The Acute Hand: Assessment and Management in the ED Setting - Part I
Part I: Anatomy, Assessment, and Initial Management
Author: Gary D. Hals, MD, PhD, Attending Physician, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, Columbia, SC.
Peer Reviewers: Alasdair K.T. Conn, MD, Chief of Emergency Services, Massachusetts General Hospital, Boston; Andrew D. Perron, MD, FACEP, Assistant Professor of Emergency Medicine, Associate Residency Director, Department of Emergency Medicine, University of Virginia, Charlottesville.
The human hand is an amazing tool, resulting from millions of years of evolutionary fine-tuning. It is capable of precise movements of less than a millimeter and, at the same time, possesses great strength and flexibility. One only needs to look at our woefully inadequate attempts to replicate or replace a hand to understand how complex hands really are. Unfortunately, as our hands are used for so many purposes, they are the parts of the body most often placed in the environment and, therefore, commonly are injured. In fact the bones of the hand are the most commonly fractured bones in the body,1 with the fingers being the most common site of hand bone fractures.2 Other hand problems frequently present to the emergency department (ED), as well: infections, dislocations, tendon lacerations, burns, bite wounds, etc. The ED physician must be aware of which problems can be managed in the ED and which require urgent or emergent consultation by an experienced hand surgeon.
Hand injuries account for between 5% and 10% of overall ED visits,3 or approximately 11 million injuries in the United States each year.4 Many people from surgeons to musicians to carpenters rely heavily on proper hand function to make a living. Disability from permanent loss of normal hand function can be devastating, and, unfortunately, is not a rare event. Hand injuries are among the leading cause of occupational injury in the United States,5 and account for 30% of all injuries at work.4 Work-related hand problems make up one-third of all chronic injuries, 25% of lost time at work, 20% of permanent disabilities6 and 75% of partial disabilities.4 Prevention of permanent hand damage and disability often starts with correct diagnosis and treatment of acute hand injuries in the ED. For example, tendon lacerations easily are missed, resulting in delayed care and limited range of motion. Angulated fractures must be recognized early and given proper reduction to restore hand function. In some cases, however, only when the patient’s hand is examined through its entire range of motion will the deformity be apparent. Deep-space hand infections often can begin in the palm but present with maximal findings on the dorsal surface. Clenched fist injuries, or "fight bites," are probably one of the best examples of a common injury that will produce serious complications if not recognized and adequately treated on the first presentation. For many acute hand problems, proper diagnosis by the emergency physician is crucial so that the patient does not leave the ED after inadequate treatment that could lead to preventable complications. Many texts on hand injuries assert the importance of the initial care of hand injuries. "The fate of the hand largely depends on the judgment of the doctor who first sees the patient. The initial evaluation and care of the injured hand is critical, for at that time the surgeon has his best opportunity to assess accurately the extent of the damage and to restore the altered anatomy," according to Green and Rowland.7 As the emergency physician typically is the first physician to treat hand problems, correct evaluation, initial treatment, and proper referral rests on our shoulders. With this in mind, this paper will cover the spectrum of acute hand problems. Basic relevant anatomy will be reviewed followed by a discussion of ED diagnosis and management of hand infections and the variety of hand trauma that can present to the ED. Unique hand injuries, such as high-pressure injection injuries and fight bites, also will be discussed. Basic laceration repair will not be discussed specifically, but the ED physician should rule out injury to deep structures as a part of any hand laceration repair. Part I of this three-part series will cover anatomy, assessment, and initial management. Parts II and III will cover fractures, dislocations, tendon injuries, amputation, and infections.—The Editor
Anatomy
Terminology. The hand’s unique function and abilities arise directly from its anatomy. When dealing with hand problems, knowledge of anatomy is crucial; the physician must know where nerves, tendons, and arteries are located to be suspicious of their injury. The physician must assume all structures deep to a wound are involved until proven otherwise. It also is important to know and use the proper terms ("handspeak") when discussing a case with a consultant. Although terminology of the hand is relatively simple, some authors refer to the phalanges by number with the thumb being 1 and the little finger being 5; it is equally acceptable, and sometimes less confusing, to refer to them by name: thumb, index, middle, ring, and little fingers. At the distal interphalangeal (DIP), proximal interphalangeal (PIP), and the metacarpophalangeal (MP) joints, the bones are connected by two collateral ligaments (radial collateral and ulnar collateral). On the palm (volar) surface, the joints are connected by the volar plate, a strong fibrocartilaginous band. (See Figure 1.)
