The Palm

Anesthesia of the palm by local infiltration may be cumbersome, and a regional wrist block is often more effective. Lacerations of the palm should be examined carefully through range of motion to exclude flexor tendon or tendon sheath involvement (Table. ,.4.0.-4.). Two-point discrimination should be carefully checked since the digital nerves are very superficial in the palm. Deeper lacerations between the metacarpophalangeal joints and distal wrist crease are judged to be in "no man's land," and specialty consultation for exploration often is needed. All flexor tendon lacerations require consultation by a hand surgeon, but primary repair of flexor tendon lacerations can be delayed. In this case, the emergency physician should close the skin, splint the extremity in the position of function, and have the patient evaluated by the hand surgeon within the next few days. The closure method of choice in the palm is horizontal mattress sutures with 5-0 nylon or polypropylene. This reduces the chance that the suture material will pull through the skin edges. Every attempt should be made to reapproximate palmar creases by placing a suture directly through the crease on either side of the laceration ( Fig 4,0.-5.). It is important to observe the placement of the needle with each pass to avoid catching underlying tendons or tendon sheaths.

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Dealing With Back Pain

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