Hand injuries and care

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Chapter 18 Hand injuries and care

Bill Croker, Iromi Samarasinghe

Hand injuries are common in emergency departments. Meticulous assessment and management is crucial because preservation of function is critical for livelihood and recreation.

ASSESSMENT

Document:

1. handedness
2. occupation
3. special interests (guitar, piano, model making etc)
4. mechanism of injury (cutting, crushing, industrial, high pressure injection, burn, bite)
5. contamination
6. time of injury
7. specific symptoms (tingling, numbness, weakness)
8. treatment so far.

EXAMINATION

Document:

1. position of hand—noting variation of finger positions from usual ‘rest’ posture
2. location of injury—

• name fingers (not count)
• palmar (volar) or dorsal surface
• radial or ulnar border

3. perfusion.

Nerve function—screening tests

Median nerve

• Motor: abduction of thumb from the plane of the palm while palpating thenar eminence
• Sensory: volar surface—thumb, palm and radial two-and-a-half fingers; dorsal surface—radial two-and-a-half fingers distal to proximal interphalangeal (PIP) joint

Radial nerve

• Motor: wrist extension
• Sensory: dorsal surface—radial two-and-a-half fingers proximal to PIP joint and dorsum of hand

Ulnar nerve

• Motor: adduction of fingers in extension (hold a piece of paper between fingers)
• Sensory: ulnar one-and-a-half fingers and extension onto volar and dorsal surfaces

Tendon function

Test each joint of fingers and thumb in flexion and extension. This will detect complete laceration only. Warn the patient about the possibility of delayed rupture. The exact posture of the injured part at the time of injury cannot be accurately known. Therefore inspect the base of the wound through the full range of movement of the adjacent joints. Testing flexor digitorum profundus (FDP) at the distal interphalangeal (DIP) joint requires the joint more proximal to be held in extension during flexion of the joint being tested. Testing flexor digitorum superficialis at the proximal interphalangeal (PIP) joint requires all fingers except the one being tested to be held in extension to neutralise the mass flexor effect of FDP at the PIP joint.

TREATMENT

Initial treatment

1. Analgesia:

• digital block (avoid adrenaline)
• wrist block
• IV narcotics.

2. X-ray the injured part if there is a possibility of bony injury or foreign body.
3. Check tetanus status (ADT).
4. Carefully clean open injuries and remove debris.
5. Antibiotics if extensive injury or compound fracture.
6. Elevate (pillow case sling from an IV pole if being admitted).
7. Keep fasted and commence IV fluids if surgery a possibility.

Splinting

The hand is splinted in a position to minimise the risk of stiffness after treatment: wrist extended (20°); metacarpophalangeal (MCP) joints flexed (70°) and fingers fully extended. This position keeps the collateral ligaments of the fingers at their maximal length.

Splint only those joints that need to be included for a particular injury.

Explain to the patient the importance of moving any joint not enclosed in the splint to minimise stiffness.

Hand therapy

Follow-up that involves a hand therapist ensures optimal outcome.

SOFT TISSUE INJURIES

Lacerations

Require careful inspection through full range of movement following local anaesthetic (without adrenaline). Document any sensory changes prior to anaesthetic.

Sutures, if required, should be 5/0 non-absorbable and are removed after 5–7 days—longer if over extensor joints, in the elderly or in patients on steroids.

Finger tip injuries

While usually not large, these can be very painful.

Small skin loss (smaller than a 5 cent piece)—without bone exposed

1. Anaesthesia.
2. Clean.
3. Apply ‘wet’ dressing (membrane).
4. Change every 2–3 days until healed (dressing Clinic, LMO or home).
5. Elevate (hand above elbow) to reduce pain and swelling for first 2–3 days.
6. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for outpatient follow-up.
7. Active and passive mobilisation to avoid stiffness after first 2–3 days.
8. Analgesia.
9. Review for infection (increasing pain, spreading redness, fever—a late manifestation).

Larger defect or with bone exposed

Defects larger than 1 cm diameter require skin graft.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice. Commence initial treatment.

Finger lacerations

Careful assessment for associated nerve and tendon injury. If present, appropriate referral.

Otherwise suture as indicated.

Palmar lacerations

‘No-man’s land’ is the zone from the midpalm to the PIP joint where the tendons of the flexor superficialis and profundus are enclosed together in tendon sheaths. Great care in assessment is necessary. Palmar skin is thick and difficult to suture. Anaesthesia is difficult to achieve with local infiltration for similar reasons.

Request senior review.