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This arrangement allows for maximal flexion and stability in that range of motion. When a hand joint is dislocated, one or more of these ligaments will be disrupted, either partially or completely. It is important to test the joint stability after reduction. The hand often is divided into zones when discussing tendon injuries, but different systems are used for flexor and extensor tendons. The hand and wrist are divided into seven zones for extensor tendons but only five for flexor tendons. (See Figures 2a and 2b.) Verdan’s classification system is most widely accepted for describing extensor tendons.9
Flexor Tendons. The flexor tendons are more complicated than the extensor tendons, because there are two flexors and only one set of extensors for each digit. The thumb is the exception, with only one flexor, as it has only one interphalangeal (IP) joint to move. The thumb flexor is flexor pollicis longus (FPL), which inserts on the distal phalanx just above the IP joint. Flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) originate in the forearm muscles and travel to each finger. FDS inserts on the middle phalanx, while FDP inserts on the distal phalanx just above the joint. Thus, FDS acts to flex only the PIP joint, while FDP is the primary flexor in the hand and acts to flex both the PIP and DIP joints. It is important to realize that the FDS can be severed completely and there still will be active flexion at both joints from the intact FDP. As would be suspected from their names, FDS runs superficial to FDP in the hand. This changes at the level of the proximal phalanx, where FDS splits in half and runs in ulnar and radial halves until they insert on the middle phalanx. (See Figure 3.)
FDP emerges through the split in FDS and from the middle phalanx runs as the single tendon to its insertion on the distal phalanx. This relationship is important to remember when evaluating finger lacerations for tendon involvement. The physician must know how many tendons there are beneath the laceration to adequately identify injuries to them. In other words, when exploring a laceration at the proximal phalanx, if one sees only a single intact tendon, this means FDS has been transected completely. If the physician is unaware that two intact tendons should be present, he could misdiagnose the injury, with potentially disastrous results. A series of fibrous bands called "pulleys" are present in all the fingers and act to prevent bowing of the flexor tendons when the finger is flexed. (See Figure 4.)
The pulleys are made by thickenings of the synovial sheath surrounding each flexor tendon. A2 and A4 are considered essential pulleys, because without them, significant bowstringing will occur. These pulleys also can be torn with or without tendon injury, and A2 or A4 injuries are important to identify. The synovial sheaths covering the flexor tendons contain synovial fluid that acts to lubricate the tendon’s movements and supply nutrients to the avascular tendons. (See Figure 5.) The presence of the tendon sheaths also provides a pathway for spread of infection (flexor tenosynovitis).
Extensor Tendons. In comparison to the rounded flexor tendons, the extensor tendons are broad and flat. The extensor tendon system is less complicated in that there is a single set of extensor tendons and there is no pulley system or tendon sheath above the wrist. The fibrous extensor retinaculum at the wrist prevents bowstringing of extensor tendons when the wrist is extended. There are, however, nine extensor tendons in six compartments on the dorsum of the hand. The first compartment contains extensor of the thumb: abductor pollicis longus (APL) and extensor pollicis brevis (EPB). APL inserts on the base of the first metacarpal and acts to radially abduct the thumb. EPB inserts on the base of the proximal thumb phalanx and extends the thumb at the MP joint. The second compartment also contains two wrist extensors: extensor carpi radialis longus and brevis. The third compartment contains extensor pollicis longus (EPL). EPL inserts on the distal thumb phalanx and acts to extend both the IP joint and MCP joint of the thumb. It is important to realize that because abductor pollicis brevis and adductor pollicis add some extension to the thumb, as a patient with complete laceration of EPL still may have some thumb extension on exam. The fourth compartment contains the tendons that extend the fingers: extensor indicis proprius (EIP) and extensor digitorum communis (EDC). EDC divides into four tendons after it passes through the extensor retinaculum and sends a separate tendon to the index, middle, ring, and little fingers. The complex attachment of the EDC to the dorsal phalanx is shown in Figure 6. Important points from this figure include the following: Disruption of the central slip mechanism will produce an acute boutonniere deformity, while rupture of the oblique retinacular ligament causes a swan-neck deformity. Given the complex nature of the extensor mechanism in the finger, meticulous repair is essential to preserve proper finger function.
