Chapter 18 Hand injuries and care
Hand injuries are common in emergency departments. Meticulous assessment and management is crucial because preservation of function is critical for livelihood and recreation.
EXAMINATION
Nerve function—screening tests
Tendon function
Test each joint of fingers and thumb in flexion and extension. This will detect complete laceration only. Warn the patient about the possibility of delayed rupture. The exact posture of the injured part at the time of injury cannot be accurately known. Therefore inspect the base of the wound through the full range of movement of the adjacent joints. Testing flexor digitorum profundus (FDP) at the distal interphalangeal (DIP) joint requires the joint more proximal to be held in extension during flexion of the joint being tested. Testing flexor digitorum superficialis at the proximal interphalangeal (PIP) joint requires all fingers except the one being tested to be held in extension to neutralise the mass flexor effect of FDP at the PIP joint.
TREATMENT
Splinting
The hand is splinted in a position to minimise the risk of stiffness after treatment: wrist extended (20°); metacarpophalangeal (MCP) joints flexed (70°) and fingers fully extended. This position keeps the collateral ligaments of the fingers at their maximal length.
Splint only those joints that need to be included for a particular injury.
Explain to the patient the importance of moving any joint not enclosed in the splint to minimise stiffness.
SOFT TISSUE INJURIES
Lacerations
Require careful inspection through full range of movement following local anaesthetic (without adrenaline). Document any sensory changes prior to anaesthetic.
Sutures, if required, should be 5/0 non-absorbable and are removed after 5–7 days—longer if over extensor joints, in the elderly or in patients on steroids.
Small skin loss (smaller than a 5 cent piece)—without bone exposed
Larger defect or with bone exposed
Defects larger than 1 cm diameter require skin graft.
Refer to the hand/plastic/orthopaedic team according to your hospital’s practice. Commence initial treatment.
Finger lacerations
Careful assessment for associated nerve and tendon injury. If present, appropriate referral.
Palmar lacerations
‘No-man’s land’ is the zone from the midpalm to the PIP joint where the tendons of the flexor superficialis and profundus are enclosed together in tendon sheaths. Great care in assessment is necessary. Palmar skin is thick and difficult to suture. Anaesthesia is difficult to achieve with local infiltration for similar reasons.
NAILS
Nailbed lacerations
Meticulous repair is critical. It is not just cosmetic; poor technique results in a permanently split nail. Refer to the hand/plastic/orthopaedic team according to your hospital’s practice for repair of laceration.
Preserve the nail; it can be used as a splint.
Subungual haematoma
With NO injury to nail or surrounding nail margin
Drill through the nail in two or three spots with a 19-gauge needle spun between thumb and index finger to release blood.
Analgesia, elevate for 48 hours.
Associated undisplaced fractures are considered ‘open’ and treated with oral antibiotics.
TENDONS
Lacerations of the extensor surface overlying the PIP joint
Otherwise innocuous-looking lacerations of the extensor surface of the PIP joint can transect the central slip of the extensor mechanism with preservation of extensor function initially. However a boutonnière deformity will subsequently develop if the tendon has been cut.

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