Traumatic Hand Injuries:

June 2011
Volume 13, Number 6
The Emergency Clinicians Authors

Aaron Andrade, MD

Evidence-Based Approach
Emergency Medicine Physician, Alameda County Medical Center,
Highland General Hospital, Oakland, CA
H.Gene Hern, MD, MS, FACEP, FAAEM
Residency Director, Alameda County Medical Center, Highland
At the start of your Saturday afternoon shift, you are not surprised to see General Hospital, Oakland, CA
that several patients are waiting to be seen for physical injuries. The first Peer Reviewers
patient is a 34-year-old woman who sustained injury to her hand while
Stephen Cantrill, MD, FACEP
skiing, 2 hours prior to her arrival. She reports falling with her hand still Emergency Medicine Physician, Denver Health Medical Center,
tethered to the poles grip, landing on her outstretched right hand. She felt a Denver, CO
painful snap in her right thumb, which still hurts, but otherwise she did not Mark Silverberg, MD, FACEP
Associate Residency Director and Assistant Professor, SUNY
sustain any other trauma. Her only complaint currently is pain at the base Downstate and Kings County Hospital, Brooklyn, NY
of the right thumb. The patient is otherwise completely healthy, has no past
CME Objectives
medical or surgical history, and takes no medications. Upon examination,
Upon completion of this article, you should be able to:
the affected hand appears to be surprisingly normal except for mild tender-
1. Perform an appropriate and complete history and physical
ness and swelling over the ulnar aspect of her first metacarpophalangeal examination of traumatic hand injury patients.
joint and mildly decreased strength in her pincher grasp. X-ray reveals no 2. Discuss the utility of different imaging modalities.
fracture. You wonder if there is additional testing that should be done to 3. Describe the physical findings and management strategies of a
evaluate this injury. wide array of hand injuries.
4. Identify limb-threatening conditions that require immediate
You move on to a second patient, a 24-year-old man who cut his ring hand surgical consultation.
finger knuckle when he punched a wall 2 days ago. Physical examination
reveals a small puncture wound over the IV metacarpophalangeal joint with Date of original release: June 1, 2011
Date of most recent review: May 10, 2011
mild swelling, erythema, warmth, and decreased range of motion secondary Termination date: June 1, 2014
to pain. X-ray reveals no fracture, but theres something suspicious about Medium: Print and Online
Method of participation: Print or online answer form and evaluation
this case. Prior to beginning this activity, see Physician CME Information on
A third patient is a 37-year-old industrial worker whose finger con- the back page.

tacted the stream of a high-powered grease injector. Physical examination

Editor-in-Chief
Andy Jagoda, MD, FACEP
Professor and Chair, Department of
Emergency Medicine, Mount Sinai
School of Medicine; Medical Director,
Mount Sinai Hospital, New York, NY
Editorial Board
William J. Brady, MD
Professor of Emergency Medicine
and Medicine Chair, Resuscitation
Committee & Medical Director,
Emergency Preparedness and
Response, University of Virginia
Health System Operational
Medical Director, Charlottesville-
Albemarle Rescue Squad &
Albemarle County Fire Rescue,
Charlottesville, VA
Peter DeBlieux, MD Gregory L. Henry, MD, FACEP
Louisiana State University Health
Science Center Professor of Clinical
Medicine, LSUHSC Interim Public
Hospital Director of Emergency
Medicine Services, LSUHSC
Emergency Medicine Director of
Faculty and Resident Development
Wyatt W. Decker, MD
Professor of Emergency Medicine,
Mayo Clinic College of Medicine,
Rochester, MN
Francis M. Fesmire, MD, FACEP
Director, Heart-Stroke Center,
Erlanger Medical Center; Assistant
Professor, UT College of Medicine,
Chattanooga, TN
Nicholas Genes, MD, PhD
Assistant Professor, Department of
Emergency Medicine, Mount Sinai
School of Medicine, New York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chief, Department of
Emergency Medicine, Maine Medical
Center, Portland, ME; Tufts University
School of Medicine, Boston, MA
Steven A. Godwin, MD, FACEP
Associate Professor, Associate Chair
and Chief of Service, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Jacksonville, Jacksonville, FL
CEO, Medical Practice Risk
Assessment, Inc.; Clinical Professor
of Emergency Medicine, University of Robert L. Rogers, MD, FACEP,
Michigan, Ann Arbor, MI
John M. Howell, MD, FACEP
Clinical Professor of Emergency
Medicine, The George Washington
University, Washington, DC; Director
of Academic Affairs, Best Practices, Alfred Sacchetti, MD, FACEP
Inc, Inova Fairfax Hospital, Falls
Church, VA
Shkelzen Hoxhaj, MD, MPH, MBA
Chief of Emergency Medicine, Baylor Chair, Department of Emergency
College of Medicine, Houston, TX
Keith A. Marill, MD
Assistant Professor, Department of
Emergency Medicine, Massachusetts
General Hospital, Harvard Medical
School, Boston, MA
Charles V. Pollack, Jr., MA, MD,
FACEP
Chairman, Department of Emergency
Medicine, Pennsylvania Hospital,
University of Pennsylvania Health
System, Philadelphia, PA
Michael S. Radeos, MD, MPH
Assistant Professor of Emergency
Medicine, Weill Medical College
of Cornell University, New York;
Research Director, Department of
Emergency Medicine, New York
Hospital Queens, Flushing, New York Scott Weingart, MD, FACEP
FAAEM, FACP
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Scott Silvers, MD, FACEP
Medicine, Mayo Clinic, Jacksonville, FL
Corey M. Slovis, MD, FACP, FACEP
Professor and Chair, Department
of Emergency Medicine, Vanderbilt
University Medical Center; Medical
Director, Nashville Fire Department and
International Airport, Nashville, TN
Jenny Walker, MD, MPH, MSW
Assistant Professor, Departments of
Preventive Medicine, Pediatrics, and
Medicine Course Director, Mount
Sinai Medical Center, New York, NY
Ron M. Walls, MD
Professor and Chair, Department of
Emergency Medicine, Brigham and
Womens Hospital, Harvard Medical
School, Boston, MA
Assistant Professor of Emergency
Medicine, Mount Sinai School of
Medicine; Director of Emergency
Critical Care, Elmhurst Hospital
Center, New York, NY
International Editors
Peter Cameron, MD
Academic Director, The Alfred
Emergency and Trauma Centre,
Monash University, Melbourne,
Australia
Giorgio Carbone, MD
Chief, Department of Emergency
Medicine Ospedale Gradenigo,
Torino, Italy
Amin Antoine Kazzi, MD, FAAEM
Associate Professor and Vice Chair,
Department of Emergency Medicine,
University of California, Irvine;
American University, Beirut, Lebanon
Hugo Peralta, MD
Chair of Emergency Services, Hospital
Italiano, Buenos Aires, Argentina
Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency
Medicine, King Chulalongkorn
Memorial Hospital, Thai Red Cross,
Thailand; Faculty of Medicine,
Chulalongkorn University, Thailand
Maarten Simons, MD, PhD
Emergency Medicine Residency
Director, OLVG Hospital, Amsterdam,
The Netherlands
Senior Research Editor
Joseph D. Toscano, MD
Emergency Physician, Department
of Emergency Medicine, San Ramon
Regional Medical Center, San
Ramon, CA
Research Editor
Matt Friedman, MD
Emergency Medicine Residency,
Mount Sinai School of Medicine,
New York, NY

Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Andrade, Dr. Hern, Dr. Cantrill, Dr. Silverberg, Dr.
Jagoda and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
reveals a small puncture wound over the volar proximal
interphalangeal joint of his left long finger, mild tender-
ness to palpation over the area, and slight decreased range
of motion secondary to pain. You wonder if the injury is
as benign as it looks.
T he hand is a complex and dynamic structure
that balances form and function. To many, the
hand is a highly versatile tool used to interact with
the surrounding world. To others, it is an instrument
of expression and beauty. It is this dual purpose that
makes the hand arguably one of our most important
body parts and, perhaps second only to the face, the
most representative of humanity.
Because of the hands constant utility, it is no
surprise that traumatic hand injuries are encoun-
tered on nearly every shift in a busy emergency
department (ED). It is estimated that, depending
on the setting, 5% to 30% of all injuries presenting
to the ED involve the hand (40% of home and work
injuries and 15% to 20% of leisure and motor ve-
hicle injuries).1,2 Presumably due to higher rates of
machine-related jobs as well as higher risk-taking
behavior, the male-to-female ratio of hand injuries
is 1.7:1, and about 60% of all patients presenting
with traumatic hand injuries are between 16 and 32
years of age.3 While mortality from isolated hand
injuries is exceedingly rare, morbidity and loss of
productivity is a major concern. Lacerations to the
fingers ranks third among reasons for lost workdays
in the United States, surpassed only by back and leg
strain.4,5 Clearly, hand injuries as a whole contribute
Table Of Contents
Critical Appraisal Of The Literature........................ 2
Etiology/Pathophysiology........................................ 3
Differential Diagnosis................................................. 3
Prehospital Care.......................................................... 3
Emergency Department Evaluation......................... 3
Diagnostic Studies....................................................... 5
Treatment...................................................................... 7
Clinical Pathway For Management Of
Hand Injuries....................................................... 12
Risk Management Pitfalls For Hand Injuries........ 17
Controversies/Cutting Edge................................... 18
Time- And Cost-Effective Strategies 18 cal subspecialties. That said, one practice guideline
Disposition................................................................. 19
Summary.................................................................... 19
Case Conclusions...................................................... 19
References................................................................... 20
CME Questions.......................................................... 23
Available Online At No Charge To Subscribers
EM Practice Guidelines Update: Current Guidelines
For Diagnosis And Management Of Anaphylaxis In
The ED, www.ebmedicine.net/Anaphylaxis
Emergency Medicine Practice 2011 2
significantly to unemployment and loss of produc-
tive work hours.
Hand trauma presents with such a wide variety
of conditions with differing outcomes that a com-
manding knowledge of hand trauma and anatomy
is essential to any practicing emergency clinician.
While most patients will require minimal treatment,
emergency clinicians must be able to correctly iden-
tify conditions that threaten long-term hand func-
tion and those that require specialty consultation or
surgical repair.
This issue of Emergency Medicine Practice focuses
on the diagnosis and treatment of the widely diverse
presentation of traumatic hand injuries using the
best available evidence from the literature.
Critical Appraisal Of The Literature
A literature search was performed using the follow-
ing online databases: PubMed, Ovid MEDLINE,
the National Guideline Clearinghouse, and the
Cochrane Database of Systematic Reviews. Searches
were limited to those published in English, those
involving human test subjects, and those involving
the widely accepted anatomic definition of the hand;
that is, all structures in the upper extremity distal to
the carpometacarpal (CMC) joint space. Search terms
included but were not limited to the following: hand
trauma, hand injuries, finger, fingernail, phalanx, digit,
palm, fracture, laceration, crush, dislocation, thumb,
amputation, and compartment syndrome. This search
yielded many review articles and analytic studies.
Of the very few randomized controlled trials found
in the literature, most were conducted comparing
intraoperative techniques and are, therefore, not ap-
plicable to emergency clinicians. Because of the wide
variety of traumatic hand injuries, no generalized
practice guidelines exist from the 3 major surgical
societies involved in surgical hand care (the Ameri-
can Academy of Hand Surgeons [AAHS], the Ameri-
can Academy of Orthopedic Surgeons [AAOS], and
the American Society of Plastic Surgeons [ASPS]).
Much more data exist in the form of review articles
concerning specific conditions in hand trauma.
Thus, the state of the literature concerning manage-
ment of traumatic hand injuries in the ED is weak,
relying mainly on tradition of practice from surgi-
in the form of a clinical policy statement does exist
from the American College of Emergency Physicians
(ACEP) regarding specific management of penetrat-
ing extremity trauma.6 Also, the American College
of Radiology (ACR) has published one guideline
regarding the appropriateness of imaging modali-
ties in hand and wrist trauma.7 Table 1 summarizes
selected portions of these guidelines that are appli-
cable in the ED setting.
ebmedicine.net June 2011
Etiology/Pathophysiology
It is often helpful to categorize hand trauma into a
manageable number of categories. Of these, lacera-
tion represents the most common injury (62%) fol-
lowed by fracture (11.4%).3 Abrasions are likely the
most common and underrepresented injury, as most
patients do not seek ED treatment.
In order to grasp how hand injuries disrupt
function, a clinician must understand the complex
mechanics of each part of the hand. While this is a
topic best discussed in an anatomy textbook chapter,
the ideas can be summarized simply: the hand is a
collection of different tissues, and as such, trauma
to the hand can be categorized as permutations of
severities of damage to these tissues. It is important
to consider each type of tissue in the hand when as-
sessing a patient with hand trauma.
Differential Diagnosis
While the differential diagnosis in hand trauma is
very broad, the majority of hand injuries are not im-
mediately threatening to life or limb. It is crucial for
the emergency clinician to quickly identify injuries
that require time-sensitive intervention, such as
vascular injuries. (See Table 2, page 4.) Strategies
aimed at thorough diagnostic assessment and proper
treatment for these etiologies is discussed further in
subsequent sections.
Prehospital Care
In most cases of traumatic hand injury, the goal of
prehospital care is stabilization of the injured limb.
Once the patient has been assessed for trauma to
other parts of the body that require more urgent
attention, prehospital providers should focus on
3 things: control of hemorrhage, patient comfort,
and (if necessary) preservation of amputated digit/
hand viability. Active bleeding in the hand is nearly
Table 1. Practice Guidelines For ED Management Of Hand Trauma
Organization Topic Type of Guidance
American College Management of Evidence-based
of Emergency penetrating ex- (Class II)
Physicians6 tremity injuries
American College Imaging for pa- Expert consensus
of Radiology7 tients with hand (Class III)
injury
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasound.
June 2011 ebmedicine.net
always stopped successfully with direct pressure
and elevation; however, a proximal tourniquet may
be used temporarily for difficult-to-control arte-
rial bleeding. Limb elevation, temporary splinting,
ice packs, and authorized analgesics are common
methods that may help alleviate patient discomfort.
All jewelry, especially rings, should be removed as
quickly as possible before tissue swelling makes
this difficult.
In the event of a digit or hand amputation injury,
prehospital providers should retrieve the limb and
initiate cooling measures (described in the Am-
putations section on page 16). Patients may be
diverted to facilities designated as special treatment
centers in circumstances such as burns, amputations,
or snake envenomation. Otherwise, patients should
be transported to the nearest ED.
Emergency Department Evaluation
Triage And Initial Stabilization
In general, patients with isolated hand trauma
require little to no stabilization. In cases of active
bleeding, efforts should be focused on source control
with direct pressure and a tourniquet, if necessary.
Elevation, immobilization, and ice packs should
be utilized if not already in place. In cases of large
blood loss or expected intravenous (IV) pain medica-
tion requirements, IV access can be considered. All