Fibrous connections called juncturae tendinae attach the four branches of EDC on the dorsum of the hand. When evaluating finger extension, it is important to understand that the juncturae tendinae aid in finger extension and in some patients will provide normal extension of a finger even in the face of complete laceration of the EDC distal to them.10 The juncturae tendinae also prevent significant proximal retraction of the tendon when lacerated. EIP is a second extensor tendon for the index finger. The little finger also has a second extensor, extensor digiti quinti, which is housed in the fifth compartment. The dual extensor system for the index and little finger provide them with considerable independent extension, whereas the middle and ring finger have limited independent extension. The sixth compartment holds the extensor carpi ulnaris, which ulnarly deviates and extends the wrist.
Intrinsic Hand Muscles. The intrinsic muscles of the hand include the lumbricals, interosseous, thenar, and hypothenar muscles. The lumbricals originate from the FDP and insert on the proximal phalanx just above the MP joint. They act in flexion of the MP joints and extension of the PIP joints, and are the primary muscles that provide these movements. Their connection to the proximal phalanx forms a complex combination with the EDC tendon. (See Figure 6.) The interosseous muscles are found between the metacarpals. The dorsal interosseous muscles abduct the digits, while the volar interosseous muscles adduct them. The thenar muscles (abductor pollicis brevis, flexor pollicis brevis, and oppenens pollicis) perform thumb abduction and serve in opposition to the other digits. The hypothenar muscles (abductor digiti minimi, flexor digiti minimi, and oppnens digiti minimi) function in abduction and opposition of the little finger.
Arteries. The radial and ulnar arteries provide blood supply to the hand. The radial artery runs radial and deep to the flexor carpi radialis tendon. Its pulse easily is assessed in the wrist. The ulnar artery lies deep to the flexor carpi ulnaris and adjacent to the ulnar nerve. The proximity of the ulnar nerve and artery make isolated injuries of either structure rare. Evidence of injury to one structure should be interpreted to mean that both are involved until proven otherwise. The ulnar artery supplies the superficial palmar arch, while the radial artery is the principal supply of the deep palmar arch. To complicate matters, both arches usually are connected to both arteries and to each other, with only one artery providing the dominant supply. Arches also can be incomplete in that they lack the normal connections. A recent study of arterial patterns found that complete arches were present in only 84% of individuals studied.11 Although it varies in each individual, the ulnar artery (through the superficial arch) usually is the dominant source of hand perfusion. The Allen test can be performed to assess if the hand has independent perfusion by the radial or ulnar artery. (See section on Examining the Acute Hand and Figure 7.)
The digits each have a dual blood supply with an ulnar and a radial digital artery arising from converging branches of the superficial and deep palmar arches. Like the ulnar artery and nerve in the wrist, the digital arteries and nerves run parallel to each other in the fingers, and injury to either structure should indicate both are involved until proven otherwise. Even when one digital artery is lost, adequate blood flow usually remains, so repair of a single digital artery is not indicated in the presence of good clinical perfusion.
