Evidence-Based Management Of Acute Hand Injuries In The Emergency Department (Trauma CME)

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal Of The Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. Triage And Stabilization
   2. History
   3. Physical Examination
      1. Assessing Motor And Nerve Function
      2. Assessing Tendon Function
      3. Assessing Vascular Function
9. Diagnostic Studies
   1. Laboratory Studies
      1. Complete Blood Count
      2. Coagulation Studies
   2. Imaging Studies
      1. Plain Radiographs
      2. Computed Tomography
      3. Magnetic Resonance Imaging
      4. Ultrasonography
10. Treatment
    1. Fundamentals Of Treatment
       1. Analgesia
       2. Hemostasis
       3. Wound Care
       4. Splinting
    2. Skin And Soft-Tissue Injury Treatment
       1. Laceration
       2. Fight Bite
       3. Fingertip Amputation
    3. Nail Plate And Nail Bed Injury Treatment
       1. Subungual Hematoma
       2. Nail Bed Matrix Injury
    4. Tendon Injury Treatment
       1. Strain Injury
       2. Flexor Tendon Injury
       3. Jersey Finger
       4. Extensor Tendon Injury
       5. Mallet Finger
    5. Treatment Of Ligamentous Injury
       1. Sprain
       2. Gamekeeper’s Thumb (Skier’s Thumb)
       3. Treatment Of Dislocations
       4. Scapholunate Dissociation
       5. Perilunate Dislocation And Lunate Dislocation
    6. Treatment Of Fractures
       1. Fractures Of Phalanges 2, 3, 4, 5
          • Distal Phalanx
          • Middle And Proximal Phalanx
       2. Fractures Of Metacarpals 2, 3, 4, 5
       3. Boxer's Fracture
       4. Thumb Fractures
          • Phalangeal And Metacarpal Shaft Fractures
          • Intra-Articular Fractures Of The Thumb Metacarpal Base: Bennett And Rolando Fractures
       5. Carpal Fractures
          • Scaphoid Fracture
       6. Vascular Injury Treatment
       7. Nerve Injury Treatment
11. Special Circumstances
    1. High-Pressure Injection Injuries
    2. Compartment Syndrome
    3. Burns
12. Controversies And Cutting Edge
    1. Subungual Hematoma: To Remove The Nail Or Not?
    2. Lidocaine With Or Without Epinephrine In Digital Nerve Blocks?
13. Disposition
14. Summary
15. Case Conclusions
16. Risk Management Pitfalls For Hand Injuries
17. Time- and Cost-Effective Strategies For Acute Hand Injuries
18. Clinical Pathway For Management Of Hand Injuries
19. Tables and Figures
    1. Table 1. Practice Guidelines For Emergency Department Management Of Hand Injury
    2. Table 2. Differential Diagnosis Of Acute Hand Injury
    3. Table 3. Physical Examination Of The Hand
    4. Table 4. Grade Of Extensor Tendon Injury By Location
    5. Figure 1. Figure 1 Bones And Joints Of The Left Hand
    6. Figure 2. Froment Sign
    7. Figure 3. Motor Assessment Of Radial, Median, And Ulnar Nerves
    8. Figure 4. Physical Examination Of Radial, Median, And Ulnar Nerves
    9. Figure 5. Physical Examination Of Tendons
    10. Figure 6. Zones Of The Fingertip
    11. Figure 7. Emergency Physician Bedside
    12. Figure 8. Intrinsic Plus Splinting Position
    13. Figure 9. Mallet Finger Splint
    14. Figure 10. Physical Examination For Suspected Gamekeeper's Thumb
    15. Figure 11. Plain Radiograph In Scapholunate Dissociation
    16. Figure 12. Plain Radiograph In Perilunate Dissociation
    17. Figure 13. Plain Radiograph In Lunate Dissociation
    18. Figure 14. The Jahss Maneuver
    19. Figure 15. Arterial Anatomy Of The Hand
20. References
21. Abbreviation List

Abstract

Although injuries of the hand are infrequently life-threatening, they are common in the emergency department and are associated with significant patient morbidity and medicolegal risk for physicians. Care of patients with acute hand injury begins with a focused history and physical examination. In most clinical scenarios, a diagnosis is achieved clinically or with plain radiographs. While most patients require straightforward treatment, the emergency clinician must rapidly identify limb-threatening injuries, obtain critical clinical information, navigate diagnostic uncertainty, and facilitate specialist consultation, when required. This review discusses the clinical evaluation and management of high-morbidity hand injuries in the context of the current evidence.