NAILS

Nailbed lacerations

Meticulous repair is critical. It is not just cosmetic; poor technique results in a permanently split nail. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for repair of laceration.

Preserve the nail; it can be used as a splint.

Commence initial treatment.

Subungual haematoma

With NO injury to nail or surrounding nail margin

Drill through the nail in two or three spots with a 19-gauge needle spun between thumb and index finger to release blood.

Analgesia, elevate for 48 hours.

Associated undisplaced fractures are considered ‘open’ and treated with oral antibiotics.

With injury to nail or surrounding nail margin

Risk of nail bed laceration. Refer for review by the team.

Avulsion

Nails take 3 months to grow from nail bed to tip, delayed by a month if injured.

If the nail is avulsed there is a risk of nail bed laceration. Refer for review by the team.

TENDONS

Lacerations of the extensor surface overlying the PIP joint

Otherwise innocuous-looking lacerations of the extensor surface of the PIP joint can transect the central slip of the extensor mechanism with preservation of extensor function initially. However a boutonnière deformity will subsequently develop if the tendon has been cut.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for exploration and repair.

Commence initial treatment.

Mallet finger

A mallet finger is an avulsion of the extensor tendon at its insertion into the distal phalanx. The patient is unable to fully extend their distal phalanx. It occurs when there is a sudden forced flexion of an extended finger (hit by cricket ball, basketball etc).

Without fracture

Splint in gentle hyperextension for 6 weeks—commercially available splints recommended.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for outpatient management.

With fracture

If there is a fracture involving more than 50% of the articular surface, this will need to be meticulously repaired. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice.

Commence initial treatment.

NERVE INJURIES

The digital nerves and arteries run in a bundle along the line joining the flexion creases of a flexed finger. Beyond the distal flexion crease the nerve breaks up into terminal branches which are not practical to repair. Some sensation will return anyway.

Lacerations proximal to the DIP joint causing sensory loss require exploration. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice.

Commence initial treatment.

Nerves regrow at a rate of 1 mm a day. After repair no guarantee can be given about return of function, which takes several months even when repair is successful. Commitment to physiotherapy is required to optimise outcome.

VASCULAR INJURIES

The ulnar artery is the dominant artery of the hand.

1. Control brisk bleeding with direct pressure—gauze and gloved fingers—to prevent exsanguination.
2. If bleeding persists when pressure removed, apply an arterial tourniquet (blood pressure cuff inflated to 50 mmHg above systolic pressure for no longer than 20 minutes) prior to exploration and definitive treatment. Tourniquets are very painful and carry the risk of tissue ischaemia if left inflated too long.
3. A history of pulsatile bleeding dictates exploration of the wound to tie off both ends of the artery to prevent formation of a pseudoaneurysm.
4. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice.
5. Commence initial treatment.

BONY INJURIES

Phalanges

Fractures with rotational deformities

1. Assess for the presence of any rotational deformation by getting the patient to touch their thenar eminence with all their fingers simultaneously. If the injured finger is twisted then a rotational deformation is present.
2. Digital block.
3. Correct rotational deformation.
4. Buddy-strap finger (gauze between fingers to minimise rubbing).
5. Elevation, analgesia, active and passive movement of fingers to reduce stiffness.
6. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for outpatient follow-up in about 1 week to ensure no delayed deformity.
7. If rotational deformation, or more than 10° of angulation, persists after reduction refer to the hand/plastic/orthopaedic team according to your hospital’s practice for accurate reduction and fixation.

Fractures without rotational deformities

If no rotational deformity is present, buddy-strap, elevate until acute pain settles and then use hand normally, provide analgesia and refer to LMO for review.

Fractures involving joint surfaces

Commence initial treatment.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for accurate reduction and fixation.

Dislocations

1. Digital block.
2. Reduce dislocation, usually by gentle traction. If unsuccessful, try increasing the deformation (i.e. if dorsal dislocation, hyperextension before traction).
3. Buddy-strap finger (gauze between fingers to minimise rubbing).
4. Elevation, analgesia, active and passive movement of fingers to reduce stiffness.
5. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for outpatient follow-up in about 1 week to assess for instability and continued hand therapy.

Compound fractures

Commence initial treatment.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for washout, reduction and closure.

Fracture of the fifth metacarpal neck

Also see a discussion of this topic in Chapter 17, ‘Orthopaedic principles: fractures and dislocations’.

Provided angulation of this common ‘punching’ injury is less than 45°, a simple dorsal back slab for 3–4 weeks will usually provide sufficient support. Refer to LMO for review to ensure fracture does not slip.

