| Abstract|| |
Background : Injuries in hands and forearms may cause significant discomfort and disability. Aim : To evaluate the accuracy of preoperative clinical examination in depicting lesions caused by penetrating wounds of hands or forearms. Setting and Design : This prospective study was conducted from August 2006 to September 2009 at Kashani University Hospital, Isfahan University of Medical Sciences, Iran. Materials and Methods : Two hundred and fifty patients with clean penetrating injury to the hand/forearm were enrolled in this study. After patient's data registration, a careful clinical examination and routine exploration without expansion of wound were done by an orthopedic resident. Each tendon was tested at each joint level. Nerves were evaluated with a two-point discrimination test, and arteries were tested with palpable pulses. Surgical exploration was done by a single hand surgeon in operation room. Accuracy of clinical examination was compared to surgical examination. Results : During the study period, 180 (72%) males and 70 (28%) females with mean age of 28±4 years participated. The preoperative examination showed a predominance of the volar zone IV injuries followed by volar zone II, III, thumb zone II, volar zone V and thumb zone III. Despite the enough accuracy of preoperative examinations in dorsal side injuries of hands and forearms (error rate = 8.3%), the preoperative examinations significantly underestimated the amount of damage to soft tissues on the volar side of hands and forearms (error rate = 14%). Conclusions : The precise surgical evaluations should be considered in patients with penetrating injury to the hand or forearm, especially in those with volar side injuries.
Keywords: Accuracy, clinical examination, hand, injury, surgical examination, tendon
|How to cite this article:|
Dehghani M, Shemshaki H, Eshaghi MA, Teimouri M. Diagnostic accuracy of preoperative clinical examination in upper limb injuries. J Emerg Trauma Shock 2011;4:461-4
|How to cite this URL:|
Dehghani M, Shemshaki H, Eshaghi MA, Teimouri M. Diagnostic accuracy of preoperative clinical examination in upper limb injuries. J Emerg Trauma Shock [serial online] 2011 [cited 2020 Jan 22];4:461-4. Available from: http://www.onlinejets.org/text.asp?2011/4/4/461/86629
| Introduction|| |
Penetrating injuries is a common cause of severe neurovascular damage, both in adults and children.  The most frequent mechanisms of injury are accidental glass lacerations (55%), knife wounds (24%), and electric saw injuries (11%).  The most frequently injured structures are different in reported studies. , Hand injuries are the second cause of medicolegal claims and ranked as second in the order of compensation paid by the insurance companies. 
Evidences show that after one month, delivery of the flexor tendon through the fibro osseous sheath and the pulley is extremely difficult. In this case, in the absence of extensive scarring and destruction of the tendon sheath, traditional single-stage flexor tendon grafting could be done.  Therefore, outcomes of primary repair are better than secondary repair and prompt diagnosis of tendon and associated injuries is of great importance. Some studies suggested that the clinical and functional assessment is more appropriate than series of individual observations and neurophysiological studies.  Other studies consider surgical wound exploration for detecting often extensive and unknown degree of injuries. , Few studies, however, were conducted to determine and compare the accuracies of pre-operative clinical examinations with surgical wound expansion in operation room for detecting soft tissue lesions in hand/forearm injuries. This study has been conducted to evaluate the accuracy of pre-operative clinical examinations and explorations without the wound expansion compared with exploration in operation room with surgical wound expansion for detecting soft tissue lesions in dorsal and volar sides of the hand and forearm injuries.
| Materials and Methods|| |
This prospective study was conducted from August 2006 to September 2009 at department of Orthopedic Surgery in Kashani University Hospital (Isfahan University of Medical Sciences), Isfahan (IRAN). The study protocol was approved by the Ethics Committee of Isfahan University of Medical Sciences and informed consent was obtained from all patients. The study was registered also at ClinicalTrials.gov (identifier: NCT01253863).
Two hundred and fifty patients with hand/forearm injuries were enrolled. After registering patients' data such as age, gender, mechanism of injury, and location of the injury, careful clinical examination and exploration of wound without expansion were done by a single orthopedic resident and soft injured tissues were determined as possible. Each tendon was tested at each joint level. The palmaris longus was excluded from consideration. Nerve testing was done via two-point discrimination (with greater than five mm deemed abnormal) and arterial testing of palpable pulse was also performed. Allen's test was performed to determine radial versus ulnar artery. Preoperative radiographs were obtained in all patients to assess the presence of foreign body or fracture.
The patient was then treated according to the usual protocol at our emergency room, which involved surgical exploration in the operating room and treatment of the lesions by a single hand surgeon. All patients were set in the supine position with an arm board and pneumatic upper arm tourniquet. Then surgical exploration was executed under regional or general anesthesia. The wound was expanded and the underlying injured structures were determined. The injuries of each soft tissue lesion were repaired. Tendon lacerations of 50% and greater were recognized as complete laceration, and then repaired. All partially injured nerves were repaired, as well. Postoperative care was also done with our standard protocol of our orthopedic hand surgery clinic.
