Hand injuries by Hilary Lee

Hand Injuries
Hilary Lee R2 EM
May 24, 2015
Hilary Lee 2015

Overview
• Review relevant anatomy
• Physical exam maneuvers
• Lacerations
• Fractures
• Dislocations
• Special ﬁngers
• Crush, injection injuries
Hilary Lee 2015

Objectives
• Perform an appropriate evaluation of a hand
injury
• Know when to consult a hand surgeon
immediately and with delay
• Be familiar with the management of common
hand trauma complaints
Hilary Lee 2015

Hand Injuries
• 30-40% of all trauma visits (major and minor)
involve a signiﬁcant hand complaint
• Highly functional body part with multiple
superﬁcial tissues
• Loss of productivity - 3rd highest reason for
missed work days
Hilary Lee 2015

Immediate/Prehospital Care
• Control bleeding
• Pressure, elevation
• Tourniquet
• Remove jewelry
• Splint deformities
• Preserve amputations
• Cooling procedures
Hilary Lee 2015

History
• SAMPLE hx
• Pain, ROM, function, strength, paralysis, numbness/
tingling, cold ﬁngers, timeline, tetanus
• Handedness, occupation
• Prior injuries/surgeries
• Immunocompromise, smoking, DM
Hilary Lee 2015

Physical
Inspection
• Deformity, bleeding, rotation, amputations, avulsions, holding of limb
• Skin integrity - lacerations, edema, scars
• Fist and open
Palpation
• Tenderness, crepitus, AROM, PROM
Ligaments, tendons
• Varus/valgus stress (DIP, PIP, MCP)
• Explore wound for tendinous injury
Vascular
• Warmth, colour, cap reﬁll
• Explore wounds for vascular injury (+/- tourniquet)
Neurological
• Ulnar, median, radial 
Hilary Lee 2015

Sensory
46% have crossover between median and ulnar nerves
Hilary Lee 2015

Tendons
Emergency Medicine Practice © 2011 6 ebmedicine.net • June 2011
ligaments, tendons, muscles, and nerves. Magnetic
resonance angiography (MRA) can be used to
evaluate vascular structures.
Ultrasonography
In the hands of a skilled operator, ultrasound can
be used to visualize soft tissue structures. The small
structures of the hand are, however, difﬁcult to scan
and usually require high-frequency linear probes
and an experienced ultrasonographer.
ogy’s published guidelines, any clinically suspected
fracture or dislocation in the hand should be evalu-
ated with at least posteroanterior and lateral views,
and an oblique view should be strongly considered.6
Conventional radiography can also be used to
evaluate lacerations that are suspected to contain a
retained foreign body. The current gold standard for
detecting radio-opaque materials (such as glass and
metal) is careful scrutiny of multi-view x-rays.10,11
Clinicians must keep in mind that some materials
Figure 3. Physical Examination Of Hand Tendons
A, Extensor digitorum. B, Flexor digitorum superficialis. C, Flexor digitorum profundus.
Used with permission of Aaron Andrade, MD.
A B C
Extensor digitorum
Flexor digitorum superﬁcialis
Flexor digitorum profundus
Hilary Lee 2015

Imaging
• X ray
• AP, lateral, oblique
• CT
• Ultrasound
Hilary Lee 2015

Regional Anesthesia
• Digital block
• Disinfect
• Volar approach
• In skin crease
• Pinch ﬁnger
• Hit bone
• Back 1-2mm
• Inject 2-3cc
Skin Lacerations
After hemostasis is achieved and appropriate local
or regional anesthesia provided, all skin lacerations
Figure 4. The Volar Single-Injection Method
For Digital Nerve Anesthesia
Note the injection site is at the volar MCP skin crease and the clinician
is lightly pinching the digit. A 25-gauge needle should be advanced
until it hits bone, backed up 1-2 mm, and 2-3 cc of anesthetic in-
jected. Used with permission of Aaron Andrade, MD.
Hilary Lee 2015