Otherwise refer to the hand/plastic/orthopaedic team according to your hospital’s practice for reduction.

Carpal bones

Scaphoid fractures

This is the keystone of the carpus and non-union following fracture results in chronic pain and instability. Management is controversial; conservative management in a scaphoid cast or open reduction internal fixation (ORIF) should be deferred to appropriate specialist team.

1. Apply scaphoid plaster of Paris (POP) cast.
2. Elevate.
3. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for outpatient follow-up in about 1 week.

SPECIFIC INJURIES

Burns

Burns of the hand represent a ‘special area’ injury and should be discussed with the regional burns injury unit.

Commence initial treatment—generous analgesia.

Superficial partial thickness dorsal surface burns (classically scalds or fat burns) should be reviewed at 24 hours to ensure correct initial assessment and then can be treated with analgesia, elevation and daily dressings by LMO or dressing clinic.

Electrical injuries

Initial assessment can be misleading, as the full extent of injury may not be apparent at first.

Perform a very careful neurovascular examination.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice.

Infections

Suspect foreign bodies.

Pain on passive stretch suggests tendon sheath infection or compartment syndrome.

If not septic and no suggestion of tendon sheath infection, commence oral antibiotics, splint and review in 24 hours (earlier if there is any sign of deterioration).

If there is evidence of tenosynovitis, early referral for operative drainage of tendon sheath under general anaesthetic is necessary. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice.

Commence initial treatment, in particular early intravenous antibiotics.

Pyogenic granuloma

These are collections of granulation tissue developing around a foreign body such as suture material. Treatment is by curette or formal surgical excision with histologic examination of excised tissue.

Felon

A felon is an abscess of the pulp of the distal phalanx which requires drainage with digital nerve block to prevent complications. Usually presents with throbbing pain, swelling and tenderness without fluctuance.

Digital nerve block and forearm tourniquet to provide bloodless field.

A central longitudinal incision avoiding crossing flexion crease protects digital neurovascular bundle and flexor tendon sheath. Avoid incision of vertical pulp space fibres. Incision is made down to bone avoiding FDP insertion.

Delay to treatment may result in osteomyelitis, pulp necrosis or loss of pinch function.

Paronychia

Paronychia is infection of the tissues around the fingernail.

1. Digital block.
2. Soak the finger in warm water for about 10 minutes.
3. Blunt dissect with fine scissors or no. 11 scalpel under the skin fold to open the abscess.
4. Irrigate.
5. Pack.
6. Analgesia, elevate and review in 24 hours.
7. Antibiotics are only indicated if there is significant surrounding cellulitis. Oral cephalosporins are generally adequate, although non-multiresistant oxacillin-resistant Staphylococcus aureus (NORSA) strains which are increasing in incidence may respond to clindamycin.
8. Complications include subungual abscess which requires nail to be removed.

Chronic paronychia

Usually occupational from prolonged exposure of hands to water. Involves bacterial and candidal infection.

Treatment involves drying hands with 70% alcohol and topical antifungal ointment such as iconazole 1%. The nail is removed only if the infection is intractable. Refer to hand surgery for marsupialisation and wedge resection of nail.

Herpetic whitlow

Herpetic whitlow is most commonly seen in healthcare workers. Presents as a vesicle around nail or finger pad. It is intensely painful.

Swabs may be taken for herpes zoster polymerase chain reaction (PCR).

Topical acyclovir is used with variable success. Unlike bacterial infections, incision and drainage is not indicated.

Bites

Bites have a high rate of infection.

• If simple, superficial and seen in under 8 hours, with no evidence of involvement of underlying structures:

• irrigate copiously
• debride as necessary
• consider delayed primary closure
• elevate
• immobilise
• review at 24 hours to ensure no infection.

• ‘Bites’ or ‘tooth penetration’ wounds, due to punching injuries, should be X-rayed to ensure there are no teeth fragments in the wound. Oral flora inoculated into the MCP joint with clenched fist injuries usually results in a septic joint effusion and requires operative drainage, splinting and elevation and broad-spectrum parenteral antibiotics (ceftriaxone + metranidazole).
• For all other injuries (complex or deep lacerations, involvement of underlying structures or delayed presentation), refer to the hand/plastic/orthopaedic team according to your hospital’s practice.

Commence initial treatment.

Crush injuries

Crush injuries cause extensive soft tissue damage, without necessarily causing any bony injury. Initial assessment may reveal minimal external evidence of injury. Contained bleeding and tissue oedema resulting from the crush injury can cause progressively increasing pressure resulting in tissue ischaemia—the compartment syndrome.