Case Presentations

It’s a busy afternoon in the ED. A 32-year-old man with a laceration of his left palm is placed in your next open bed. The injury occurred 1 hour prior to arrival as he was using a flat-head screwdriver to open a can of paint. He complains of pain and swelling at the wound site and inability to flex his fifth digit. The patient is right-handed, works in construction, has a history of hypertension, and his last tetanus shot was 12 years ago. There is a 3-cm laceration of the palmar surface of the base of the fifth digit. He is unable to flex the fifth digit at the PIP joint or DIP joint. You order 3-view hand radiographs, update his Tdap vaccine, and prepare for local anesthesia, irrigation, and wound exploration. You suspect the patient has a flexor tendon injury.

A second patient is brought in by EMS after 911 was called to a local bar. The patient exhibits confusion, dysarthria, ataxia, and nystagmus. The paramedic states, “He drank way too much.” The patient’s right hand is swollen over the fourth and fifth MCP joints and there is a 5-mm puncture wound over the fourth MCP joint. The stumbling patient states, in slurred speech, “I’m fine. I punched a wall and I’m outta here! ” Hospital security is contacted.

Your third patient is a 55-year-old woman, who is brought in by EMS following a motor vehicle crash. She is on a spine board with cervical spine immobilization. The paramedic tells you she was the restrained driver in a head-on motor vehicle crash at high speed, and the airbag deployed. She is confused, with a GCS score of 14. There is a large abrasion over her left maxilla. During your secondary survey, you notice swelling over the MCP joint of her left thumb. You are most concerned about an intracranial injury and want to expedite CT imaging, but you jot down a note to reassess her left hand.

Introduction

The anatomical complexity of the hand mirrors its diverse functional capabilities. A significant subset of patients presenting to the emergency department (ED) with acute hand trauma are at risk for poor compliance, delayed presentation, and substance abuse. ^1,2 The complexity of the hand, the psychosocial characteristics of the prototypical hand trauma patient, and the potential for missed injury in multi-system trauma create a challenging environment for the emergency clinician in evaluating hand injuries. Understanding the limitations of imaging studies (eg, the presence of false-negative radiographs in suspected fracture) and acknowledgement of several critical diagnoses made purely on clinical criteria (e.g., gamekeeper's thumb) underscores the significance of physical examination skills.

The National Electronic Injury Surveillance System (NEISS) data on acute hand injury show that hand injuries are more likely to occur amongmales (male-to-female ratio of occurrence, 1.7:1), and are more common among individuals aged ≥ 18 years.^3,4,5

The United States Bureau of Labor Statistics reports that hand injuries are the second most common injury resulting in days away from work.⁶

Decreasing reimbursement rates, changing perceptions of medicolegal risk, and requirements for the Subspecialty Certificate in Surgery of the Hand has resulted in variable hand surgeon availability in many EDs.⁷ Although rarely life-threatening, hand injuries are associated with significant patient morbidity and physician medicolegal risk.⁸ A 2010 retrospective review by Brown et al of 11,529 closed malpractice claims from 1985 to 2007 reported that open finger injuries were in the top 10 most common diagnoses resulting in medical malpractice litigation.⁹

While most hand injuries require straight-forward treatment, the emergency clinician must rapidly identify limb-threatening injuries, obtain specific critical clinical information, navigate diagnostic uncertainty, and facilitate rapid intervention, transfer, and/or specialist consultation. This issue of Emergency Medicine Practice discusses the evaluation and treatment of high-morbidity hand injuries, with review of the current available evidence.

Critical Appraisal Of The Literature

A literature search was performed in Ovid MED-LINE®, PubMed, the National Guidelines Clearinghouse, and the Cochrane Database of Systematic Reviews. Articles included in the search were limited to human studies relevant to acute traumatic hand injuries published in English or translated into English. Search terms were individualized for each topic and included: nail bed, subungual hematoma, jersey finger, mallet finger, extensor tendon, and scaphoid fracture. The search yielded numerous review articles, case reports, cross-sectional analytical studies, multiple randomized controlled trails, and several Cochrane meta-analyses. The American Association of Hand Surgeons, American Academy of Orthopedic Surgeons, and American Society of Plastic Surgeons have no generalized guidelines on diagnosis and management of undifferentiated hand injuries.

The availability of meta-analyses of randomized controlled trial data (class I) is limited, and many current practice habits are based upon historical precedent, retrospective studies, and expert opinion (class II/III). The American College of Emergency Physicians (ACEP) published a set of guidelines regarding penetrating extremity injury in 1999.¹⁰ The American College of Radiology (ACR) published guidelines on imaging modalities in acute hand and wrist trauma in 2013.¹¹ Major recommendations of these guidelines are included in Table 1.