patients expected to require urgent surgical repair
should be specified as nothing by mouth (NPO).
History
Because etiology of hand trauma varies greatly, the
approach to the patient with traumatic hand in-
jury must first focus on narrowing the differential
diagnosis by establishing the timing and mechanism
of injury. All patients should be asked about the
circumstances surrounding the injury. As with any
trauma, patients should be asked if they have in-
jured themselves anywhere else, especially the head
Recommendations
Thorough wound exploration, cleansing, and neurovascular examinations
Consider antibiotics for very contaminated wounds, bites, and immunosup-
pressed patients
Tetanus prophylaxis as appropriate
Low threshold for specialist consultation or outpatient follow-up
X-ray is always recommended in suspected bony injury
CT recommended in suspected metacarpal fractures/dislocations not seen on
x-ray
CT considered for complex intra-articular fractures for surgical planning
MRI recommended for gamekeepers thumb without fracture
US recommended as possible alternative to MRI in gamekeepers thumb
3 Emergency Medicine Practice 2011
or neck, or had a loss of consciousness, since these
injuries may require priority attention. In children
or in patients who do not remember the event, ask
parents, prehospital providers, and available wit-
nesses for details of the injury. Inquiring about hand
dominance and occupationwhile not crucial to
narrowing the differentialcan be helpful in deter-
mining expected recovery time, risk for functional
impairment, and potential temporary job limitations.
Patients should be asked to give a detailed
description of the symptoms they have encoun-
tered since the injury and their progression over
time. Specifically, ask about presence and location
of pain, decreased range of motion, functional loss,
decreased strength, muscle paralysis, cold/blue
fingers, numbness, and tingling. In the event of an
amputation injury, ask patients and prehospital pro-
viders what happened to the amputated part, how it
was cared for, and how much time elapsed before it
was cooled. If the skin is broken, history should in-
clude bleeding severity and the time since injury, as
well as tetanus immunization status. If tetanus im-
munization has not been given in the past 10 years
(5 years for tetanus-prone wounds), patients should
be given a tetanus booster. If the 3 childhood vac-
cinations against tetanus were never completed, or
tetanus status is unknown, tetanus immune globulin
should be given in the case of dirty or particularly
large or tetanus-prone wounds.8
Finally, important questions from past medi-
cal history include previous injuries or surgeries to
the affected limb, current medications (especially
anticoagulation medications if uncontrolled hemor-
rhage is an issue), medication allergies, and whether
the patient is immunocompromised. Smoking and
diabetes are particularly important, as they slow
wound healing.
Table 2. Differential Diagnosis Of Hand
Trauma
Immediately Limb-Threatening
Compartment syndrome
Crush injuries
High-pressure injections
Vascular injuries
Injuries Requiring Rapid ED Assessment/Intervention
Dislocations
Amputations
Not Immediately Limb-Threatening
Nerve injuries
Fractures
Lacerations
Tendon injury
Ligamentous injury
Fingertip/fingernail injury
Emergency Medicine Practice 2011 4
Physical Examination
The physical examination of an isolated hand injury
should begin by assessing the general appearance
of the hand for gross deformity, active bleeding, and
amputations or avulsions as well as how the patient
holds the limb at rest. Check skin integrity by exam-
ining for any lacerations, swelling/edema, or scars.
Palpate for crepitus, particularly in older injuries
that may be infected or in mechanisms where air
injection is possible. Examine the bones for proper
anatomic alignment, tenderness, and active/passive
range of motion. (See Figure 1.) Examine for liga-
mentous injury by placing varus and valgus stress
on injured joints, especially the distal interphalange-
al (DIP), proximal interphalangeal (PIP), and meta-
carpophalangeal (MCP) joints. Inspect the digits for
rotational variation. If all fingers are not pointing in
the same direction when the fist is closed, there is
likely a spiral fracture.
Particular care and attention should be placed
on the vascular, neurologic, and musculotendinous
portions of the examination. Vascular examinations
generally rely on the detection of pulses distal to the
injury. Because hand trauma is often distal to both
the radial and ulnar arteries, it is much more useful
to assess warmth, color, and capillary refill. Cold,
blue digits with poor (> 2 sec) capillary refill are con-
cerning for arterial injury. Furthermore, lacerations
and other penetrating wounds should be carefully
explored for vascular injuries. Excessive bleeding
can impede a complete exploration of open wounds,
and a proximal tourniquet can be helpful in achiev-
ing a bloodless field.
Neurologic testing of the hand includes mo-
tor and sensory function of 3 nerve distributions:
ulnar, radial, and median. (See Figure 2.) Testing
should be performed before local anesthetics or
Figure 1. Bones Of The Hand
Phalanges Distal Phalange
Medial Phalange
Proximal Phalange
Metacarpal
Bones
Carpal
Bones
Ulna
Radius
ebmedicine.net June 2011
regional nerve blocks are performed. While the Diagnostic Studies
sensory dermatomes and motor functions of the
hand are complex, the emergency clinician can rely Laboratory Evaluation
on a quick repertoire of examination maneuvers Isolated hand trauma usually does not require any
to cover all 3 nerves. The maneuvers suggested in laboratory testing, and the majority of cases will be
Table 3 isolate motor function and sensation for managed without drawing any blood. The follow-
each nerve.9 It is important to keep in mind that ing laboratory tests are suggested only in very rare
motor function is dictated by a delicate balance of circumstances, and no studies exist to suggest they
intrinsic and extrinsic hand muscles. change management or outcome.
Musculotendinous injuries are a feared com-
plication of lacerations and other hand trauma. As Complete Blood Count
such, all lacerations should be explored completely A complete blood count (CBC) can be considered in
for visible tendon injury. Complete and partial ten- cases of significant blood loss, although this is not
don lacerations can be seen directly through a lac- specific to hand trauma. Providers should keep in
eration window by observing the tendon through a mind that in acute hemorrhage, whole blood is lost
full range of motion. To test for occult tendon injury, and hemoglobin and hematocrit levels are unlikely
examine each tendon group individually. For exten- to reflect degree of blood loss. For cases of significant
sor tendons, have the patient place his hand, palm hemorrhage where a patient is likely to be admitted,
down, on a hard surface. Test each digit in turn by a CBC in the ED can serve as a baseline to compare
holding 4 of the digits to the table while the patient future trends and help aid in the decision for blood
extends the digit in question. The flexor tendons are transfusion. Because white blood cell counts are
more difficult to assess because they are controlled often followed in injuries that are likely to become
by 2 separate muscles: the flexor digitorum super- infected, a baseline value at initial presentation is
ficialis (FDS) and the flexor digitorum profundus helpful. A platelet count is important for patients
(FDP). Each digit must be assessed for the integrity with uncontrolled bleeding.
of each muscles tendon. To test the superficialis
tendon, have the patient place his hand, palm up, on Coagulation Studies
a hard surface and, just as with testing the exten- Prothrombin time (PT), partial thromboplastin time
sor tendons, isolate each finger by holding the rest (PTT), and international normalized ratio (INR) can
down and having the patient flex the finger in ques-
tion. To test the profundus tendon, which flexes the
distal phalanx, hold the PIP of each finger in forced
extension while the patient attempts to flex the DIP Table 3. Hand Nerve Function And
of the finger in question. Particularly forceful tendon Suggested Examination Maneuvers
examinations should be avoided for fear of convert- Nerve Action/Innervation Examination
ing a partial laceration into a complete tear. Refer to Maneuver
Figure 3, page 6, for photographs of these examina- Ulnar motor Finger abduction/ad- Finger abduction
tion maneuvers. duction against resistance
Ulnar sensory All dorsal and palmar LT/PP to tip of digit V
surfaces medial to
ulnar half of digit IV
Figure 2. Sensory Nerve Distributions Of Radial motor Wrist/finger/thumb Wrist/finger/thumb
The Hand extension extension against
resistance
Radial sensory Dorsum of thumb and LT/PP to dorsal first
hand not innervated web space
by ulnar, dorsum of
digits II-IV proximal
to PIP joint
Median motor Thumb opposition; Maintain ring created by
flexion of digits I-III thumb and digits II-V
Median sensory Palmar surface LT/PP to tip of digit II
not innervated by
ulnar nerve, dorsal
aspects of digits II-IV
distal to PIP joints