Nerves. Three nerves supply the hand: radial, median, and ulnar. The radial nerve in the hand is purely sensory, while the median and ulnar are mixed motor and sensory nerves. The radial nerve supplies the extrinsic wrist and hand extensors, but supplies no intrinsic hand muscles. These muscles allow wrist and MP joint extension as well as thumb extension and abduction. The radial nerve does supply sensation to the proximal dorsal aspect of the thumb, index, on middle fingers and half the ring finger. At the level of the forearm, the median nerve innervates FDS, the radial part of FDP, and FPL. After passing through the carpal tunnel, the recurrent branch innervates the abductor pollicis brevis, opponens pollicis, and, in some people, flexor pollicis brevis. Digital branches of the median nerve innervate lumbricals for the index and middle fingers. The median nerve provides sensation for the radial two-thirds of the palm, and the palmar surface of the thumb, index, on middle fingers and half of the ring finger. It also supplies sensation for the distal section on the dorsal index on middle fingers and half of the ring finger. Substantial variation in the sensory distribution of the median and ulnar nerves can exist. (See section on Examining the Acute Hand.)
The ulnar nerve is critical for proper hand function. It innervates the hypothenar muscles, seven interosseous muscles, lumbricals for the ring and little fingers, adductor pollicis, and both flexors to the ring and little fingers. Loss of ulnar nerve function will destroy the pinching action of the index finger and thumb. Sensation for the entire ulnar side of the hand, entire little finger, and half the ring finger is provided by the ulnar nerve.
Examining the Acute Hand
Prior to a full hand exam, a brief directed history should be obtained. This information often will be crucial for the hand consultant and should not be overlooked. The following information will be needed: detailed history of the complaint (time since onset, functional impairment, mechanism of injury, etc), hand dominance, occupation (and important hobbies), medical illnesses, last food and drink, allergies, previous injury or treatment of the affected hand, any current medications (especially antibiotics "borrowed" from another), tobacco use (important for revascularization), and tetanus status.
The following sections assume that one is dealing with an isolated hand problem, and that, in the case of multiple injuries, proper attention to advanced trauma life support principles already have been given. One must be aware that traumatic hand injuries can be accompanied by initially occult but more serious injuries. Gunshot wounds (GSWs), industrial accidents, knife injuries, motor vehicle accidents (MVAs), and assault are just some of the instances in which distressing and conspicuous damage to the hand potentially can divert the physician’s attention away from higher-priority problems. The physician must be sure to evaluate the patient for life-threatening injuries before focusing on the acute hand injury. Do not forget to fully examine the rest of the patient and adhere to airway, breathing, and circulation (ABCs) in every case to avoid unnecessary risk for the patient.
Initial Evaluation. In many situations, such as advanced infection or significant trauma, the patient can be in considerable distress from pain. The patient should be reassured that after a brief (and necessary) exam his or her discomfort will be treated humanely and without any avoidable delay. Anesthesia (local, digital block) never should be provided without first performing an adequate exam (especially of sensory function). The hand consultant’s treatment often hinges on the results of the initial exam, and this information can be lost or greatly delayed by well-intentioned but inappropriately timed anesthesia.
The initial hand exam begins with observation of the two hands, after removal of any rings or other jewelry to avoid potential circulatory compromise. Much can be deduced from just this simple maneuver. Look at the resting position of the affected hand in comparison to the unaffected side (assuming a single hand is involved—for bilateral problems the hands can be compared to the resting position of your own hand). Comparison with the patient’s normal hand can make swelling, bruising, pallor, deformity, etc., easier to appreciate. Tendon damage also will be apparent from changes in the normal lie of the hand. Normally, the fingers will be in a cascade of increasing flexion with the little finger having the most flexion. The MP joints are at approximately 45° of resting flexion, around 30-40° at the PIP joints, and 10-20° at the DIP joints. The IP joint of the thumb rests at 10-20°, similar to the DIP joints. Loss of an extensor tendon will produce an exaggeration of flexion as loss of a flexor tendon will give a pronounced extension at rest. This change in position is very reliable with complete tendon lacerations, but incomplete lacerations may not show changes at rest.
Vascular Status. It is very important to remember that blind clamping of a bleeding vessel never should be done to control bleeding in the hand. Nerves and tendons can be crushed unintentionally and permanently damaged in the process. Bleeding of the hand can be controlled with direct pressure or through inflation of a blood pressure (BP) cuff for temporary control. Inflate the cuff to 30 mmHg above systolic pressure, but release periodically after every 30 minutes to alleviate ischemic pain. Even with complete transection of an artery, bleeding usually will stop spontaneously from constriction and retraction of the vessel. Often this occurs before presentation to the ED, and one should not be misled by a benign presentation. Remain suspicious of arterial injury if the history (blood "shooting into the air," etc.) and location of injury are consistent with such an injury.