Data were analyzed using the SPSS software v. 16.0. We used Chi-square and T-test to compare categorical and parametric variables, respectively. P < 0.05 was considered as statistically significant.
| Results|| |
0During the study period, 180 (72%) males and 70 (28%) females participated with the mean age of 28.6±4.3 years. The right upper limb involvement was 68% and the left upper limb involvement was 32%, in regard to hand dominancy. The mechanisms of injuries were the following: Knife wounds (45%), glass lacerations (23%), hacksaw injuries (20%) and jigsaw wounds (12%). Deep wound was localized on the dorsal side of hands and forearms in 57 (22.8%) patients (hands: 37, forearms: 20), and volar side of hands and forearms in 193 (77.2%) patients (hands: 122, forearms: 71).
The preoperative examination of hand showed a predominance of the volar zone IV injuries (40/122, 32.7%) followed by volar zone II (25/122, 20.4%), III (21/122, 17.2%), thumb zone II (18/122, 14.7%), volar zone V (12/122, 9.8%) and thumb zone III (6/122, 4.9%). The frequencies of volar side injuries of forearm zones contain the zone of VI (43/71, 60.5%) and zone of VII (28/71, 39.4%), preoperatively [Table 1]. In patients with dorsal side injuries of hand, preoperative examination showed the dorsal zone VI (14/37, 37.8%), zone V (9/37, 24.3%), zone VII (7/37, 18.9%), zone IV (4/37, 10.8%), zone III (2/37, 5.4%) and zone II (1/37, 2.7%). The injured zones of dorsal side in forearm are the following: zone of VIII (12/20, 60%) and zone of IX (8/20, 40%).
|Table 1: Distribution of injured structures in volar side without exploration |
Click here to view
Preoperative data demonstrated that 355 tendons, 82 nerves and 45 arteries were implicated. Three hundred tendons were injured in the volar side of hands and forearms, and 55 tendons were found in the dorsal side of hands and forearms [Table 2]. The most common tendon injured was the flexor digitorum superficialis (FDS) (210/355, 59.1%) with a branch of index finger (88/210, 41.9%). The most common injured nerve was radial nerve (33/82, 40.2%), and the most common injured artery was the radial artery (17/45, 31.1%).
|Table 2: Lesion findings in clinical examination versus surgical exploration |
Click here to view
Intraoperative examination showed the structural injuries as follows: 467 tendons, 141 nerves and 80 arteries. In total, 407 tendons were found in the volar side of hands and forearms, and 60 tendons were determined in dorsal sides [Table 2]. The most common injured tendon was FDS (144/467, 30.8%) with the branch of ring finger (51/144, 35.4%). The most common nerve which had been implicated was the median nerve (29/141, 20.5%) and the ulnar artery was the most common injured artery (36/80, 45%).
The comparison between preoperative examinations and intra operative soft tissue damages detection in the volar side of hands and forearms showed a significant difference (P<</i>0.001). In contrast to volar side, there were no statistical differences between detecting the injured structures in clinical examinations and injured structures according to surgical wound expansion in dorsal side injuries of hands/forearms (P=0.518). There were statistical differences between the injured nerves and the arteries which were detected in the volar side preoperatively and postoperatively (P < 0.001).
The error rates of clinical examination for founding injured tendons in the volar and dorsal sides were 14% (57/407) and 8.3% (5/60), respectively. The error rate for diagnosing arterial and nerve lesions were 43.7% (35/80) and 41.8% (59/141), respectively. The mean of error rate for determining structural lesions with preoperative clinical examination was 26.9% and the most discrepancy was existed for determining FDS (branch of middle and ring fingers) and flexor digitorum profundus.
| Discussion|| |
Injuries in hands and forearms are common conditions in adults and children. It may cause significant discomfort and disability. Accurate assessment of the lesion by relying only on the physical examination can be difficult to achieve in patients with these injuries. Thus, physical examination may miss or result in over-diagnosis of lesions of the tendons, nerves, and arteries. Despite several epidemiologic studies concerning hand injuries, there are a few studies about the accuracy of preoperative clinical examinations and surgical wound expansions for detecting underlying soft tissue lesions.
According to the obtained data, we found that clinical examination and preoperative explorations have enough accuracy to determine the injured structure on the dorsal side of forearms. However, we found that the accuracy of clinical examinations and explorations was significantly lower in regard to the operative explorations for detecting lesions in volar side of hands/forearms. The difference between accuracy of preoperative clinical examinations of dorsal and volar side might be related to the anatomy of tendons and nerves in these regions. There are two flexor digitorum tendons (superficialis and profundus) for each fingers in the volar side of wrists and forearms. If one of these structures were torn, another tendon can flex finger. However, there is one extensor digitorum tendon for each finger on the dorsal side of wrists and forearms and if one extensor digitorum tendon is torn, the patient cannot extend that finger. 