Blue: Median. Red: Ulnar. Green: Radial.

Abbreviations: LT, light touch; PIP, proximal interphalangeal; PP, pin
Used with permission of Aaron Andrade, MD. prick.

June 2011 ebmedicine.net 5 Emergency Medicine Practice 2011

be considered in patients with difficult-to-control
bleeding or bleeding out of proportion to injury.
This is particularly true for patients known to be
taking warfarin or other anticoagulants. Because
hand surgeries are typically low-blood-loss pro-
cedures (thanks to intraoperative tourniquet use),
baseline or preoperative coagulation studies are not
typically indicated.
Imaging In Hand Trauma
Imaging is, by far, the most useful diagnostic tool
in traumatic hand injury after history and physical
examination. More often than not in the ED, the
diagnosis and management hinges on the results
of an imaging study. Diagnostic imaging should be
tailored to confirm or exclude suspected injuries
based on the history and physical examination
findings. Any attempt at closed reduction in the
ED (with the exception of a distal phalanx fracture)
requires a set of postreduction films to assess align-
ment of bony structures.
Conventional Radiography
Plain x-ray is the most useful tool for the emergency
clinician in assessment of traumatic hand injury. Un-
like the Ottawa rules for ankle and knee injuries, no
decision rules exist for when to order x-rays of the
hand. According to the American Society of Radiol-
ogys 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 B
A, Extensor digitorum. B, Flexor digitorum superficialis. C, Flexor digitorum profundus.
Used with permission of Aaron Andrade, MD.
Emergency Medicine Practice 2011 6
(such as plastics and wood) may not show up on x-
rays. A 1998 prospective study concluded that mech-
anisms most likely to have retained glass included
motor vehicle collisions and puncture wounds.12
Computed Tomography
Computed tomography (CT) scanning is rarely
used in the evaluation of hand trauma, as it usually
does not add significant information to that already
obtained by conventional radiography. While no
studies have specifically addressed this matter, the
following are important exceptions where CT scan-
ning can be considered: complex and/or intra-artic-
ular fractures, clinical scenarios highly suspicious of
fracture with absence of fracture on x-ray, and at the
request of a subspecialist for surgical planning. The
emergency clinician should keep in mind that CT
scans can provide high resolution of the bony struc-
tures of the hand but provide limited information
regarding soft tissues such as ligaments, tendons,
and muscles.
Magnetic Resonance Imaging
Like CT, magnetic resonance imaging (MRI) is
only used in specific circumstances in hand trau-
ma. It is important to remember that while MRI
is not suited for evaluation of bony structures,
it does offer visualization of soft tissues such as
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.
C
ebmedicine.net June 2011
Treatment
Local And Regional Anesthesia
The classic methods for obtaining hand anesthesia
in the ED are local anesthetic infiltration, digital
nerve blocks, and anatomic forearm nerve blocks
using lidocaine without epinephrine. (Refer to the
Epinephrine In Digital Nerve Blocks section on
page 19 for further discussion on epinephrine use.)
When longer anesthesia is desired, bupivacaine or
other longer-acting local anesthetics without epi-
nephrine may be substituted.
The traditional teaching for digital nerve blocks
includes a 2-injection dorsal approach that is quite
painful to patients. A 2006 randomized trial of 27
patients concluded that a volar single-injection tech-
nique produces similar anesthetic results (except for
patients who require very proximal dorsal anesthe-
sia) with less patient discomfort.13 (See Figure 4.)
Classically, anatomic landmark injections and
ring wrist blocks have been used for regional anes-
thesia to the hand. With the ever-increasing ubiquity
of bedside ultrasound in the ED, ultrasound-guided
nerve blocks are emerging in the literature. (See
Figure 5, page 8.) A 2006 prospective study of 11
patients concluded that ultrasound-guided forearm
nerve blocks are feasible for emergency clinicians
to perform, with high patient satisfaction.14 More
randomized clinical trials in this area may acceler-
ate ultrasound-guided nerve blocks to become the
standard of care for regional anesthesia for the hand
and elsewhere in the body.
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.
June 2011 ebmedicine.net
should be fully explored to their base to assess the
extent of tissue injury and to search for any foreign
bodies. Particularly deep lacerations to the palm of
the hand should not be explored aggressively, for
fear of further damage to deep structures and risk
of infection. All lacerations that involve tissue deep
to the dermis or those that have continued bleeding
should be repaired. A 2002 randomized controlled
trial suggests that simple hand lacerations (< 2 cm in
length and without associated nerve, tendon, joint,
or bony involvement) can be managed conservative-
ly (irrigation, ointment, and dressing) with similar
cosmetic and functional outcomes.15
Lacerations should be thoroughly irrigated to
remove any debris, and devitalized tissue should
be carefully debrided. Classically, sterile saline has
been the preferred irrigation solution. However, a
2008 Cochrane systematic review of local wound
irrigation demonstrates that irrigation with potable
tap water has identical rates of wound infection
as sterile saline.16 Solutions of iodine, peroxide, or
detergents should be avoided, as they have been
shown to be toxic to fibroblasts.17
The ideal time interval between injury and
laceration repair has not been fully elucidated in the
literature. Several factors must be weighed when
considering wound closure: location, depth, degree
of contamination, and patient health. A classic emer-
gency medicine prospective study of 204 patients
concluded that uncontaminated wounds can be
repaired by primary intention up to 12 hours after
the time of injury, though it is believed that many
can be closed even later. Contaminated wounds can
be cleaned, packed, and reexamined for infection
3-5 days post injury. If no signs of infection exist,
delayed primary closure is a reasonable option.
Infected wounds should be allowed to close by sec-
ondary intention.18
The vast majority of hand lacerations are best
repaired with nonabsorbable monofilament suture
material using a simple interrupted technique. Al-
though there are no current trials supporting timing
of suture removal, traditional practice dictates that
sutures should be removed in 10-14 days except for
those on the palm, which require 14-21 days. There
has been a recent push towards using materials that
do not require a repeat visit for suture removal,
especially in children. A well-designed 2004 ran-
domized controlled trial of 147 children showed no
long-term cosmetic or functional difference between
the use of plain gut and nylon sutures.19 Absorbable
sutures are also useful in repairing deep structures
of the hand. Additionally, a 2002 randomized con-
trolled trial of 814 patients concluded that low skin
tension on the dorsum of the hand allows it to be
repaired successfully with tissue adhesives.20
7 Emergency Medicine Practice 2011
Fingertip Injuries
Fingertip injuries are those that involve any struc-
ture distal to the DIP. These injuries are very com-
mon, occurring most frequently in young males as a
crush/jam injury.21,22
Distal Phalanx Fractures
Fractures of the distal phalanx can be subcategorized
into 3 types: tuft (distal) fractures, shaft fractures, and
intra-articular fractures. Though no research exists,
reference books generally agree that for the purposes
of the emergency clinician, tuft and shaft fractures
(see Figure 6) can usually be managed conservatively
with repair of soft tissues (as necessary) and splinting
in extension for 2-3 weeks. Splinting of the entire fin-
ger is unnecessary and may cause stiffness. Severely
angulated shaft fractures can be reduced in the ED
after digital block and should be splinted for 3 weeks.
A hand surgeon should evaluate open fractures or
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
A B
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.
Emergency Medicine Practice 2011 8
onstrated no outcome difference at 2 years between
operative and trephination groups regardless of
presence of underlying fracture or mechanism of
injury. Furthermore, the study showed a substantial
cost benefit in the nail trephination group.31 There-
fore, current literature supports the recommenda-
tion that subungual hematomas caused by nail bed
lacerations do not require nail removal and direct re-
pair if the nail and its margins are intact.32 If the nail
itself is significantly disrupted, the nail bed matrix
should be exposed and repaired with fine absorbable
sutures. Patients and parents should be warned of
potential for infection and permanent nail deformity.
Fingertip Amputations
Management of fingertip amputations must be
approached on a case-by-case basis, as there are no
current guidelines and little supporting evidence
in the literature. Amputations distal to the DIP can
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
C
ebmedicine.net June 2011
splinting. While specific reduction techniques can
vary widely, there is one universal safe position
for splinting of hand fractures, called the intrinsic
plus position. The thumb is extended and abduct-
ed, while the other fingers are flexed to 90 at the
MCP and fully extended at the PIP and DIP. Addi-
tionally, the wrist is extended 15 to 30. The actual
location of the splint varies depending on the loca-
tion of the fracture: thumb spica for thumb injuries,
volar for digits II and III, and ulnar gutter for digits
IV and V. Traditionally, orthopedists prefer plaster
splints over fiberglass due to their durability and
ability to be molded. Refer to Figure 8 (page 10)
for an example of the safe position. The thumb is
extended and abducted and fingers II-V have MCPs
flexed to 90 and interphalangeal (IP) joints fully
extended. This position prevents shortening of ten-
dons and ligaments while the hand is immobilized,
reducing stiffness.
Proximal And Middle Phalanx Fractures
Unlike distal phalanx fractures, proximal and
middle phalanx fractures require precise alignment.
That said, the majority of phalangeal fractures do
not require reduction, as they are stable and nondis-
placed (usually transverse).35 These stable fractures
are managed by buddy-taping the affected finger
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.
June 2011 ebmedicine.net
Unstable phalangeal fractures include oblique
fractures, malrotated fractures, and angulated frac-
tures. After anesthesia with either a digital block or
hematoma block, the emergency clinician should
attempt to reduce the fracture with gentle manipu-
lation. Adequate alignment should be confirmed
with postreduction x-rays as well as examination of
the fingers for evidence of malrotation. Successfully
reduced phalangeal fractures should be splinted
in extension and referred for outpatient follow-up.
Immediate surgical consultation is required for open
fractures, unsuccessful reduction, malrotation, and
intra-articular fractures involving more than 30% of
the joint surface.36
Metacarpal II-V Fractures And Boxers Fracture
Management of fractures of the II-V metacarpals
varies based on the location of the fracture. Meta-
carpal head and base fractures are relatively rare
and require little management in the ED. A volar
splint should be applied in a neutral position and
the patient referred to a hand surgeon. The emer-
gency clinician can reduce metacarpal shaft frac-
tures after adequate anesthesia with a hematoma
block or regional nerve block. Reduction goal is less
than 10 of angulation in metacarpals II and III, less
than 20 of angulation in metacarpals IV and V, less
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
Figure 7. Zones Of Fingertip Amputation
Zone I II III
Zone I II III
2001. Renee L. Cannon. Used with permission.
9 Emergency Medicine Practice 2011
 Metacarpal neck fractures deserve special men-
tion as they are among the most common fractures
of the hand. Nondisplaced, nonangulated fractures
should be treated with a gutter splint that immobi-
lizes the CMC and MCP joints for 3-4 weeks, with
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 boxers fracture, can be
reduced in the ED after adequate anesthesia. In the
authors 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 boxers 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
Used with permission of Aaron Andrade, MD.
Emergency Medicine Practice 2011 10
of angulations up to 70 to 75.39,40 The emergency
clinician should not forget that boxers fractures are
often a consequence of violent and intentional be-
havior and patients are at risk for recurrent injury.41
In addition, boxers fracture patients have higher
rates of anxiety, borderline personality disorder, and
antisocial personality disorder.42 As such, patients
with boxers fractures should receive in their ED
evaluation psychiatric questioning as well as pre-
vention strategies.
Thumb Metacarpal Fractures: Bennett And Rolando
Fractures
Fractures of the first metacarpal are less common
than those of the remaining metacarpals. They can
be subdivided into extra-articular and intra-articular
fractures. Extra-articular fractures follow the same
conservative management principles as other meta-
carpal fractures, namely, closed reduction with an
angulation goal of less than 20 to 30 followed by
thumb spica splinting for 4 weeks. Oblique fractures
are unstable and require prompt consultation by a
hand surgeon.43
Intra-articular fractures of the first metacarpal
involve the CMC joint and generally occur due to
an axial injury to a partially flexed metacarpal. A
Bennett fracture is an intra-articular fracture and
dislocation; a Rolando fracture is a comminuted
intra-articular fracture.44 (See Figure 11.) While
debate exists regarding the specific type of surgical
correction each fracture requires, the available litera-
ture supports that emergency management should
consist of closed reduction (Bennett fracture only),
Figure 9. Buddy-Taping An Injured Finger
Used with permission of Aaron Andrade, MD.
ebmedicine.net June 2011
thumb spica immobilization, and early consultation
with a hand specialist.45-52 The emergency clinician
should also warn patients that both Bennett and
Rolando fractures carry a high risk of future compli-
cations such as degenerative arthritis, with Rolando
fractures being particularly vulnerable.
Tendon Injuries
Injuries to hand tendons most often occur due to
laceration, crush, or forceful hyperextension/hyper-
flexion injuries. Regardless of the mechanism, ten-
don injuries share the following common manage-
ment strategies: (1) radiographs should be obtained
to rule out associated fractures and avulsions, (2)
surgical consultants should evaluate open tendon
lacerations immediately for surgical repair, and (3)
closed tendon injuries require splinting and surgical
follow-up. Clinicians in the ED should remember
that tendons often run close to peripheral nerves
and vascular structures, so the presence of a tendon
injury should raise suspicion for possible neurovas-
cular injury.53
Mallet Finger
A mallet finger is a very common injury of the exten-
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
Used with permission of Aaron Andrade, MD.
June 2011 ebmedicine.net
extension for at least 6 weeks.54,55 Strict compliance
is necessary, which can prove difficult for patients
due to hygiene and comfort issues. Because of this,
many different types of splints are available for com-
mercial use.56,57 (See Figure 12.) Note that the PIP is
not splinted. The few randomized trials comparing
splints demonstrate equal efficacy as long as patients
follow strict compliance.58-60 One study in cadavers
has shown that PIP motion does not affect structural
integrity of the DIP tendon, and therefore splint-
ing of the entire finger is not recommended, as it
may cause unnecessary stiffness.61 Furthermore, no
difference in outcome has been measured between
early and delayed splinting of mallet finger.62
In spite of the high success rates of conservative
management, some debate remains over which cases
of mallet finger require surgical management. Clas-
sically, all open injuries and those with greater than
Figure 11. Radiographs Of A Bennett
Fracture (Left) And A Rolando Fracture
(Right)
From Carsen BT, Moran SL. J Hand Surg. 2009;34A:945-953. Used
with permission from Elsevier.
Figure 12. Splinting The DIP In Full To
Hyperextension
Used with permission, Aaron Andrade, MD.
11 Emergency Medicine Practice 2011
 Clinical Pathway For Management Of Hand Injuries (Continued on page 13)