Risk Management Pitfalls For Hand Injuries

1. “The patient with a laceration overlying a joint was unable to move the joint through full range of motion due to pain during wound exploration, but I did not see any evidence of tendon injury.”

Complete examination through full range of motion is required to assess for tendon injury because the injured tendon may be retracted in the neutral position. Regional nerve block or digital nerve block is often necessary to permit full range of motion during wound exploration. If diagnostic uncertainty persists, splint and refer.

2. “The patient seemed to be in a lot of pain following the crush injury. I repeated multiple doses of opioid analgesia at appropriate dosages, but the patient continued to complain of worsening pain and then she subsequently complained of numbness and tingling.”

Pain out of proportion to the injury is an early clinical sign of possible compartment syndrome. Repeat focused hand examination should include palpation for tense, swollen hand compartments, eliciting severe tenderness on passive stretching of compartments, finding impaired sensory function (including 2-point discrimination), and looking for evidence of impaired perfusion. Emergent consultation with hand surgery is critical.

3. “I gave cefoxitin for an acute, clean, open distal tuft fracture and consulted a hand surgeon for operative wash-out, intravenous antibiotics, and admission.”

Parenteral antibiotics are not indicated for lowrisk open distal tuft fractures. Patients require analgesia, meticulous wound care, reduction, splinting, and referral to a hand surgeon.

4. “In a patient with mallet finger, I buddy-taped the affected digit to the adjacent digit to immobilize it.”

Mallet finger requires limited splinting of the DIP alone, in extension, for 6 to 8 weeks and referral to a hand surgeon.

5. “A patient with wrist pain after a FOOSH injury had point tenderness over the lunate and severely impaired wrist range of motion. No anatomical snuffbox tenderness was noted. Anterior-posterior, lateral, oblique, and navicular view radiographs showed 2-mm scapholunate diastasis. Since no fracture was present on radiographs, I diagnosed the patient with a wrist sprain. The patient was discharged home with rest, ice, compression wrap, NSAIDs and primary care follow-up.”

Patients with suspected scapholunate instability require thumb spica splinting and outpatient referral to hand surgery.

6. “I could not stop the bleeding with direct pressure, so I placed a figure-of-eight suture.”

Figure-of-eight suture, or blind clamping of bleeding vessels, should be avoided due to possible injury to adjacent structures. Hemorrhage control should be managed with focal direct pressure and limb elevation. Temporary tourniquet placement should be considered if significant bleeding persists.

7. “A patient with high-pressure injection injury of an unknown substance had no symptoms. Following routine wound care and tetatnus vaccination, I discharged him home with a referral to primary care.”

Early high-pressure injection injury often appears clinically innocuous. The injected material tracks along neurovascular bundles along the path of least resistance. These injuries are associated with a high rate of infection, necrosis, and considerable amputation risk. All patients should receive intravenous antibiotics and immediate hand surgery consultation for operating room wound exploration and admission.

8. “My patient had a fifth metacarpal neck fracture on the dominant hand with an overlying laceration. I gave him cefoxitin for the open fracture and called hand surgery to admit him.”

Lacerations overlying the MCP joints or distal metacarpal should be considered a fight bite injury until proven otherwise. Amoxicillin-clavulanate is an appropriate choice for prophylaxis.

9. “The patient presented with a grossly contaminated laceration overlying the hypothenar eminence. Wound exploration revealed no complicating soft-tissue injuries. Tissue debridement was required to remove organic plant debris. Radiography did not reveal retained foreign body or fracture. I closed the laceration with simple interrupted sutures and the patient was instructed to see his primary care doctor in 14 days for suture removal.”

Wounds at moderate to high risk of infection should receive prophylactic antibiotics. Primary closure is not recommended. High-risk wounds may be considered for delayed primary closure.

10. “Despite multiple attempts, I was unable to reduce a fourth proximal phalanx oblique shaft fracture, and 15° of rotational deformity and 20° of angulation persists. I buddy-taped the affected digit and discharged the patient with instructions to follow up with a hand surgeon.”

Inability to achieve reduction goals (in this case, 0° rotational deformity and < 10° angulation) requires immediate hand surgery consultation for closed reduction or possible open reduction. This patient should also have been placed in an ulnar gutter splint and not buddy-taped.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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Abbreviation List

• CMC — Carpometacarpal joint
• DIP — Distal interphalangeal joint
• FDP — Flexor digitorum profundus
• FDS — Flexor digitorum superficialis
• FOOSH — Fall on outstretched hand
• FPL — Flexor pollicis longus
• IP — Interphalangeal joint
• MCP — Metacarpophalangeal joint
• NSAID — Nonsteroidal anti-inflammatory drug
• PIP — Proximal interphalangeal joint
• UCL — Ulnar collateral ligament