A significant arterial injury often will present with marked pallor or cyanosis of the affected digit(s). Capillary refill can best be assessed under the nail, and will be slowed in digits with decreased arterial supply. The radial pulse in the wrist should be felt, and the ulnar pulse assessed with a Doppler signal if unable to be palpated. Normal pulses are 2+, with 1+ describing a distinct but weaker pulse than normal. Likewise, Doppler probes also can be used to assess the status of digital arteries.
The Allen test (see Figure 7) is performed to ensure that normal arterial supply is present, with both ulnar and radial arteries contributing to the palmar arches and to ensure that there is collateral circulation between the superficial and deep arches. Some individuals will have incomplete palmar arch connections, resulting in a single artery providing dominant blood flow to the entire hand. Loss of this artery obviously will compromise much more of the hand than in a patient with normal blood supply from both arteries. As seen in Figure 7, first both radial and ulnar arteries are compressed in the wrist, and then the patient opens and closes the hand about 10-20 times to temporarily remove blood from the hand. The pressure over a single artery then is relieved. A normal result occurs when restoration of blood flow from a single artery reestablishes adequate blood flow to all fingers. An abnormal Allen test would be useful to identify a person with a single dominant arterial blood supply with injury to that vessel. The Allen test can be modified for use on a single digit, as well, by compressing the radial and ulnar digital arteries at their bases instead.
Neurological Evaluation: Sensation. Nerve injuries are common and should be suspected any time a patient presents with an injury over the known location of a nerve. Even if a patient is unconscious, nerve function still can be tested. Loss of sweating can provide a clue to nerve injury and does not require the patient’s cooperation to be evaluated. Another test used in the unconscious patient is the O’Riain’s test. It is performed by immersing the involved hand in hot water for 10 minutes and observing the skin’s reaction.12 Normally innervated skin will wrinkle, while skin supplied by a severed nerve will not wrinkle. For a cooperative patient, first ask if he is experiencing any changes: differences in light touch, tingling, numbness, decreased (hypoesthesia) or increased sensation (hyperesthesia).
As mentioned previously, the radial nerve is a pure sensory nerve in the hand, while the ulnar and median nerves provide both motor and sensory input. As sensory input to the hand can vary in each individual, the integrity of each nerve should be tested where the least amount of dual innervation is likely. For the radial nerve, test the skin proximal to the first dorsal web space (radial side of the index metacarpal). For the ulnar nerve, test the volar tip of the little finger. For the median nerve, test the volar tip of the index finger. The most objective and accurate method to test for sensory nerve damage is with the two-point discrimination. Uninjured fingertips should be able to distinguish two points 2-5 mm apart while, the normal palm threshold is 7-12 mm apart. Wider distances imply some loss of sensation.13 Usually a bent paper clip is used to perform the test, but electrocardiogram (ECG) calipers may provide more accurate testing. The patient should be shown the process on an uninjured area first so that he is not confused about what is being done. When evaluating for a digital nerve injury, one should test the sides of a finger where dual innervation is less likely. Although a useful test in general, it is of limited value in children, patients with severe pain, mental status changes, or heavy calluses.