METACARPAL FRACTURES

CMC fracture-dislocations or open fractures Emergent/urgent surgical consult (Class I-II)

Displaced intra-articular, unstable, irreducible, Splint and refer (Class III)

or comminuted fractures Surgical consult from ED to discuss timing of repair (Class III)

Reducible/stable MC II-V fractures Gutter splint and refer (Class II)

Thumb MC fractures (Bennett, Rolando, etc) Thumb spica; early referral if operative repair required
(Class II)

FINGER FRACTURES

Nondisplaced, stable fractures Buddy-tape splint and refer (Class II)

Displaced intra-articular, unstable, or angulated fractures Splint and refer (Class III)
Surgical consult from ED to discuss timing of repair (Class III)

OPEN FRACTURES

Proximal/middle phalanx Emergent/urgent surgical consult (Class II-III)

Distal phalanx Irrigate/debride/repair in ED (Class III)

DISLOCATIONS/LIGAMENT INJURIES

Reduced IP or MP dislocations, collateral ligament, or Splint and refer (Class II-III)

volar plate injury

Complex or irreducible dislocations Urgent surgical consult (Class III)

Thumb UCL (skiers thumb) or RCL injury Thumb spica and refer (Class II)

Abbreviations: CMC, carpometacarpal; ED, emergency department; IP, interphalangeal; MC, metacarpal; MP, metacarpophalangeal; RCL, radial col-
lateral ligament; UCL, ulnar collateral ligament.

Emergency Medicine Practice 2011 12 ebmedicine.net June 2011

 Clinical Pathway For Management Of Hand Injuries (Continued from page 12)

TENDON INJURIES

FLEXOR TENDONS

Closed FDP avulsion (jersey finger) Splint; early referral for operative repair (Class II-III)

Open flexor tendon laceration Surgical consult for timing of repair (Class III)
Close skin and splint, if referring (Class II)

EXTENSOR TENDONS

Closed injury (mallet, PIP, or extensor digitorum injury, Splint appropriately and refer (Class II)
acute boutonniere)

Open uncontaminated laceration Consider repair of zone II-IV lacerations in ED (Class III)
Close skin and splint, if referring early (Class II)

High-pressure injection injury X-ray (Class III)

Avoid digital blocks (Class III)
Tetanus prophylaxis (Class I-II)
IV antibiotics (Class III)
Emergent/urgent surgical consult (Class II)

Abbreviations: ED, emergency department; FDP, flexor digitorum profundus; IV, intravenous; PIP, proximal interphalangeal joint.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I
Always acceptable, safe
Definitely useful
Proven in both efficacy and
effectiveness
Level of Evidence:
One or more large prospective
studies are present (with rare
exceptions)
High-quality meta-analyses
Study results consistently posi-
tive and compelling
Class II Class III Indeterminate tatives from the resuscitation
Safe, acceptable May be acceptable Continuing area of research councils of ILCOR: How to De-
Probably useful Possibly useful No recommendations until velop Evidence-Based Guidelines
Considered optional or alterna- further research for Emergency Cardiac Care:
Level of Evidence: tive treatments Quality of Evidence and Classes
Generally higher levels of Level of Evidence: of Recommendations; also:
evidence Level of Evidence: Evidence not available Anonymous. Guidelines for car-
Non-randomized or retrospec- Generally lower or intermediate Higher studies in progress diopulmonary resuscitation and
tive studies: historic, cohort, or levels of evidence Results inconsistent, contradic- emergency cardiac care. Emer-
case control studies Case series, animal studies, tory gency Cardiac Care Committee
Less robust RCTs consensus panels Results not compelling and Subcommittees, American
Results consistently positive Occasionally positive results Heart Association. Part IX. Ensur-
Significantly modified from: The
Emergency Cardiovascular Care ing effectiveness of community-
Committees of the American wide emergency cardiac care.
Heart Association and represen- JAMA. 1992;268(16):2289-2295.

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2011 EB Practice, LLC d.b.a. EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of
EB Practice, LLC d.b.a. EB Medicine.