Regional Anesthesia
• Local infiltration
• Forearm nerve blocks - ultrasound guided
Emergency Medicine Practice © 2011 8 ebmedicine.net • June 2011
usually heal by secondary intention if less than 1 cm
in diameter. If there is a small amount of exposed
bone, the bone can be trimmed back in the ED with
a rongeur until it is underneath the surrounding soft
tissue and allowed to heal by secondary intention.
Follow-up with a hand surgeon is advised. Imme-
diate consultation of a hand surgeon is required in
cases of wounds larger than 1 cm in diameter, per-
sistently exposed bone, or amputation of the volar
pad.33
Additionally, surgeons subclassify fingertip
injuries into zones I, II, and III. (See Figure 7.) Zone
I injuries are managed conservatively as described
above. Zone II injuries may require rongeuring of ex-
posed bone. Zone III injuries generally require distal
phalanx amputation and warrant follow-up with a
hand specialist.34
Fractures
Perhaps the most important job of an emergency
clinician in hand fractures is proper reduction and
severe crush injuries with large losses of soft tissue.
Intra-articular fractures require thorough examination
to rule out associated tendon avulsions and should
always be evaluated by a hand specialist.23
Subungual Hematoma/Nail Bed Lacerations
In crush injuries of the finger, nail bed lacerations
causing subungual hematomas are common. They
are characterized by throbbing pain and purple
discoloration under the nail. Two management
strategies are commonly used in the ED: removal
of the nail, with direct repair of nail bed laceration;
and nail trephination with a heated paperclip, a
cautery device, or a twirled 18-g needle. A review of
the classic literature yields a long-standing debate
about which management strategy is superior. The
commonly taught “consensus” is that nail bed repair
should be considered for subungual hematomas
covering greater than 25% to 50% of the nail bed.25-30
However, a 1999 prospective study in children dem-
Figure 5. Ultrasound Visualization Of Nerves And Arteries In The Forearm
Ulnar, medial, and radial nerves are shown by the arrow across the bottom of the images. Arrowheads show arteries, A (ulnar), B (medial), and C
(radial).
Liebmann O, Price D, Mills C et al. Ann Emerg Med. 2006;48(5)558-562. Used with permission of Mosby, Inc.
A B C
Hilary Lee 2015

Lidocaine +/- Epinephrine
• Digital ischemia secondary to epinephrine in nerve
block extremely rare
• 17 cases worldwide
• Multiple large safety studies over last 10 years
• Phentolamine -> injectable antidote
• Epinephrine improves anesthesia, decreases
bleeding, decreases systemic anesthetic
absorption
Hilary Lee 2015

Lacerations
• Hemostasis
• Local anesthesia
• Exploration
• Irrigation
Hilary Lee 2015

Primary Closure
• Noncontaminated wounds - within 12 hours?
• Delayed primary closure
• Contaminated wounds
• Irrigate
• Pack
• Reinspect after 3-5 days
Hilary Lee 2015

Primary Closure
• Nonabsorbable vs absorbable
• Monoﬁlament
• Simple interrupted
• 10-14 days (14-21 days palmar)
Hilary Lee 2015

Distal Phalanx
be splinted and
fractures and th
ceive immediat
Figure 6. Radiograph Demonstrating
Phalanx Fractures
Left arrow notes a tuft fracture of digit IV. Right arrow notes a shaft
Figure 7. Zon
Zone I
Zone I
Hilary Lee 2015

Distal Phalanx
• Fractures
• Tuft
• Shaft
• Intraarticular
Hilary Lee 2015

Distal Phalanx
• Fractures
• Tuft
• Shaft
• Intraarticular
Reduce and repair soft tissues prn
Splint in extension
Hilary Lee 2015

Distal Phalanx
• Fractures
• Tuft
• Shaft
• Intraarticular
Reduce and repair soft tissues prn
Splint in extension
Carefully assess tendons, +/- hand surgeon
Hilary Lee 2015

Distal Phalanx
• Amputations
• Zone I - secondary intention
• Zone II - ﬁle down bone,
secondary intention, follow up
• Zone III - distal phalanx
amputation, immediate consult
9 Emergency Medicine Practice © 2011June 2011 • ebmedicine.net
than 3 mm of digit length loss, and no rotational
deformity.35
All metacarpal shaft fractures should
be splinted and referred to a hand surgeon. Open
fractures and those that fail reduction should re-
ceive immediate surgical consultation.35
to the adjacent ﬁnger to promote early mobilization
and reduce stiffness. (See Figure 9, page 10.)
Figure 6. Radiograph Demonstrating
Phalanx Fractures
Left arrow notes a tuft fracture of digit IV. Right arrow notes a shaft
fracture of the distal phalanx of digit III.
Used with permission of John D. Lubahn, MD.
Figure 7. Zones Of Fingertip Amputation
© 2001. Renee L. Cannon. Used with permission.
Zone I II III
Zone I II IIIHilary Lee 2015

