336 Emergency Medicine
distal phalanx. This type of injury occurs often from a sudden forceful
flexion of an extended finger when an object, such as a football, strikes the
tip of the finger. This is the common mechanism among athletes. Clinically,
patients present with pain and swelling over the DIP joint, which is held in
flexion of up to 40 degrees because of loss of the extensor mechanism. The
most important aspect in managing these injuries is to keep the DIP joint
in continuous extension until healing occurs.Therefore, a splint should
be applied so that only the DIP is immobilized in extension for 6 to 8 weeks.
The PIP and MCP joints should be mobile. Any disruption of the immobile
DIP joint can result in improper healing.
301.The answer is d.(Tintinalli, p 1791.)Kanavel criteriaforflexor
tenosynovitisare known as S.T.E.P.: (1) Symmetric swelling of the finger,
(2)Tenderness over the flexor tendon sheath, (3) Extension (passive) of the
digit is painful, and (4) Posture of the digit is flexed. A tenosynovitis is an
infection of the flexor tendon sheath caused by penetrating trauma and dirty
wounds (eg, a dog bite). Infection spreads along the tendon sheath; there-
fore, failure to diagnose and treat a flexor tenosynovitis may lead to loss of
function of the affected digit and eventually the entire hand. It is, therefore,
a surgical emergency. Treatment includes hand immobilization and eleva-
tion, immediate consultation with a hand surgeon, and IV antibiotics. Pain
control and tetanus immunization should be provided, if not up-to-date.
(a)The Finkelstein test for DeQuervain tenosynovitis is positive when,
with the thumb cupped in a closed fist, ulnar deviation reproduces pain
along the extensor pollicis and abductor pollicis. (b)Trousseau sign for
hypocalcemia is positive when a BP cuff inflated above the systolic BP for
3 minutesinduces carpal spasm. (c and e)Compression of the median
nerve may result in carpal tunnel syndrome, which presents with pain and
paresthesias in the median nerve distribution. Tinel sign is positive when
tapping over the median nerve at the wrist produces pain and paresthesia,
while the Phalen test is positive when one minute of forced palmar flexion
produces pain and paresthesia over the median nerve distribution.
302.The answer is b.(Rosen, pp 547-549.)Carpal tunnel syndromeis
a neuropathy of the median nervethat occurs as a result of compression of
the nerve within the carpal tunnel of the wrist. Symptoms include pares-
thesias and painin the distribution of the median nerve; the volar thumb,
second, third, and half of the fourth digit. Symptoms are usually worse after
strenuous activities and at night. Pain improves with shaking of the hand or