June 2011 ebmedicine.net 13 Emergency Medicine Practice 2011

one-third of joint surface involvement should receive
immediate surgical consultation. More-recent trials
demonstrate no outcome difference between splint-
ing and surgical correction as far as 2 years postin-
jury.63-65 Some hand surgeon experts believe that all
closed mallet fingers should be initially splinted and
that surgical correction should be saved for those
that fail conservative management.66 A 2008 Co-
chrane meta-analysis demonstrated no difference in
surgical and conservative management as well as no
difference between different types of splints.67
Jersey Finger
Jersey finger is the disruption of the FDP tendon in-
sertion to the volar surface of the distal phalanx dur-
ing a resisted, forceful extension. It derives its name
because it often occurs during sporting events when
one player tugs at anothers jersey. Patients will
present with inability to flex the DIP joint despite
full passive range of motion. (See Figure 13.) Like
mallet finger, jersey finger can be an isolated tendon
injury or it can be associated with a bony avulsion.
Unlike mallet finger, all jersey finger injuries require
prompt surgical correction, so immediate special-
ist consultation is the rule.68,69 Very little evidence
exists in the literature regarding this rare injury.
Nonetheless, ED interventions should include pain
control and immobilization in a neutral position
to prevent further tendon retraction. While every
suspected jersey finger requires x-rays, one case
report describes using ultrasound as a useful tool in
confirming FDP tendon injury.70
Fight Bite
Fight bite, or clenched fist injury, occurs when a
closed fist strikes a tooth, causing a laceration at
the MCP joint. As the fist is relaxed and the fingers
extended, oral bacteria that entered the extensor
tendon sheath are tracked back along the tendon.
In spite of a fight bites minor external appearance,
a retrospective study of 194 surgical explorations
of fight bite injuries demonstrated that nearly 75%
of these injuries had damage to underlying ten-
don, joint, or bone.71 Patients often will hide the
true cause of this injury (as in the second clinical
vignette patient), so the clinician must consider
any MCP laceration to be a fight bite until proven
otherwise. The available literature supports that
fight bites require aggressive early management,
including radiographs to evaluate for foreign bod-
ies and fractures, elevation, immobilization, early
surgical consultation for exploration and washout,
and admission to the hospital for IV antibiotics.72,73
Known infectious complications in untreated
patients include osteomyelitis, tenosynovitis, and
septic arthritis. Many studies demonstrate a wide
range of microbes infecting closed-fist injuries, clas-
sically Eikenella, but most commonly polymicrobial
mouth and skin flora.74-79 The chosen antibiotic
Emergency Medicine Practice 2011 14
regimen must cover Staphylococcus, Streptococcus,
and anaerobic species for example, ampicillin/
sulbactam, cefoxitin, or a carbapenem.
Boutonniere Deformity
Though more commonly thought of as a complica-
tion of rheumatoid arthritis, boutonniere deformity
can occur as a result of acute injury to the central
slipthe anchor of the extensor tendon to the dorsal
middle phalanx. This results in disruption of normal
extensor/flexor balance. While large deformities are
visibly obvious (see Figure 14), subtle deformity is
detected by testing active PIP extension strength or
by detecting PIP extension lag during forced MCP
flexion, as discussed in a case series of 67 patients by
Smith et al and a cadaveric study by Rubin et al.80,81
Very little literature exists about this rare injury.
A case series of 3 patients by Cardon et al82 and a
retrospective study of 8 patients by Imatami et al83
provide weak evidence supporting general treat-
ment principles. Open injuries and those associated
with fractures require immediate hand specialist
consultation for possible surgical correction. Closed
injuries can be conservatively managed with splint-
ing of the PIP joint in extension for 4 weeks and
outpatient hand specialist follow-up.
Ligamentous Injury
Ligamentous injuries vary from simple sprains to
complete rupture, causing joint subluxation or dislo-
cation. The emergency clinician should test for joint
stability, order radiographs to rule out fractures,
and reduce any subluxations or dislocations after
appropriate regional anesthesia. Simple sprains and
strains should be managed conservatively with oral
pain medications, ice, rest, elevation, and soft wraps
as necessary.9
Figure 13. Jersey Finger In The Right Digit IV
A B
Notice that in minimal flexion (A) and full flexion (B), the DIP of the
fourth digit remains extended. In contrast, mallet fingers are unable
to be fully extended.
Used with permission, Aaron Andrade, MD.
ebmedicine.net June 2011
Subluxation/Dislocation
Disruption of the IP joints or the MCP joints gener-
ally warrants closed reduction in the ED, splinting
in slight flexion for 2-3 weeks, and outpatient hand
specialist follow-up. Plain films are necessary to
assess presence of associated avulsion fractures and
to confirm postreduction alignment. While a lack
of literature exists on ED management, traditional
practice suggests that avulsion fractures that involve
more than one-third of the joint surface require im-
mediate hand surgeon consultation and operative
management. Closed reduction of IP joints and MCP
joints are fairly similar and require gentle traction
following appropriate regional nerve block. If a
dislocation is irreducible, this may be due to entrap-
ment of a bony fragment, a tendon, or the volar plate
in the joint space. Such cases require immediate
hand surgeon consultation.9,84
Gamekeepers Thumb And Skiers Thumb
Ligament tears and ruptures can occur anywhere
in the hand, but the most common ligament to be
injured is the ulnar collateral ligament (UCL) of the
thumb, as seen in the patient in the first clinical vi-
gnette. Traditionally, this injury was given the name
gamekeepers thumb because it most commonly
affected English gamekeepers from the repetitive
motion of breaking rabbit necks. Today, this injury
is seen more acutely after skiing accidents and as
such has been named skiers thumb. The injury
itself occurs due to a forceful radial deviation of
the thumb, causing pain and swelling on the ulnar
aspect of the first MCP joint.85
The examination of joint laxity is often difficult
due to pain, usually requiring median and radial
nerve blocks. The emergency clinician should place
valgus stress (radial deviation) on the first MCP
joint while the thumb is in full extension and in 30
of flexion. (See Figure 15.) Thumb deviation greater
than 35 or 15 further than the unaffected thumb is
indicative of a complete ligament tear.86 Complete
tears have a high incidence of associated Stener
lesion (the adductor pollicis aponeurosis becomes
Figure 14. Boutonniere Deformity
Central slip disruption
Volar migration of the lateral bands
June 2011 ebmedicine.net
stuck between ruptured ends of the UCL), resulting
in poor healing. This requires prompt hand spe-
cialist follow-up so that surgical repair may occur
within 3 weeks of injury.87 Partial tears usually heal
well with conservative management and should
be immobilized in a thumb spica cast for 4 weeks,
with outpatient follow-up.
In cases where it is difficult to distinguish partial
versus complete UCL tears, additional imaging
is very useful. In a 1999 double-blind prospec-
tive study of 34 patients using surgical findings as
the gold standard, MRI was shown to have a 96%
sensitivity and 95% specificity in detecting complete
tears.88 Because repair is not required for 3 weeks,
MRI may be scheduled as an outpatient and should
not delay ED disposition.
More recent literature assesses the utility of
ultrasound in these cases, showing a sensitivity of
83% and specificity of 75% compared to surgical and
cadaveric gold standards.89,90 A 1997 retrospective
study concluded that the most common ultrasound
error is misdiagnosing a complete tear as a partial
tear, while the opposite is rarely true.91 Therefore,
partial tears diagnosed on ultrasound should be con-
firmed with an MRI as an outpatient before opera-
tive management is entirely abandoned. While ultra-
sound is dependent on technical ability, it should be
considered as a useful alternative or adjunct to MRI.
Vascular Injuries
Significant morbidity from vascular injuries of the
hand is actually quite rare due to the dual sup-
ply from the radial and ulnar arteries. Initial ED
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 2007
by Sage Publications. Reprinted by permission of SAGE.
15 Emergency Medicine Practice 2011
management should focus on control of active
hemorrhage with direct pressure and application
of a tourniquet. Although evidence in the litera-
ture is lacking, traditional practice recommends
against direct clamping of arteries in the ED, due
to a high risk of irreparable damage to vasculature,
tendons, and nerves. Ligation, suturing, and injec-
tion with epinephrine are also tempting strategies
that should be avoided. Rather, any suspected or
confirmed vascular injury causing distal ischemia
requires immediate surgical consultation. The
traditional maneuver for testing ulnar and radial
arterial flow to the hand is called the Allens test.
Both arteries are manually occluded; the patient
makes a tight fist and then lets go, squeezing out
venous blood. The artery in question is released
to see if the hand reperfuses appropriately. A 2004
prospective cross-sectional study of 1010 patients
concluded pulse oximetry to be a more sensitive
predictor of intact circulation than the Allens test.92
Furthermore, a 1995 case report suggests that in
cases where vascular injury is in doubt, Doppler
ultrasound as well as pulse oximetry can be par-
ticularly useful tools in confirming diagnosis.93
Nerve Injuries
The management strategy of hand nerve injuries in