Nail
• Subungual hematoma
• Trephination
• Nail removal and nail bed repair
• Nail fold preservation
Hilary Lee 2015

Proximal/Middle Phalanx
• Require precise alignment
• Stable, nondisplaced
• Buddy tape
• Oblique, angulated, malrotated
• Digital block / hematoma block
• Reduction
• Post-reduction ﬁlm
• Splint in extension
Hilary Lee 2015

• Require precise alignment
• Stable, nondisplaced
• Buddy tape
• Oblique, angulated, malrotated
• Digital block / hematoma block
• Reduction
• Post-reduction ﬁlm
• Splint in extension
Repeat if not properly aligned
Hilary Lee 2015

Middle and proximal phalangeal fractures are classified according to
whether they involve the joint surface.
Extraarticular Fractures
Extraarticular fractures affect the part of the bone that is not involved
with the joint surface. The main concern is whether a rotational deformity
is present when the patient attempts to bend the fingers. See chapter 26,
“Normal Hand Exam,” for discussion of rotational finger alignment.
Any malrotation associated with metacarpal or phalangeal fractures must be
corrected. Left, Normally all fingers point toward the region of the scaphoid
when a fist is made. Right, Malrotation at the fracture site causes the affected
finger to deviate. (From Crenshaw AH (ed): Campbell’s Operative
Orthopaedics, 7th ed. St. Louis, Mosby, 1987, with permission.)
Hilary Lee 2015

consist of closed reduction (Bennett fracture only),ting
Figure 9. “Buddy-Taping” An Injured Finger
Hilary Lee 2015

• Refer immediately if:
• Open
• Unsuccessful reduction
• Malrotation
• Intraarticular >30% joint surface
Hilary Lee 2015

Hilary Lee 2015

Fractures
• Safe position /
intrinsic plus
rates of anxiety, borderline per
antisocial personality disorder
with boxer’s fractures should
evaluation psychiatric questio
vention strategies.
Thumb Metacarpal Fractures:
Fractures
Fractures of the first metacarp
than those of the remaining m
be subdivided into extra-articu
fractures. Extra-articular fractu
conservative management prin
carpal fractures, namely, close
angulation goal of less than 20
thumb spica splinting for 4 we
are unstable and require prom
hand surgeon.43
Intra-articular fractures of
involve the CMC joint and gen
an axial injury to a partially fle
Bennett fracture is an intra-art
dislocation; a Rolando fracture
intra-articular fracture.44
(See
debate exists regarding the spe
correction each fracture requir
ture supports that emergency
consist of closed reduction (Be
surgical clinic follow-up. Unstable fractures of the
II and III metacarpals generally require immediate
consultation by a hand surgeon for surgical correc-
tion. Unstable fractures in the IV and/or V meta-
carpals, also known as a boxer’s fracture, can be
reduced in the ED after adequate anesthesia. In the
author’s experience, a forearm ulnar nerve block in
conjunction with a hematoma block using 1% lido-
caine without epinephrine provides excellent results.
Reduction is achieved by traction decompression
followed by the “90-90 method.” (See Figure 10.)
The MCP, PIP, and DIP joints are flexed at 90° and
volar-ward pressure is applied to the dorsum of the
metacarpal shaft. An ulnar gutter splint should be
applied with prompt clinic follow-up within 1 week.
Much controversy exists in the literature regard-
ing the goal of boxer’s fracture reduction. Classic
literature supports acceptable angulation between
20° and 70°.37
More-recent studies are incongruent.
A 1999 cadaveric study concluded that angulation
greater than 30° resulted in measurable functional
impairment.38
Two more recent prospective stud-
ies, however, found good outcomes with 1 week of
soft wrap followed by immediate buddy-wrapping
Figure 8. The “Intrinsic Plus” Splinting
Position
Figure 9. “Buddy-Taping”
Used with permission of Aaron Andrade,
Hilary Lee 2015