Neurological Evaluation: Motor Function. Although one will perform a complete motor exam on every patient, one can perform a simple screening test to quickly identify deficits. Have the patient extend his thumb fully (like hitchhiking). Next have the patient spread the fingers widely apart. Finally, ask him to move the tip of each finger and thumb (one at a time) in a circle around the tip of a pen. If the patient can perform all of these simple actions, then all three major nerves to the hand are intact.12
A complete motor evaluation is done by testing movement and strength at each joint of the hand. Range of motion of the wrist should be included. Lack of wrist extension ("wrist drop") implies radial nerve damage in the forearm. Loss of strength in the little and ring fingers ("claw hand") indicates ulnar nerve injury, and the same finding in the index and middle fingers implies median nerve damage. Laceration of the recurrent branch of the median nerve will cause loss of thumb opposition ("ape hand"). Test this by having the patient form an "O" with thumb and index finger. Ulnar nerve function also is required to perform this maneuver. Asking the patient to hold a single piece of paper tightly pinched with the thumb and index finger will perform the same action. An abnormal result is obtained if the examiner can easily pull the piece of paper away. Tendon lacerations can, at times, be confused initially with nerve injury as both can result in loss of movement. A simple tendon laceration will not result in changes in sensation unless there is a combined injury. Likewise, laceration of a single tendon only will affect the digit it terminates on. When one sees a single wound that produces loss of movement in multiple digits, a nerve injury is more likely, but a series of tendon lacerations can produce a similar result. Ultimately a patient with multiple deficits will not have his injuries truly defined outside the operating room (OR). For the emergency physician, the prime objective is not to miss an injury to a deep structure and refer the patient for consultation rather than to identify all the involved structures in every patient.
Range-of-motion tests rely on the presence of intact tendons. Tendon function can be tested simply with the following maneuvers. First, test the strength of digit extension against the examiner’s finger. Remember from the anatomy section that the thumb, index, and little fingers have dual extensors and can maintain full strength with a significant tendon laceration. Likewise, the connections between the different branches of the extensor digitorum communis (juncturae tendinae) can provide some extension to a digit with complete EDC injury. The flexor tendons are tested by isolating flexion at the PIP joint (FDS) and the DIP joint (FDP). Both joints must be tested in all fingers to help rule out flexor tendon injury. It is important to realize that these range-of-motion and strength tests cannot by themselves rule out injury. A deficit can rule an injury in, but a normal result still requires sterile exploration in a bloodless field with adequate anesthesia to rule out an injury. Every time a laceration in the hand is repaired, it should be done only after a diligent search for injury to deep structures has been carried out.
Cleaning the Hand
Some controversy exists concerning the proper solution and technique to clean soft-tissue wounds.14 It generally is accepted that cleaning solutions (hydrogen peroxide, iodine, hexachlorophene, etc.) should not be used directly in the wound. While useful in cleaning surrounding uninjured epidermis, they are damaging to exposed tissue in the wound. The axiom to remember is: "Only put into the wound what also would be used in the physician’s eye." Use of large volumes of saline under moderate pressure is the most often recommended method for cleaning soft-tissue injuries. Using an 18-gauge needle or angiocath attached to a 20 cc or 30 cc syringe is the recommended approach for irrigation of hand wounds.
When to Get an X-ray
Radiographs of the hand are recommended in evaluation of any hand problem beyond minor trauma (i.e., superficial lacerations). It is important to remember that one must remain suspicious of injury to deep structures even in innocuous-appearing wounds. Although one may see evidence of fractures, etc., of the hand on wrist films and visa versa, separate hand and wrist series must be ordered to adequately characterize injuries of each area. The hand is positioned improperly on a wrist series for satisfactory imaging, and likewise, the wrist is not aligned correctly on a hand series. One should obtain posteroanterior (PA), true lateral, and oblique films in a standard hand series. The PA is useful but does not show fractures of the articular surface of the metacarpal (MC) head well. The lateral shows displacement of fractures and dislocations, and the oblique is helpful for assessing fractures of the base of the MCs and dislocations of MP and carpometacarpal (CMC) joints. If evaluating a thumb injury, separate PA and lateral views of the thumb are needed, as the thumb rests at 90° to the fingers and, thus, standard hand films will not give true PA or lateral views of the thumb. Stress views of a joint can be helpful to identify ligamentous injury of the thumb MP joint.
Plain films can identify many retained foreign bodies, but not all. Magnetic resonance imaging (MRI) and computed tomography (CT) may identify foreign bodies not seen on plain films, but these images of the hand are not effective screening tools for all patients as they can cost up to $1500. Ultrasound (US) is a much less expensive, and often readily available, alternative. US recently has been shown to be successful for location of wooden foreign bodies, which often are missed on plain films.15 Another study evaluated 166 wood, glass, or metal foreign bodies specifically in the hand, and found US had a specificity of 99% and sensitivity of 94%.16 They concluded a combination of US and plain films should locate virtually all foreign bodies in the hand.
