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Hand Injuries

One-third of all orthopaedic injuries seen in emergency rooms are hand or upper extremity injuries. When a patient comes into the emergency room, we all know we need a history, but why? We need to know what happened, how it happened and what the environment was. Let’s examine the hand. You’re afraid that there is a tendon injury, do we just have the patient move the finger, you have a laceration at the wrist. If you move your fingers and you’ve got a cut, it’s going to hurt, you can numb it up, but then you can’t examine the neurologic examination. So how can we examine the patient? Well if you each take your hand and just let it drop into extension, supination and extension, you get this, you get normal tension on the flexor tendons, flex the fingers in this arcade, like holding an egg in the hand with the little finger more flexed than the ring, then the long, then the index, and even the thumb.

You want to do a vascular examination. Well, the best exam is, you look at capillary refill, you do an Allen’s test, so you press on both vessels, you have them make a fist or you have a nurse or colleague squeeze the blood out of the hand and then you take your thumb off the radial artery, count how long it takes to pink up again, then you repeat it, looking at the ulnar artery.

Wound care: Cleaning the wound is good, irrigate it, don’t soak it, two things are wrong; the hand is dependent, and don’t use Betadine because if it’s toxic to the bacteria, it’s also tissue toxic, it kills white cells, it kills the edges of the tissue under the skin. Take a syringe and put an angiocath, 16 or 18 gauge angiocath on the end of it and pulse irrigation, that’s what we use in the operating room, we use pump pulse irrigation for bigger areas, but same thing, you want to dilute and diffuse out the bacterial inoculum so that the hand can handle the problem. You don’t have to pick out all the pieces of dirt, you have to wash.

What do we do? We want to rest an injured extremity, whether it’s a laceration, a bruising or a fracture, we want to rest it because if it’s a laceration, we get edema, edema fluid is culture media. If you rest it, you decrease the culture media, you decrease the edema, you decrease the culture media and you decrease the risk of infection, so we put nonadherent dressing on it, I use wet gauze over the nonadherent dressing just like when you’re cleaning your sink in your kitchen, you moisten your sponge, wring it out and then wipe up to clean up a spill, a dry sponge doesn’t work, a moistened sponge works much better as a wick to soak out the serous fluid, decreasing the contaminant. I then put a bulky dressing and I actually recommend a splint for 48 hours and then when we splint it, we put the wrist in extension of 20 to 30 degrees of dorsiflexion, the MP’s we aim for 90 degrees of flexion just like this, you take an x-ray it’s 60 degrees, but you have aimed for that. If you aim for 60, it will only 40 degrees. The IP joints should be in neutral or comfortable position which is 10 to 15 degrees of flexion, the thumb in palmar abduction.

Proximal phalangeal fracture. The splint is put volarly. Again, not enough flexion, doesn’t control rotation, doesn’t control angulation, tape around the wrist and add insult to injury, where does the splint end, at the carpal tunnel, so if this patient hadn’t had a previous carpal tunnel release, this splint itself could cause compression at the carpal tunnel. If you want to control a finger fracture that is unstable and you need to flex the metacarpal phalangeal joints, I am not opposed to using metal splints, you just have to connect those metal splints to a short arm cast and include two fingers. You need to stabilize the wrist.

Subungual hematoma, it’s greater than 30%. When it’s like this you have to suspect that there is a laceration, a major injury to the nail bed that can affect future nail bed growth. So what do we do? Under a digital block, we can remove the nail, and we can repair the nail bed and that can be done in the office or the emergency room. Ideally, I use 7-0 Chromic.

Fingertip injuries that are less than 1 cm, clean it off, if there is a little bone sticking up, you can take a little filer or what we call a rongeur and trim it flat and let it heal with secondary intent, just put a dressing on it, some Xeroform wet gauze and a dressing, change it at 48 hours and then patient’s can go to band aids and change it, and they can wash their hand and change it every day to keep it clean, this will granulate in and then the skin will grow right over the top, and they will have sensation return.

Extensor tendon injury. Almost anyone can handle this injury in the office. It’s distal to the juncture, those are those little bands just proximal to the metacarpal phalangeal joint that interconnect the extensor tendons. Because of that, the tendons don’t retract up the forearm, so here is this laceration, the two ends were visible in the wound with a little cutback under local, some delicate suturing with some 4-0 nylon, try to bury the knots and then close the wound, and then you immobilize. Wrist in extension, this is the one time you don’t bend the MP’s all the way, you put them in about 20 degrees of flexion for three to four weeks, but you can leave the interphalangeal joints free. First of all, extension at the interphalangeal joints when our MP’s are in extension.

Infections. Infections come in multiple forms, cellulitis, abscesses, bites, Paronychia, and suppurative flexor tenosynovitis. Most of these are the same bacteria, similar antibiotics, but they have different levels of importance and aggressiveness in which we treat them. A cellulitis is almost always a strep infection, minor injury, we are always sticking ourselves, cutting ourselves, getting minor scrapes, why don’t we develop infections in our hands, because we are able to tolerate it most of the time and overcome the inoculum. But occasionally we don’t, and then we get some localized redness, that’s a cellulitis, that’s strep.