Hand SGD

1. Hand SGD July 25, 2011 Block 10a

2. Patient profile • Patient is Pedro R. Anonuevo, 42 year-old male, married with 4 children, Filipino, Roman Catholic, farmer, left-handed, but uses right hand for writing, from Luciana, Laguna who was first seen by our institution at the OPD last June 1, 2011 due numbing of the left hand.

3. History of Present illness: • 4 mo. PTA: Patient sustained hacking wounds on his left wrist and upper arm from an unknown drunk assailant. Said wrist wound produced profuse bleeding and laceration of wrist tendons. He was brought to a local hospital in Santa Cruz, Laguna where his vitals were stabilized and open wounds sutured. He was then sent home well, given pain and prophylactic antibiotic medications, and advised to come back immediately M/W/F which he complied to. Allegedly, there was already note of loss of sensation on fingers and decreased finger mobility. Upon follow-up within that week and note of healing of wound, he was advised to have PT mgt after a month.

4. History of Present illness: • 3 mo. PTA: Patient complied with physician's advise for PT for 1 mo. There was relative improvement in range of motion of the left digits, however, there was still note of decrease sensation on the entire left hand. • 1 mo. and 3 wks PTA: After a month of PT and no improvement in sensation, and starting to have difficulty extending the wrist, patient opted to consult at PGH-OPD Ortho Dept. where x-ray done on left wrist showed unremarkable findings. EMG was done but result unrecalled. Patient was advised for surgery and was advised to wait for admission. During the waiting period, patient discontinued PT mgt.

5. REVIEW OF SYSTEMS: • (-) cough, colds, fever, headache  • (-) dizziness (-) BOV     (-) dysphagia • (-) nausea (-) vomiting • (-) DOB, palpitations • (-) bladder and bowel changes  • (-) joint pain • (+) LOM Left shoulder elevation, wrist flexion, fingers flexion and extension • (+) loss of L palmar sensation • (+) pins and needle pain radiating towards the fingers

6. PAST MEDICAL HISTORY • (+) s/p amputation of distal phalanx, 4th finger of the left hand in 1990s due to firecracker explosion (allegedly return of function upon healing of wound and no loss of sensation) • (-) DM, HPN, PTB, BA, CA, liver/kidney disease, CVD • (-) food/drug allergies

7. FAMILY MEDICAL HISTORY • (-) HPN, DM, PTB, BA, CA, liver/kidney disease, CVD, allergy

8. PERSONAL and SOCIAL HISTORY • (+) smoker • (+)alcoholic drinker • (-) illicit drug use • Works as a farmer, mostly coconuts and rice

9. Physical Examination

10. Awake, coherent, ambulatory, NICRD. • BP 120/80 HR 88 RR 16 T: 37.4 • Pink conjunctivae, anicteric sclerae, (-) CLAD, NVE, ANM, trachea midline • ECE, CBS, (-) ABS • AP, NRRR, DHS, (-) murmurs, heaves, thrills • round abdomen, NABS, (-) masses/tenderness • (-) cyanosis, edemaa

18. Diagnostics

21. Assessment Multiple Tendon Transection Median and Ulnar Nerve Transection

22. Musculature • Extrinsic muscles of the wrist and hand originate on the medial and lateral humeral condyles and the proximal radius and ulna: • The extrinsic extensor tendons cross the wrist and are surrounded by tendon sheaths in six compartments bounded by the extensor retinacular ligament. • The extrinsic finger and thumb flexor tendons and the median nerve enter the hand through the carpal canal.

23. Musculature • Intrinsic musculature includes thenar, hypothenar, and interosseous muscles . • Thenar muscles: abductor pollicisbrevis, the opponenspollicis, and the superficial head of the flexor pollicisbrevis. • Hypothenar muscles: abductor digitiquinti, the opponensdigitiquinti, and the flexor digitiquinti. • The dorsal interossei, commonly referred to as dorsal intrinsics, abduct the fingers; the palmarinterossei (palmarintrinsics) adduct the fingers.

25. ASSESSMENT

26. Loss of Median Nerve Function Results In: • - loss of palmar sensation along the volar aspect of the thumb, index, long, and radial border of the ring finger • - causes weak wrist flexion, and an “ape hand” with thenar atrophy and weakness of thumb opposition. • - motor strength deficits include loss of thumb opposition (loss of abductor pollicisbrevis), loss of thumb interphalangeal (IP) joint flexion (loss of flexor pollicislongus muscle function), and loss of index distal interphalangeal joint flexion (flexor digitorumprofundus function).

28. Loss of Median Nerve Function • - Restoration: • - Restoration of thumb IP joint flexion can be restored using a transferred brachioradialis muscle (radial nerve innervated) to the FPL tendon. • - Restoration of FDP function of the index finger can be accomplished using the extensor carpiradialislongus (radial nerve innervated) tendon rerouted to the index FDP tendon in the mid forearm. • - Lastly, thumb opposition can be restored with transfer of the abductor digitiminimi muscle (ulnar nerve innervated).

29. Loss of Ulnar Nerve Function: • “Clawhand” of ulnar nerve palsy is known as Duchenne's sign. • Wartenberg's sign is the inability to pull in (adduct) the small finger against the ring finger. • Froment's sign is the hyperflexion of the thumb IP joint to substitute for the lack of thumb-pinch power against the index finger. Weakness of DIP joint flexion due to loss of FDP function of the ring and small finger is known as Pollock's sign. • The flattening of the natural metacarpal arch of the hand seen in association with hand muscle wasting is known as Masse's sign.

31. Loss of Ulnar Nerve Function: • Reconstruction • Tendon transfers for ulnar nerve palsy are limited in their ability to restore hand strength. • The ECRB tendon can be transferred to the thumb proximal phalanx to provide thumb pinch (adduction) while the extensor pollicisbrevis (EPB) tendon is transferred to the index interosseous muscle. • Additionally, the thumb MCP joint may be fused to prevent thumb hyperextension and instability. The combination of these surgeries has been reported to restore approximately 50% of the lost pinch strength.