Management Tips—What Not to Do
Several principles should be kept in mind while treating a patient with an acute hand problem. First, do no harm. One of the most important mistakes to avoid is making predictions on the type of treatment that will be done or the outcome of the treatment. This especially is evident in the case of amputations, from small fingertip to multiple digits. A good rule is that only the physician who is rendering the final treatment (i.e., the consultant) should give the patient predictions on outcome and ultimate use of his hand. Loss of use of even part of a hand can be devastating in many ways. Giving patients unrealistic expectations at the outset, even if well-intentioned, can make it very traumatic for the patient and the consultant when the outcome does not live up to the initial prediction. In these situations it is very easy for the patient to become confused, hostile, and disappointed with conflicting information and lose confidence in the consultant’s care. One should be very careful to make only general statements when treating amputations. In the case of less complex situations, such as an isolated tendon laceration, one can be comfortable providing general information on the situation (repair can be done any time in the next few days without affecting the end result; it can take six weeks to heal; and rehabilitation may be necessary afterwards, etc.). Nerve injuries involve long and sometimes complicated treatment, and it should be underscored to the patient that full recovery may not be possible even with the best care.
Several other management issues require emphasis. As previously stated, do not give local anesthesia to a hand injury without performing a full sensory exam first. The consultant may be called early in that case to give him the opportunity to perform his own sensory exam before anesthesia if he desires. This "preemptive strike" involves the consultant early in decision-making and avoids later complaints that something wasn’t done to his preference. In the case where amputation(s) will be obvious candidates for re-implantation (proximal thumb, etc.), one should call the re-implantation team immediately upon presentation or begin arranging transfer for the patient. This will minimize ischemic time for the amputated part and maximize the chances of successful surgery. The care these patients require in the ED can be provided in parallel with the consultation, but ischemic time of the amputated part is critical; the arrival of the patient in the OR should not be delayed in any way by the ED. Repeated examinations of a painful hand should be avoided if possible. When there are several people in the ED who need to see the exam (i.e., a teaching situation), it is best to assemble everyone at one time so that the patient does not undergo unnecessary discomfort. As previously mentioned, blind clamping of bleeding arteries should be avoided. In most cases, bleeding can be controlled by direct pressure or inflation of a BP cuff proximal to the injury. Blind clamping is likely to accidentally injure adjacent nerves and tendons. Finally, in many cases a consultant may elect (appropriately) to see a patient in the office 24-48 hours after an injury. It is important to close lacerations with simple sutures before discharging the patient to the consultant. This helps prevent the complication of infection and growth of granulation tissue over tendons that can make primary repair impossible. Exceptions to this would be when the consultant specifically asks that the wound be left open, such as in the case of an infection, or injuries at very high risk for infection (bite wounds).
References
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10. Belliappa PP, Scheker LR. Functional anatomy of the hand. Emerg Med Clin North Am 1993;11:557-583.
11. Gellman H, Botte MJ, Shankwiler J, et al. Arterial patterns of the deep and superficial palmar arches. Clin Orthop 2001;383:41-46.
12. Stewart C, Winograd SM. Hand injuries: A step-by-step approach for clinical evaluation and definitive management. Emerg Med Reports 1997;18:223-234.
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14. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg 2001;9:219-226.
15. Jacobson JA, Powell, A, Craig JG, et al. Wooden foreign bodies in soft tissue: Detection at US. Radiology 1998;206:45-48.
16. Bray PW, Mahoney JL, Campbell JP. Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand. J Hand Surg 1995;20:661-666.
The bones of the hand are the most commonly fractured bones in the body. Other hand problems frequently present to the emergency department, as well: infections, dislocations, tendon lacerations, burns, bite wounds, etc. The ED physician must be aware of which problems can be managed in the ED and which require urgent or emergent consultation by an experienced hand surgeon.
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