Metacarpal Fractures
Hilary Lee 2015

Metacarpal Fractures
• Base or head
• Rare
• Volar splint and consultation
• Shaft
• Common
• Reducible in ED
Hilary Lee 2015

Metacarpal Shaft Fractures
• Regional block
• Hematoma block
• Reduction goals
• <10 degrees
• <20 degrees
• <3mm impaction
• No rotation
Hilary Lee 2015

Metacarpal Shaft Fractures
• Splint (ulnar or radial gutter)
• Refer
Hilary Lee 2015

Metacarpal Neck Fracture
• Nondisplaced, nonangulated
• Gutter splint - immobilize CMP and MCP
• Refer in 3-4 weeks
• Unstable, MCP 2 or 3
• Immediate consultation for OR
Hilary Lee 2015

Boxer’s Fracture
• 5th (or 4th) metacarpal neck
• Volar angulation of distal segment
• Inexperienced punch -> axial load
• >95% young adult males
Hilary Lee 2015

Boxer’s Fracture
• Hematoma block plus ulnar nerve
block
• Traction decompression
• 90 / 90 method
• Volar pressure to dorsum
• Ulnar gutter splint, refer
• 20-70 degrees angulation
accepted 11June 2011 • ebmedicine.net
sor tendon insertion into the distal phalanx, usually
caused by forced flexion of the DIP joint. It is so
named because the flexed DIP cannot be extended
and looks like a mallet. The injury can sometimes
be associated with an avulsion fracture of the dorsal
base of the distal phalanx. The classic strategy for
treating closed mallet finger injuries with less than
one-third of the joint surface disrupted is continuous
splinting of the DIP joint in full extension to hyper-
Figure 10. The “90-90” Method
From
wit
Fig
Hy
Use
Hilary Lee 2015

Thumb Metacarpal
Fractures
• Less common
• Extraarticular
• Closed reduction
• Goal 20-30 degrees angulation
• Thumb spica splint x 4 weeks
Hilary Lee 2015

Thumb Metacarpal
Fractures
Intraarticular
Hilary Lee 2015

Thumb Metacarpal
Fractures
Bennett fracture
• Intraarticular fracture /
dislocation of 1st MCP
• Fragment continues to
articulate
• Axial load on ﬂexed digit
• ORIF if >3mm
displacement
• Closed reduction, refer
Hilary Lee 2015

Thumb Metacarpal
Fractures
• Rolando fracture
• Comminuted
intraairticular 1st
metacarpal fracture
with dislocation
• Unstable, requires
ORIF
Hilary Lee 2015

Tendon Injuries
• Laceration, crush, hyperﬂexion, hyperextension
• XR - r/o associated avulsion or #
• Closed tendon injuries - splint, close follow up
• Open tendon injuries….
Hilary Lee 2015

Tendon Injuries
• Extensor
• Generally reparable in ED
• Few associated structures
• Flexor
• Wound closure and referral
• Many associated structures, evaluate carefully for
nerve or vascular injury
Hilary Lee 2015

Mallet Finger
• Hyperﬂexion injury at DIP
• Extensor digitorum tear +/-
avulsion # dorsal base distal
phalanx
• Splint DIP in hyperextension for
6 weeks, refer
• Do not splint DIP
• If open or >30% articular
surface avulsed, ORIF
Hilary Lee 2015

Mallet Finger
• Hyperﬂexion injury at DIP
• Extensor digitorum tear +/-
avulsion # dorsal base distal
phalanx
• Splint DIP in hyperextension for
6 weeks, refer
• Do not splint PIP
• If open or >30% articular
surface avulsed, ORIF
Hilary Lee 2015

Jersey Finger
• Extension against resistance injury
• Flexor digitorum profundus tear
• Named after jersey tugging at a sports match….
Hilary Lee 2015

Jersey Finger
• Isolated or plus avulsion fracture
• Immediate consultation for surgical intervention
Hilary Lee 2015

Fight Bite
• Laceration to MCP
• High rate of associated tendon, joint or bone
injury - 75%
• Clenched ﬁst mechanism - with relaxation, oral
bacteria on extensor tendon sheath track back
Hilary Lee 2015

