Traumatic hand injuries are a common yet potentially complex injury to manage in the emergency department. About 5% of injuries presenting to the ED involve some part of the hand. The hand is a complex and dynamic structure that allows us the opportunity for creativity and precision through its mobility and sensation. Most injuries to the hand are relatively straight forward and easy to manage, but the emergency clinician needs a sound assessment and management approach to be able to identify and correct injuries that may profoundly alter a patient’s ability to function.
Andrade, A. & Hern, H. (2011). Traumatic Hand Injuries: The Emergency Clinician’s Evidence-Based Approach. Emergency Medicine Practice. 13 (6). (Abstract and subscription link)
Q1.What are the common etiologies of traumatic hand injuries?
- Lacerations are the most common injury (62%)
- Hand fractures are considered the second most common etiology (11.4%)
- Abrasions may be more common than either lacerations and fractures but these patients generally don’t seek care in emergency department.
Q2.What is the differential diagnosis of traumatic hand injuries, and how are they classified according to triage priority?
Immediately Limb-Threatening injuries
- Compartment syndrome
- Crush injuries
- High-pressure injection injuries
- Vascular injuries
Injuries Requiring Rapid ED Assessment/Intervention injuries
Not Immediately Limb-Threatening injuries
- Nerve injuries
- Tendon injuries
- Ligamentous injuries
- Fingertip/fingernail injury
Q3. What are the 5 initial treatment principles that should be applied at triage?
- Ensure Airway, Breathing and Circulation are intact
- Assess for other injuries
- Irrigate the wound and remove any debris
- Apply pressure to bleeding wound, elevate, provide ice to reduce swelling and analgesia for pain management.
- Remove any jewelry that may impair circulation
Q4. What is the most effective way of providing analgesia to traumatic hand injuries?
- There are multiple routes of providing analgesia to traumatic hand injuries in the emergency department.
- Most common ways are either local anaesthetic infiltration, digital nerve blocks, and anatomical forearm nerve blocks.
- Generally lignocaine is preferred anaesthetic agent for providing local anaesthesia, although bupivacaine is becoming more popular as its longer acting, though it has a longer time to effect.
- The traditional method for digital nerve blocks using a 2-injection approach may cause considerable pain. Recent studies have shown a single volar injection technique can deliver the same anaesthetic results as the 2-injection dorsal approach.
Q5. What is the most common imaging modality used to to assess traumatic hand injuries?
- Plan X-ray is the most useful tool for the assessment of traumatic hand injuries.
- Unfortunately no clinical decision rules exist to guide when to image a traumatic hand injury, however current recommendations suggest that if there’s a clinical suspicion for a fracture or dislocation, then this should be evaluated with at least a posteroanterior and lateral view of the affected hand.
- X-ray is also useful for detecting radio-opaque foreign bodies.
- Other imaging modalities that can be used but rarely offer little more over plain X-rays are ultrasound, computed tomography and MRI.
Q6. What is the emergency department management of proximal and middle phalanx fractures?
- Unlike distal phalanx fractures, proximal and middle phalanx fractures require precise alignment for good functional and cosmetic outcomes.
- The majority of pharyngeal fractures however are not displaced and are usually simply transverse fractures requiring simple “buddy-tapping” the affected finger to the adjacent finger to promote early mobilisation and reduce stiffness.
- Unstable pharyngeal fractures include oblique fractures, malrotated fractures, and angulated fractures. These generally require gentle manipulation under digital block to reduce to adequate alignment. Once alignment has been achieve, the fracture should be splinted in extension and refereed to the outpatient hand clinic for follow up.
Q7.What are the 3 most important points when assessing and managing a tendon injury?
- Radiographs should be obtained to rule out associated fractures and avulsions
- Surgical consultants should evaluate open tendon lacerations for surgical repair
- Closed tendon injuries require splinting and surgical follow-up
Q8. Why do fight bites require early aggressive treatment?
- Fight bite, or clenched fist injury, occurs when a closed fist strikes a tooth, causing a laceration at the MCP joint. These laceration allow bacteria to enter along the extender tendon sheath and track along the tendon leading to infection and functional impairment, and damage to underlying bones, tendons and joints.
- Patients are often reluctant to provide an accurate history, and a high index of suspicion should be held for a fight bite when presented with a laceration over the MCP.
- Current literature reports early aggressive management of these injuries. Arrange for prompt X-ray’s to evaluate for retained foreign bodies and fractures, elevate and immobilize the affect limb, provided early intravenous antibiotics, and arrange for hand surgeon review for exploration and wash-out in theatre.
- Untreated fight bites can result in osteomyelitis, tenosynovitis and septic arthritis.
Q9. What are the management priorities when dealing with hand/finger amputations?
- These are medical emergencies and should be triaged appropriately with prompt hand surgeon evaluation.
- Replantation should nearly always be considered, and surgical repair is required even if replantation is contraindicated.
- Success rates for reimplantation depend on ischaemia time, degree of tissue damage, and mechanism of injury.
- Emergency department management revolves arounds haemorrhage control, pain control, and maximising storage condition for the amputated part by cooling it, and preserving the tissues integrity.
- Optimal storage of the amputated part involves wrapping it in saline soaked gauze, placing it inside a sealed plastic bag, then placing this sealed bag inside another bag containing ice that is placed in a cooled insulated container for storage until a hand surgeon can assess the viability of the amputated part and prepare it for reimplantation.
Q10. Can compartment syndrome occur in hand/finger injuries?
- Although rare, compartment syndrome can occur, and may result in devastating tissue injury and functional impairment.
- Have a high index of suspicion in the following presentations: crush injuries, circumferential burns, pain out of proportion to mechanism, increasing pain despite treatment, palpably tense tissue, and evidence of nerve or vascular injury.
- Remember the hand has up to 10 different compartments depending on how its assessed making diagnosis difficult. Look for early signs of of paresis and pallor followed by late sign’s of pulselessness, cold and cyanosed digits.
- Emergency department management involves urgent hand surgeon review — keep the patient NBM and prepare for theater. Elevate the hand and remove any constrictive jewelry, bandages or cast.
- Avoid regional and digital nerve blocks if a compartment syndrome is suspected as they may hinder subsequent clinical examination.
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