History should be extended to include mechanism of crush, duration of compression and areas included under the compressive forces.

Examine in particular for signs of the compartment syndrome: pain out of proportion to the injury, pain on passive stretch of the compartment, tense feel to the compartment and distal paraesthesia. Pulses are normal until very late in the evolution of the compartment syndrome.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for observation and possible fasciotomy.

Commence initial treatment.

Treat associated injuries as appropriate (lacerations, fractures or dislocations, arterial injuries).

Strict elevation and hourly limb observations to detect early signs of compartment syndrome.

High-pressure injection injuries

Industrial accidents involving injection (e.g. paint, grease, gas) into the hand are urgently referred to the hand/plastic/orthopaedic team according to your hospital’s practice for observation and possible debridement of devitalised tissue or fasciotomy for decompression of ensuing compartment syndrome.

Commence initial treatment.

Hydrofluoric acid burns

Hydrofluoric acid is an industrial cleaning agent which causes liquefactive necrosis resulting in deep tissue damage and intense pain, often without much external sign of injury.

Specific treatment is calcium, which can be administered by a variety of routes. Calcium gluconate 2.5% gel (made by mixing 10% calcium gluconate solution with 3 times the volume of KY gel) can be used topically. For finger burns, the gel can be placed in a latex glove and the affected hand inserted into it for up to 45 minutes. This can be repeated 6 hourly for 24 hours until pain eases.

Intra-arterial calcium gluconate is effective second-line therapy for more severe and extensive hand burns. Infusion of 10–20 mL of 10% calcium gluconate in 200 mL 5% dextrose over 4 hours via a radial artery catheter is more effective than intravenous burns and safer than local infiltration, which risks compartment syndrome due to the volumes required.

Refer to the hand/plastic/orthopaedic team, according to your hospital’s practice, for treatment.

Gamekeeper’s thumb

Also see a discussion of this topic in Chapter 17, ‘Orthopaedic principles: fractures and dislocations’.

Forced abduction of the thumb (as in skiing) results in rupture of the ulnar collateral ligament of the thumb.

Assess for tenderness over the ulnar border of the MCP joint. If present, treat with a scaphoid plaster and refer to the hand/plastic/orthopaedic team according to your hospital’s practice for outpatient follow-up in about 1 week to reassess and for continued hand therapy.

Amputations

Indications for replantation or revascularisation include thumb amputations, multiple digits, amputations distal to insertion of flexor digitorum superficialis (FDS), cold ischaemia time less than 24 hours.

Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for consideration of reimplantation.

Commence initial treatment.

Care of the amputated part

No amputated part should be discarded until a formal plan of replantation has been discussed with surgeon and patient.

1. Carefully clean.
2. Wrap in sterile saline-soaked gauze.
3. Place in sealed plastic bag in an ice-water bath at 4°C.
4. X-ray the amputated part.

Carpal tunnel syndrome

Compression neuropathy of the median nerve as it traverses the wrist deep to the flexor retinaculum can be chronic or acute (suppurative infection, burn, haemorrhage, postoperative) and idiopathic or secondary to increase in carpal tunnel contents (tenosynovitis, haematoma, oedema) or decrease in size of tunnel (arthritis, fracture or dislocation of the lunate).

Indications for decompression include acute carpal tunnel syndrome with rapid onset and progression of median nerve impairment, persistent symptoms despite conservative measures or impaired sensation in radial two-and-a-half fingers or thenar muscle palsy.

1. Conduct a thorough neurovascular and functional assessment.
2. Splint and elevate.
3. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for endoscopic release or open carpal tunnel release.

EDITOR’S COMMENT

Hand/finger injuries are very common but require extra knowledge and care to avoid major functional problems that may impact on livelihood etc.

RECOMMENDED READING

American Society for Surgery of the Hand (ASSH), Berger R., Weiss A. Hand surgery. Philadelphia; London: Lippincott Williams & Wilkins, 2004.

Conolly W.B., editor. Atlas of hand surgery. New York: Churchill Livingstone, 1997.

Green D., Hotchkiss R., Pederson W., et al. Green’s operative hand surgery, 5th edn. Philadelphia: Elsevier Churchill Livingstone; 2005.

Hunter J., Mackin E., Callahan A., editors. Rehabilitation of the hand: surgery and therapy, 4th edn, St Louis: Mosby, 1995.

McRae R., Esser M. Practical fracture treatment, 5th edn. Edinburgh: Churchill Livingstone; 2008.

Semer N.B. Practical plastic surgery for nonsurgeons. Philadelphia: Hanley & Belfus; 2001.

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