Fight Bite
• Aggressive early management
• XR r/o foreign body or fracture
• Irrigate, elevate, immobilize
• Early surgical consultation
Hilary Lee 2015

Fight Bite
• Polymicrobial
• alpha-hemolytic streptococcus (s viridans)
• staphylococcus aureus
• eikonella corrodens (25%)
• gram negatives, anaerobes
• If joint or tendon sheath involved
• Admit for IV antibiotics (ampicillin/sulbactam, cefoxitin, carbapenem)
• OR for I&D
• PO amox-clav at discharge for 5-7 days
• Complications: osteomyelitis, tenosynovitis, septic arthritis
Hilary Lee 2015

Dislocations/Subluxations
• Closed reduction with local anesthesia
• XR r/o avulsion #, conﬁrm post-reduction
alignment
• Avulsion >30% articular surface = immediate consult
• Splint in slight ﬂexion x 2-3 weeks
• Consultation as outpatient
Hilary Lee 2015

Skiier’s/Gamekeeper’s
Thumb
• Ulnar collateral ligament tear
• Forceful radial deviation of the thumb
• Pain, swelling on ulnar aspect of 1st MCP joint
• Valgus stress / radial deviation on 1st MCP with thumb
fully extended and in 30 degrees ﬂexion
• Distal deviation >35 degrees or 15 degrees more than
unaffected thumb = complete tear
Hilary Lee 2015

d place
CP
in 30°
greater
umb is
mplete
ner
omes
Figure 15. Valgus Stress Testing Of The First
MCP Joint
Ulnar deviation by greater than 35° or 15° more than the unaffected
side is diagnostic of a complete UCL rupture.
From Rhee S, Cobiella C. Trauma. 2007;9:163-170, copyright © 2007ateral bands
Hilary Lee 2015

Skiier’s/Gamekeeper’s
Thumb
• High incidence of Stener lesion (adductor
pollicis aponeurosis sticks between ends of
UCL) -> poor healing
• Consult, requires ORIF within 3 weeks
• Partial tear -> thumb spica x 4 weeks, outpatient
follow up
Hilary Lee 2015

Vascular Injuries
• Rarely causing signiﬁcant morbidity -> ulnar and
radial collaterals
• Direct pressure, tourniquet
• Distal ischemia -> immediate consultation
• Doppler u/s, pulse oximetry
Hilary Lee 2015

Nerve Injuries
• Splint to prevent further damage
• Closed -> likely neurapraxia or axonotmesis
• Endoneurium intact, will spontaneously regenerate
• Outpatient referral for repeat physical exams
• Open -> likely severed
• Without endoneurium, regeneration not possible
• Immediate referral for repair
Hilary Lee 2015

High Pressure Injection
• Nondominant hand of industrial workers
• Paint, oil, water, air, solvents, metal, cement
• Cannot estimate tissue damage with superﬁcial signs or
imaging
• High risk of infection, vascular compromise, amputation
• Immediate consultation for debridement
• Splint, elevate, pain control, broad spectrum abx
• Nerve blocks contraindicated
Hilary Lee 2015

Amputations
• Wrap amputated part in saline-moistened gauze,
place in sealed plastic bag, in insulated
container with sealed bag of ice
• Proper cooling -> viable for 12-24 hrs
• Control hemorrhage, pain
• Immediate consultation
Hilary Lee 2015

Compartment Syndrome
• Rare
• Difﬁcult to identify, 10 compartments in the hand
• Pain -> parasthesias -> paresis -> pallor -> pulselessness
• Suspect if…
• Crush
• Circumferential burn with eschar
• Pain out of proportion or rapidly increasing
• Palpably tense tissues
• Nerve/vascular injuries
• Immediate consultation, limb elevation, removal of constricting materials
Hilary Lee 2015

Summary
• Impossible
• Extensive, highly speciﬁc knowledge that is not
generalizable
• If in doubt, discuss case with a hand surgeon for
appropriate guidance
• Always manage pain, provide immobilization, thoroughly
investigate functional components
• Practice defensively - hands are the most occupationally
signiﬁcant limb and disability will have lasting consequences
Hilary Lee 2015

Hand injuries by Hilary Lee

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