Evidence-Based Management of Acute Hand Injuries in Urgent Care (Trauma CME)

Table of Contents

 

About This Course

Hand injuries are common presentations in urgent care. While these injuries are not likely to be life-threatening, proper management is necessary to prevent or minimize critical loss of function for the patient. Diagnosis of most hand injuries in urgent care can made clinically and/or with plain radiographs, and clinicians must then determine which injuries can be treated in the urgent care setting and which patients require ED transfer and/or emergent referral to a hand surgeon. In this issue, you will learn:

How to assess the injured hand, including for motor, nerve, tendon, and vascular functions

How to manage skin and soft-tissue injuries of the hand, including lacerations, fight bites, and fingertip amputations

Which repair options for nail plate and nail bed injuries are most appropriate based on the current evidence

How to diagnose and treat tendon injuries, and when to refer to a hand surgeon

How to diagnose and treat gamekeeper’s thumb and other ligament injuries

How to recognize lunate, perilunate, and scapholunate dislocations on radiographs

Which types of fracture reductions can be performed in urgent care, and which require emergent referral

Why high-pressure injection injuries and suspected compartment syndrome require emergent transfer

CHARTING & CODING: How to accurately document patient encounters for acute hand injuries

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Urgent Care 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. Lacerations
       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
    6. Treatment of Dislocations
       1. Scapholunate Dissociation
       2. Perilunate Dislocation and Lunate Dislocation
    7. 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
          • Boxer's Fracture
       3. Thumb Fractures
          • Phalangeal and Metacarpal Shaft Fractures
          • Intra-Articular Fractures of the Thumb Metacarpal Base: Bennett and Rolando Fractures
       4. Scaphoid Fracture
    8. Vascular Injury Treatment
       1. 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. Risk Management Pitfalls in Hand Injuries
16. 5 Things That Will Change Your Practice
17. Clinical Pathway for Management of Hand Injuries in Urgent Care
18. Charting & Coding: What You Need To Know
    1. Medical Decision Making
    2. Charting and Documentation
19. References

Abstract

Hand injuries are common presentations in urgent care and are associated with significant patient morbidity and medicolegal risk for clinicians. Care of patients with acute hand injuries begins with a focused history and physical examination. In most clinical scenarios, a diagnosis is achieved clinically or with plain radiographs. While the care of most patients with hand injuries is straightforward, urgent care clinicians must rapidly identify limb-threatening injuries, obtain critical clinical information, navigate diagnostic uncertainty, and facilitate specialist consultation and referral when required. This review discusses the clinical evaluation and management of high-morbidity hand injuries in the urgent care setting.

Case Presentations

A 32-year-old man with a laceration of his left palm arrives at your urgent care center...

• The injury occurred 1 hour prior to arrival when 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 a right-hand dominant construction worker with a history of hypertension; his last tetanus shot was 12 years ago.
• There is a 2-cm laceration of the palmar surface of the hand at the base of the fifth digit. He is unable to flex the fifth digit at the proximal interphalangeal joint or distal interphalangeal joint.
• You order 3-view hand radiographs, update his Tdap vaccine, and prepare for local anesthesia, irrigation, and wound exploration. You suspect this patient has a flexor tendon injury…

A 22-year-old man presents with an injury to his right hand sustained the previous night...

• He admits to drinking “a bit too much” and states that he punched a wall in anger at a local bar.
• The patient’s right hand is swollen over the fourth and fifth metacarpophalangeal (MCP) joints and there is a 5-mm puncture wound over the fourth MCP joint.
• You confirm in the EMR that his tetanus vaccination status is up to date.
• The patient says he needs “a stitch or two and maybe some antibiotics.” You wonder if there's more to the story...

A 65-year-old woman arrives after falling backwards on uneven ground outdoors...

• The patient reports that she attempted to break the fall with her right hand and says, “maybe my thumb hit the ground first before the rest of my hand, because it really hurts here,” as she points to the base of the thumb.
• There is tenderness and mild swelling at the first MCP joint, with restricted range of motion due to pain
• You don’t appreciate any deformity, and as you’re ordering radiographs you wonder how best to treat this patient if the x-rays are negative...

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Clinical Pathway for Management of Hand Injuries in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. U.S. Department of Labor Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work, 2011. November 8, 2012. Accessed January 10, 2023. (Press release)

7. * Brown TW, McCarthy ML, Kelen GD, et al. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med. 2010;17(5):553-560. (Retrospective study; 11,529 malpractice claims) DOI: 10.1111/j.1553-2712.2010.00729.x

9. * Torabi M, Lenchik L, Beaman FD, et al. ACR Appropriateness Criteria^®Acute Hand and Wrist Trauma. J Am Coll Radiol. 2019;16(5S):S7-S17. (Expert consensus practice guideline) DOI: 10.1016/j.jacr.2019.02.029

30. * Haughey RE, Lammers RL, Wagner DK. Use of antibiotics in the initial management of soft tissue hand wounds. Ann Emerg Med. 1981;10(4):187-192. (Prospective randomized controlled trial; 394 patients) DOI: 10.1016/s0196-0644(81)80159-x

77. * Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. J Hand Surg Br. 2003;28(5):388-394. (Double-blind randomized controlled trial; 193 patients) DOI: 10.1016/s0266-7681(03)00175-x

119. American Medical Association. CPT^® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. 2021. Accessed January 10, 2023. (Summary of coding guidelines)

120. American Medical Association. Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM). 2021. Accessed January 10, 2023. (Medical decision making table)

Subscribe to get the full list of 120 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: finger fracture, finger dislocation, distal phalanx, proximal phalanx, tuft fracture, dislocation, DIP, PIP, MCP, Froment sign, Allen test, splinting, intrinsic plus position, gamekeeper’s thumb, skier’s thumb, flexor tendon injury, extensor tendon injury jersey finger, mallet finger, high-pressure injection injury, fight bite, boxer’s fracture, Bennett fracture, Ronaldo fracture, Jahss maneuver, subungual hematoma, nail bed matric injury, fingertip amputation