the ED is determined by whether the injury is closed
or open. All nerve injuries should be splinted to
prevent further nerve damage. Closed injuries are
more likely to be due to neuropraxia or axonotme-
sisinjuries to the axon without disruption of the
endoneurium required for regeneration. They re-
quire outpatient hand surgeon follow-up for repeat
physical examinations. Open injuries, in contrast, are
much more likely to be due to fully severed nerves.
Without an intact endoneurium, nerve regeneration
is not possible. Therefore, all open injuries associat-
ed with significant sensory or motor deficits require
immediate hand surgeon consultation for possible
nerve repair.9,94
Special Circumstances
High-Pressure Injection Injuries
High-pressure injection injuries are very uncommon,
so strong evidence regarding their management
is lacking. They tend to occur in the nondominant
hands of industrial workers.95 While paints and
oils are the most common materials involved, the
literature is filled with case reports of incidents
involving water, air, solvents, and even molten metal
and cement.96-103 Superficial signs of injury can be
deceptively minimal, as in the third clinical vignette
patient, and even imaging may misrepresent the full
extent of tissue damage. (See Figure 16.) Regardless
of the material injected, these injuries are associ-
ated with a high risk of infection and amputation,
Emergency Medicine Practice 2011 16
particularly when vascular compromise is present.104
Long-term functional impairment is common and
even associated malignancy has been reported.105-108
While certain cases can be successfully man-
aged conservatively (such as water injections only
involving the fingertips), every case of high-pres-
sure injection requires immediate hand surgeon
consultation for probable surgical debridement.109
Other management in the ED includes splinting,
elevation, pain control, and broad-spectrum anti-
biotics. Regional nerve blocks are contraindicated
because they impair serial examinations for vascu-
lar compromise. While rare, a case report suggests
that patients presenting with acute chest pain,
shortness of breath, or cardiovascular collapse
following a high-pressure air injection should be
evaluated for pneumomediastinum, pneumotho-
rax, and gas embolism.110
Amputations
Every case of finger and hand amputation requires
immediate consultation by a hand surgeon, with the
exception of very distal tip amputations as discussed
in the section Fingertip Amputations on page 8.
Replantation is nearly always considered, and surgi-
cal repair is required even if replantation is contra-
indicated. Success rates depend on ischemia time,
degree of tissue damage, and mechanism of injury.
Sharp lacerations are more likely to yield successful
replantation than crush injuries (62% vs 50%).111 In
one study, fingertip amputations (the most common
amputation injury of the hand) had a 78% replanta-
tion success rate.112 This is because, based on 1988
Figure 16. Tissue Involvement Of High-
Pressure Injection Of Paint97
Radiograph (left) and intraoperative photograph (right) showing the
extent of tissue involvement in a high-pressure injection of paint.
Used with permission of New Zealand Journal of Medicine.
ebmedicine.net June 2011
 Risk Management Pitfalls For Hand Injuries
1. I couldnt see all the way to the base of the
laceration, but Im sure there is no glass inside.
Lacerations caused by glass and other brittle
materials are at high risk for retained foreign body.
Inability to explore the laceration completely to its
base or a patient having the sensation of foreign
body should prompt multiple-view radiographs
prior to laceration repair.
2. A patient with a sutured laceration came back
for a wound check with signs of infection, so I
prescribed antibiotics and asked the patient to
return in a few days for suture removal.
While antibiotic treatment is reasonable in this
case, infected lacerations or those that present for
repair later than 12-24 hours after injury should
be allowed to heal by secondary intention. In this
case, immediate suture removal and irrigation/
debridement of the wound is essential.
3. I didnt see a fracture on the x-ray.
Radiographs are not 100% sensitive for detection
of fracture. To maximize the sensitivity, emergency
clinicians should ensure that multiple views are
obtained, including posteroanterior, lateral, and
oblique. In cases where fracture is highly suspected,
the safest practice is to splint the affected extremity
and refer for outpatient hand specialist follow-up.
In cases where formal radiology reads are pending,
patients should be informed that they may be called
back with additional findings.
4. I saw the bleeding artery in the laceration, so
I clamped it.
Lacerated hand vessels, even when easily
visible, should never be clamped by an
emergency clinician. The risk of causing
further vascular damage, tendon damage, and
nerve damage is extremely high. Emergency
department management should focus on
hemorrhage control with direct pressure and
proximal tourniquet application. Direct repair of
vasculature is best left to a surgical specialist.
5. The child with the severely crushed hand was
having so much pain and tingling, I had to
perform a regional nerve block.
While rare, compartment syndrome of the hand
does exist. The emergency clinician must be
able to recognize high-risk mechanisms such as
crush injuries and early physical examination
findings such as increasing pain and paresthesias.
Regional nerve blocks are contraindicated in
suspected compartment syndrome as they prevent
meaningful repeat physical examinations.
June 2011 ebmedicine.net
6. The pressurized injection injury looked like
a very small red dot on the finger, so I sent the
patient home with pain medications
High-pressure injection injuries can look
deceptively minor on physical examination. All
cases require x-rays to better visualize the extent
of injury. Due to the high risk of amputation and
permanent functional impairment, every case
should be admitted for IV antibiotics and likely
surgical debridement.
7. I cleared the patient as fit for incarceration
because all he had was a bite mark on his
knuckle.
Fight bites may look minor on physical
examination, but they carry a high risk of soft
tissue infection and loss of function. All cases
require antibiotics and surgical consult for
possible debridement and washout. Patients will
often hide the true mechanism of this injury, so
lacerations to the MCP should be considered a
fight bite until proven otherwise.
8. I wanted to be safe, so I splinted the entire
mallet finger from the DIP to the MCP.
Mallet fingers have been shown to heal with
good functional outcomes after DIP splinting in
extension for 6 weeks. Immobilization of more
proximal joints is unnecessary and can lead to
undue joint stiffness.
9. I couldnt successfully reduce the dislocation,
so I splinted it and referred the patient for
outpatient follow-up.
Any dislocation or fracture that fails closed
reduction warrants immediate surgical
consultation. In particular, irreducible
dislocations often occur due to intra-articular
bone fragments or an entrapped volar
plate. While awaiting surgical consultation,
management should focus on pain control and
splinting in a comfortable position.
10. I placed the amputated finger directly in a
bucket of ice water to increase viability.
Direct contact with ice and excessive water can
cause irreversible damage to amputated limbs.
The proper technique for cooling is to wrap the
amputated part in saline-moistened gauze and
place in a sealed plastic bag. This bag is placed
into an insulated container with a sealed bag
of ice. Properly cooled parts can remain viable
up to 12-24 hours, depending on the tissues
involved.
17 Emergency Medicine Practice 2011
animal data, muscle can only withstand 6 hours
of warm ischemia and 12 hours of cold ischemia
(compared to 12 and 24 hours, respectively, for bone
and other soft tissues), so distal replantations have a
higher success rate than proximal ones.113
ED management of amputations, therefore,
should focus on hemorrhage control, pain control,
and maximizing the viability of the amputated part
by cooling. The preferred method for cooling is to
wrap the amputated part in normal saline-moist-
ened gauze (to prevent tissue dessication) and place
into a sealed plastic bag. This bag should be placed
into another sealed bag containing ice and then
placed into an insulated container for storage or
transport. This process avoids damage to the tissue
from direct contact with the ice.114
Compartment Syndrome
While rare, compartment syndrome of the hand does
occur and results in devastating tissue damage if left
untreated.115 The hand has 10 separate compartments,
making detection based on a pattern of examination
findings difficult. Increasing pain and paresthesias
are the earliest signs to emerge, followed by paresis
and pallor, and finally pulselessness (unless vessels
are directly injured). Emergency clinicians should
Time- And Cost-Effective Strategies For Hand Injuries
1. Prescribe antibiotics for patients only when
clinically necessary. The majority of hand inju-
ries will not require antibiotic therapy. Impor-
tant exceptions include animal/human bites,
grossly contaminated wounds, contaminated
penetrating trauma, high-pressure injection
injuries, and amputations.
Risk management caveat: Immunosuppressed
patients are at higher risk of infectious
complications. Physicians should have a lower
threshold for treating these patients with
antibiotics. When not prescribing antibiotics,
closer and earlier follow-up is warranted.
2. In the hands of an experienced sonographer,
ultrasound can be used as a time- and cost-
effective alternative to MRI in diagnosing liga-
ment and tendon injuries.
Risk management caveat: Keep in mind that the
reliability of ultrasound is user-dependent.
Studies have shown that ultrasound has a higher
specificity than sensitivity in detecting complete
