Hand injuries and care

Published on 14/03/2015 by admin

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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.

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