128; EMCNA, pages 277278.
L: i:
Objectives-Hand
Surgery
5. Identify the signs, complications, and treatment of the following: a. Paronychia b. Felon c. Herpetic felon d. Septic arthritis e. Deep palmar space abscess Reference: Carter, chapter 17; EMCNA, pages 263-274. 6. Identify and discuss the etiology, potential complications, and treatment of ganglion and mucous cysts. Reference: The Hand - Examination and Diagnosis, pages 89-92; Rosen, chapter 44. 7. Give a typical history and physical exam and describe the treatment of the following: a. Carpal tunnel syndrome b. Claw hand c. Dupuytren’s contracture d. Trigger finger Reference: EMCNA, pages 275-281; The Hand - Examination and Diagnosis, chapter 5. 12.2.6 Soft Tissue or Muscle Injuries 1. For a near or complete amputation/avulsion injury discuss appropriate care of the limb or amputated parts and indications/contraindications for replantation. Reference: Carter, chapter 14; EMCNA, pages 365-372. 2. Describe the findings and treatment for a compartment syndrome involving the hand. Reference: Carter,, pages 185-187; The Hand - Primary Care of Common Problems, pages 56-69. 3. Discuss possible complications and treatment of a high pressure injection injury. Reference: Carter, chapter 15; EMCNA, pages 373-38 1. 12.4.2 Upper Extremity: Hand 12.4.2.2.1 Bony Injury 1. Be able to describe normal radiographic anatomy of the hand Reference: EMCNA, pages 221-233; Carter, chapters 9 and 10. 2. Discuss mechanism of injury, clinical findings, and treatment for fractures of the following location or description: a. Phalangeal b. Volar plate c . Bennett’s d. Boxer’s e. Navicular f. Colle’s g. Smith’s Reference: Carter, chapter 8; Rosen,chapter 44. 3. Describe clinical and radiographic findings and treatment of the following dislocations: a. Distal interphalangeal joint
657
b. Proximal interphalangeal joint c. Metacarpal phalangeal joint d. Lunate dislocation e . Perilunate dislocation f. Carpal, metacarpal dislocations g. Scapho-lunate dissociation Reference: Carter, chapters 9 and 10. 4. Be able to classify a fracture of bones of the hand and wrist into the proper Salter-Harris category and describe treatment implications. Reference: Carter, pages 98-99. 12.2.2.2 Soft Tissue Injury 1. Describe pathogens, potential complications, and treatment of a bite to the hand. Reference: Carter, chapter 16; EMCNA, pages 271-173. 2. For the following nerve injuries, identify the expected deficit: a. Digital b. Median c. Radial d. Ulnar Reference: Carter, pages 29-34; EMCNA, pages 351363. 3. For a nail bed injury, describe proper management. Reference: Carter, page 195; EMCNA, pages 255-261. 4. Describe proper treatment and assessment of fingertip injuries. Reference: EMCNA, pages 245-254. 5. Describe assessment and care for a burn of the hand. Reference: EMCNA, pages 391-403. 12.2.2.3 Tendon or Ligament Injuries 1. Discuss clinical findings, mechanism of injury, and treatment for the following injuries: a. Mallet finger b. Shirt grasp injury (profundus tendon rupture) c. Trigger finger d. Extensor tendon laceration e . Boutonniere Reference: Carter, chapter 11; EMCNA, pages 341-349. 2. Describe the five flexor tendon zones and their implications. Reference: EMCNA, pages 341-349. 3. Describe the following injuries and their treatment: a. Hyperextension sprain b. Collateral ligament sprain c . Gamekeeper’s thumb Reference: Carter,chapter 7. PROCEDURAL 20.0 Manipulative Skills 20.1 Anesthesia 20.1.2 Regional Nerve Blocks 1. Describe the technique and anesthetics for the following nerve blocks: a. Digital block
658
M. A. Eilers et al
b. Metacarpal block c. Wrist block of the radial, median, and ulnar nerves. Reference: Roberts and Hedges, chapter 32. 20.3 Diagnostic Procedures 20.3.13 Compartment Pressure monitoring 1. Describe the technique of measuring compartment pressures. Reference: Roberts and Hedges, chapter 75. 20.5 Skeletal Procedures 20.5.3 Fracture or Dislocation Immobilization Techniques 1. Describe the application of the following:
a. Finger aluminum splintb. Volar and ulnar splint c. Thumb spica splint Reference: Roberts and Hedges, chapter 45. 20.9 Other Techniques 20.9.3 Suture Techniques 1. Discuss repair of an extensor tendon laceration. Reference: Roberts and Hedges, chapter 44. 20.9.4 Incision and Drainage 1. Describe the proper technique of incision and drainage of the following: a. Felon b. Paronychial infection. Reference: Carter, chapter 17.
REFERENCES *The hand - examination and diagnosis. 2nd ed. American Society for Surgery of the Hand. New York: Churchill Livingstone; 1983. *The hand - primary care of common problems. 1st ed. American Society for Surgery of the Hand. New York: Churchill Livingstone; 1985. *Treatment of hand emergencies. Emerg Med Clin North Am. 1985;3. *ATLS Manual, student manual. American College of Surgeons,
Chicago, Illinois; 1985. 5. Rosen P, Baker FJ, Barkin R, Braen R, Dailey R, Levy R. Emergency medicine: concepts and clinical practice. 2nd ed. St. Louis: CV Mosby; 1986. 6. Carter P. Common hand injuries and infection. Philadelphia: WB Saunders; 1983. I. Roberts J, Hedges J. Clinical procedures in emergency medicine. Philadelphia: WB Saunders; 1985.