tears. Therefore, a complete tear can be ruled in
but cannot be ruled out with ultrasound. MRI
remains the gold standard for detecting tendon
Emergency Medicine Practice 2011 18
be suspicious of compartment syndrome in crush
injuries, circumferential burns with eschar forma-
tion, pain out of proportion to mechanism, rapidly
increasing pain despite treatment, palpably tense
tissues, and evidence of nerve or vascular injuries.116
Measuring compartment pressures, while possible, is
difficult due to complex compartmental anatomy and
is reasonable to leave to a hand surgeon. Immediate
surgical consultation is required.
While awaiting definitive treatment, ED man-
agement should focus on reducing compartment
pressure by means of limb elevation and removal
or loosening of bandages and casts. In the case of
circumferential full-thickness burns, escharotomy
should be attempted if surgical management will be
delayed. Finally, regional nerve blocks are contra-
indicated in suspected compartment syndrome as
they eliminate the ability to perform serial physical
examinations.117
Controversies/Cutting Edge
NSAIDs And Impaired Wound Healing
Patients are commonly prescribed nonsteroidal
anti-inflammatory drugs (NSAIDs), such as ibupro-
fen, for pain relief for skin and soft-tissue wounds.
and ligamentous injury and should be used in
cases where complete tears are highly suspected.
3. Subungual hematomas without disruption of
the nail can be treated with simple nail trephi-
nation, a cheaper and faster alternative to nail
removal and nail bed laceration repair.
Risk management caveat: Carefully examine the
nail and its margins to be sure that they are
intact. Disruption of these structures warrants
complete nail removal and direct repair of nail
bed lacerations.
4. Regional nerve blocks often produce more
complete and longer-acting anesthesia than
local anesthesia or enteral and parenteral pain
medications. Patient satisfaction is generally
higher as well.
Risk management caveat: Be sure to have a
high index of suspicion for compartment
syndrome. Patients with significant crush
injuries, pain out of proportion to mechanism,
paresthesias, pressure-injection injuries, and
tense compartments on palpation are at higher
risk of developing compartment syndrome.
Regional nerve blocks are contraindicated in
these patients.
ebmedicine.net June 2011
There is little evidence supporting the theory that
short-term use of NSAIDs interferes with wound
healing. Recent literature, however, is split on
whether long-term NSAID use may inhibit wound
healing. Four animal models conducted between
1993 and 2007 concluded that NSAID use inhibited
wound contracture, epithelialization, prolifera-
tion of fibroblasts, and angiogenesis.118-121 On the
contrary, a 2007 randomized controlled trial of 122
patients showed that topical ibuprofen does not
inhibit wound healing of chronic venous ulcers.122
For the ED patient population (acute wounds in
humans), it is difficult to draw a meaningful con-
clusion from this literature. A safe practice would
be for an emergency clinician to use NSAIDs in
conjunction with other analgesic medications for
short periods of time and to encourage long-term,
high-dose NSAID users to reduce their dose of
NSAID until their wound has healed properly.
Epinephrine In Digital Nerve Blocks
Avoiding the use of epinephrine in digital nerve
blocks for fear of distal ischemia is a concept that is
deeply ingrained in practicing emergency clini-
cians. Benefits of epinephrine include less bleed-
ing, less systemic absorption of anesthetic, and
longer and more complete anesthesia with less
medication. In the past 10 years, several studies
have shown that the true incidence of epinephrine-
induced ischemia is extremely low.123,124 Only 17
cases have ever been reported in worldwide litera-
ture.125 Furthermore, phentolamine, the injectable
antidote, is readily available in hospitals. Based
on this recent data, epinephrine use is likely very
safe for use in digital nerve blocks. It should still
be avoided in injuries with suspected vascular
damage and in patients with known digital vaso-
spasm (such as Raynauds) or peripheral vascular
disease.126-128 Despite this data, this author will
continue to avoid the use of epinephrine in hand
anesthesia because the benefits of longer-lasting
anesthesia and less bleeding can be achieved by the
use of bupivacaine and a proximal tourniquet.
Disposition
Most patients with isolated hand trauma do not
require admission to the hospital. Exceptions, of
course, include cases that need ongoing IV antibiot-
ics, immediate surgical repair or exploration (fight
bites), or therapeutic amputation as determined by
consultants. Patients with minor soft-tissue injuries
should follow up in the ED or with a primary care
provider for suture removal (if necessary) and repeat
physical examination. Patients with more extensive
tissue injuries that do not require admission warrant
outpatient follow-up with a hand surgeon.
June 2011 ebmedicine.net
Summary
The hand is one of the most precious parts of the hu-
man body, and loss of its normal function has signifi-
cant and long-lasting impact on productivity, ability
to earn a livelihood, quality of life, and self-esteem.
The patterns of traumatic hand injury are varied and
complex, and as such, management must be tailored
to each individual case. A sound knowledge of hand
anatomy and high-risk conditions is essential to
the emergency clinicians practice. Respect for the
hands importance should generally sway practitio-
ners to a more conservative management approach.
When in doubt, specialty consultation, immobiliza-
tion, and prompt follow-up are safe strategies that
ensure optimal patient outcomes.
Case Conclusions
Based on your physical examination findings, you
suspected that your 34-year-old female skier with thumb
MCP joint laxity had a UCL tear, or skiers thumb.
Knowing that the feasibility of conservative management
hinges on whether the tear is complete or partial, you
decided to perform your examination again after radial
and median nerve blocks. Under valgus stressing in full
extension and 30 of flexion, the affected and unaffected
thumbs deflected to 20 and 10 of angulation, respective-
ly. Still suspicious of a complete UCL tear, you decided to
pursue further imaging. Because MRI was not available
until Monday morning, you performed an ultrasound,
which revealed significant disruption of the UCL. Re-
membering that complete UCL ruptures can be surgically
repaired with equal outcomes up to 3 weeks postinjury,
you placed the patient in a thumb spica cast and arranged
a follow-up appointment with the local hand specialist in
2 weeks.
Returning to your second patient, the 24-year-old
male with a dorsal MCP laceration supposedly from
punching a wall, you astutely questioned the patient
about the possibility of the injury being from a punch to a
human mouth. After advising the patient on the impor-
tance of the matter, the patient disclosed that the injury
was, in fact, from a fistfight. You started IV antibiotics,
consulted the hand specialist, and admitted the patient for
likely surgical debridement.
You made your way back to your final patient, the
37-year-old male with a high-pressure grease injection to
his finger. Despite minor findings on physical examina-
tion, you remembered that these injuries are associated
with high rates of infection, limb ischemia, and need for
amputation. You ordered x-rays, started broad-spectrum
IV antibiotics, and called the hand specialist to come in
immediately for surgical evaluation.
19 Emergency Medicine Practice 2011
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1. What is the most common type of traumatic
hand injury?
a. Fractures
b. Lacerations
c. Crushes
d. Burns
2. Which of the following physical examination
findings is most consistent with a limb-threat-
ening injury?
a. Fracture
b. Tendon injury
c. Ligament injury
d. Crush injury
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3. Which nerve distribution(s) must be blocked to
achieve complete anesthesia of the thumb?
a. Radial only
b. Median only
c. Radial and median
d. Radial, median, and ulnar
4. Which of the following combination of physi-
cal examination findings tests the function of
the ulnar nerve?
a. Pinprick sensation to the middle finger tip/
thumb and middle finger opposition
b. Pinprick sensation to the index finger tip/
wrist extension
c. Pinprick sensation to the little finger tip/
little finger extension
d. Pinprick sensation to the medial distal
aspect of the ring finger/index finger
abduction
5. How much time should elapse before sutures
may be removed from the dorsal finger and the
palm, respectively?
a. 7-10 days and 14-21 days
b. 3-5 days and 10-14 days
c. 3-5 days and 14-21 days
d. 10-14 days and 14-21 days
6. According to the literature, what finding deems
nail removal and direct nail bed laceration
repair a superior intervention to nail trephina-
tion in the setting of subungual hematoma?
a. Tuft fracture
b. Hematoma covering greater than 50% of the
nail surface
c. Disruption of the nail or its margins
d. Finger pad amputation
7. What is the minimum amount of joint laxity
required to clinically confirm the diagnosis of
complete ulnar collateral ligament tear of the
thumb?
a. 15 or 5 greater than the unaffected side
b. 20 or 10 greater than the unaffected side
c. 30 or 10 greater than the unaffected side
d. 35 or 15 greater than the unaffected side
8. Which of the following represents the most
complete and appropriate ED management of a
brisk arterial hemorrhage of the hand?
a. Direct pressure, elevation, and proximal
tourniquet placement
b. Localization and direct clamping of the
artery
c. Localization and tying off of the artery with
absorbable suture
d. Injection of the area with high-dose (1:1000)
epinephrine
23 Emergency Medicine Practice 2011
9. What structure must be intact for axons to Physician CME Information
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