In our study, the error rates were estimated about 14% for volar and 8.3% for dorsal sides of wrists and forearms lesions, but in the study by Nassab et al., these rates were found to be about 32% and 25%, respectively.  This difference could be due to the retrospective nature of their study and different experiences of the examiners. In our study, the mean of error rate for structural lesions was estimated to be about 26.9%. This result agreed with Gibson et al.'s, report, which showed that 33% of underlying injuries were not detected in preoperative examinations.  The difference of these results in error rate may be due to differences in observer or patient characteristics. Patient cooperation is often a problem because of pain, anxiety, chemical impairment, or psychological disturbance and observer errors could not be eliminated, as well. Although almost many authors agree with the role of observer experience in the clinical examination,  Gibson et al., showed that the error rate in determining structural lesions were correlated with the injured structure, but not well correlated with the level of experience of the examiner. 
Nowadays, studies are ongoing to find an instrument with optimum accuracy in determining structural lesions of the upper limbs. Soubeyrand et al.,  showed that ultrasonography is highly effective in detecting lesions of tendons and arteries, but it is less reliable regarding nerve damages. The frequencies of injured tissue were different in previous studies. Noaman et al., reported that the most frequently injured structures were median nerve, flexor digitorum superficialis, flexor digitorum profundus, ulnar nerve and ulnar artery.  In another study, Weinzwei et al., reported that the most frequently injured structures were flexor carpi ulnaris, median nerve, flexor digitorum superficialis and ulnar nerve.  Our study showed that the most injured structures were flexor digitorum superficialis tendons, radial nerve and flexor carpi ulnaris tendon on the volar side and extensor digitorum tendons on the dorsal side of hands and forearms.
Mechanisms of injuries were also varied in previous studies,  but knife and glass are the most common causes of injuries. We found that knife wounds were the most common cause of injuries and glass injuries obtained the second degree. Other causes such as hacksaw and jigsaw injuries may be related to the properties of Isfahan city, which is an industrial city.
The limitation of our study was that the hand surgeon was not blinded to the physical examination results which might overvalue the accuracy of surgical examination.
| Conclusions|| |
According to the results of this study, preoperative clinical examination has an acceptable accuracy for injuries in the dorsal side of the hands/forearms compared with surgical examination. However, it significantly underestimates the extent of injuries to the volar side. Therefore, precise surgical evaluation is recommended for patients with upper extremity injuries, especially in patients with volar side. Further studies on comparing the accuracy of other instruments such as ultrasonography for detecting soft tissue lesions of the upper extremities are warranted.
| Acknowledgment|| |
This study was supported by the Isfahan University of Medical Sciences. We are thankful to Dr. Ali Gholamrezaei for editing this report. Also, we are thankful to emergency department staff of the Kashani Hospital for helping us in conducting this study.
| References|| |
|1.||Iconomou TG, Zuker RM, Michelow BJ. Management of major Penetrating glass injuries to the upper extremities in children and adolescents. Microsurgery 1993;14:91-6. |
|2.||Noaman HH. Management and Functional outcome of combined injuries of flexor tendons. Microsurgery 2007;27:536-43. |
|3.||Weinzweig N, Chin G, Mead M, Gonzalez M. "Spaghetti wrist": Management and results. Plast Reconstr Surg 1998;102:96-102. |
|4.||Riggs L Jr. Medical-legal problems in the emergency department related to hand injuries. Emerg Med Clin North Am 1985;3:415-8. |
|5.||Kleinert HE, Verdan C. Report of the committee on tendon injuries (International Federation of societies for surgery of the hand). J Hand Surg Am 1983;8:794-8. |
|6.||Bukhari AJ, Saleem M, Bhutta AR, Khan AZ, Abid KJ. Spaghetti wrist: management and outcome. J Coll Physicians Surg Pak 2004;14:608-11. |
|7.||Athwal GS, Wolfe SW. Treatment of acute flexor tendon injury: Zones III-V. Hand Clin 2005;21:181-6. |
|8.||Voche P, Merle M. Injuries of the flexor tendons of the hand. Rev Prat 1994;44:2423-8. |
|9.||Wright PE. Flexor and extensor tendon injuries. In: Canale ST, Beaty JH, editors. Campbell's operative orthepaedic. 11 th ed. Philadelphia: Elsevier; 2008. p. 3852-99. |
|10.||Nassab R, Kok K, Constantinides J, Rajaratnam V. The diagnostic accuracy of clinical examination in hand lacerations. Int J Surg 2007;5:105-8. |
|11.||Gibson TW, Schnall SB, Ashley EM, Stevanovic M. Accuracy of the preoperative examination in zone 5 wrist lacerations. Clin Orthop Relat Res 1999;365:104-10. |
|12.||Patel J, Couli R, Harris PA, Percival NJ. Hand lacerations: An audit of clinical examination. J Hand Surg Br 1998;23:482-4. |
|13.||Soubeyrand M, Biau D, Jomaah N, Pradel C, Dumontier C, Nourissat G. Penetrating volar injuries of the hand: Diagnostic accuracy of us in depicting soft-tissue lesions. Radiology 2008;249:228-35. |
Medical Student's Research Committee, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]