Injury

The first person caring for an injured hand may determine its ultimate usefulness. Following injury, the hand is particularly susceptible to complications that may lead to serious disability.

History

  • Time and place of accident
  • Agent and mechanism of injury
  • Amount and type of first-aid given
  • Right- or left-hand dominance
  • Occupation
  • Age

Examination

A thorough examination of all motor, sensory and vascular components of the hand will yield an accurate diagnosis and aid in th correct treatment. The contralateral hand (if uninjured) may serve as control and should be examined.

Observation

  • Position of fingers
  • Sweating patterns
  • Anatomic structures that the injury overlies

Sensory

  • Use a needle and a light cotton swab to measure sharp and dull sensitivity and a paper clip to measure two-point discrimination.
  • Test all sensory areas (median, ulnar, radial)

Figure1

  • Test both sides of each finger.
  • Test prior to anesthesia administration – especially local anesthesia in emergency room – for accurate diagnosis.
  • Record areas of decreased or absent sensation; diagram on chart.
  • Observe and test for areas of abnormal sweating indicative of nerve damage.

Motor

Profundus
Stabilize PIP joint in extension and ask patient to flex fingertip.
Figure2
Superficialis (sublimis)
Stabilize other fingers in extension (this neutralizes profundus action)--ask patient to flex finger at PIP.
Figure4
Motor branch of the median nerve
Test palmar abduction of thumb against resistance and palpate muscle belly of abductor pollicis brevis.
Motor branch of the ulnar nerve
Ask patient to extend fingers completely and spread them apart.
Test abduction of index and/or little finger against resistance and palpate appropriate muscle belly.
Extensor tendons
Extension at MP joints by long extensors (radial nerve)
Extension at PIP and DIP joints by intrinsic muscles (ulnar or median nerve)

Vascular

Color
Nail appears pink, blanches with pressure, demonstrates good capillary refill – if longer than one second, blood supply may be compromised.
Temperature
The temperature of the finger to be examined should be comparable to that of other non-injured digits.
Turgor
Pulp space should be full with absence of wrinkles.

Early Care

Use pneumatic tourniquet or BP cuff on upper arm to control bleeding for examination and/or treatment.
Inflate to 250-300 mmHg.
Awake patient will tolerate tourniquet about 30 minutes. Forearm tourniquet may be adequate and better tolerated.
If bleeding is a problem, apply direct pressure with snug dressing and elevate extremity.
Don't clamp vessels with hemostat.
Tourniquet may be used as a last resort, but should be released intermittently.
Reduce to safe position, splint and elevate during transfer.
Prevents vessel obstruction.
Prevents proximal tendon retraction.
Maintains optimum bone fragment position.
All flexor tendon, nerve and vascular injuries, open fractures, and complex injuries should be cared for in the operating room.
Administer tetanus prophylaxis as indicated. Antibiotic coverage, if indicated, may be started.

Definite Treatment

Thoroughly cleanse entire hand and forearm around the wound, with the wound protected.
Clean and trim fingernails.
Soap-and-water-scrub skin.
Don't put soap or other irritating agents in the wound.
Apply sterile drapes.
Inspect wound with adequate exposure.
Use tourniquet or BP cuff on upper extremity. Remember to deflate cuff after 90-120 minutes.
Additional incisions, if needed, should closely parallel natural creases.
Thoroughly irrigate wound withnormal saline.
Assure hemostasis.
Take extreme care to avoid injury to nerves or blood vessels. Cauterization should be avoided to prevent such damage. If bleeding cannot be controlled using general pressure and elevation, referral to a hand surgeon is appropriate.
Tendons are repaired primarily except in special instances (e.g., a human bite).
A flexor tendon cut in "no man's land" (between the distal palmar crease and the middle of the middle phalanx) should be repaired primarily by a trained hand surgeon.
Figure5
If a hand surgeon is too far away for primary repair, cleanse and close the wound and splint the hand, then refer as soon as possible for delayed primary tendon repair. Antibiotic coverage is indicated.
Fractures and dislocations
Fractures and dislocations requiring internal fixation (e.g., pins, plates, screws) should be referred to a hand surgeon
Postoperative dressing
Apply protective dressing, immobilizing only that part of the hand necessary for healing of the wound.
Splint with fingers and wrist in safe position when possible. Alternative positioning may be necessary to protect tendon or nerve repair.
Dressing should not apply pressure.
Hematoma is prevented by thesurgeon, not by the use of a tight dressing.
Edema is controlled by elevation, not by pressure.