Module 7 - Hand Injuries

Assessment


 
A. History

The time from injury, type of injury, and other related factors should be sought. In particular, a very detailed understanding of the injurious agent is essential to the correct assessment and treatment of the patient .

 

B. Physical Examination

  • Viability: Test each finger tip for viability: capillary refill, colour, turgor, and capillary bleeding from pinprick if non-sensate.
  • Tendon Function: Test flexor digitorum profundus to each finger, flexor digitorum sublimis to each finger, and flexor pollicis longus. Test extensors of each of the digits. Note any lack of complete flexion or extension.
  • Sensation: Assess in radial, ulnar, and median nerve distributions. Radial light touch dorsoradial aspect of the hand and dorsum of the thumb and index fingers; ulnar light touch on the little finger; median light touch on teh index finger and thumb.
  • Motor Nerve Function: Test ulnar and median function.
  • Median Nerve Integrity: Oppose abductor pollicis brevis strength to assess.
  • Ulnar Nerve Function: Abduct and adduct fingers to test.
  • Bones: Palpate each bone in the hand to determine if there is tenderness deformity, swelling or crepitus which suggests fracture.
  • Joints: Test lateral and anterior-posterior stability of each joint to determine integrity of ligaments.
  • Soft Tissue Coverage: Assess the viability of skin flaps or burned areas to determine the need for soft tissue coverage.

 

C. Investigations


  • X-ray: Virtually all patients sustaining a hand injury should have an x-ray of the hand. Special vies may be obtained for particular circumstances. In general, three views of a digit should be obtained.
  • Bone Scan: Can be used in a situation in which a fracture is suspected but not apparent on x-ray. Also, a bone scan may be useful for cases of possible osteomyelitis.
  • Culture & Sensitivity: In situations of sever hand trauma, a swab for Gram stain and culture and sensitivity prior to the start of antibiotics will help provide antibiotic choice.
  • Blood Work: Type and crossmatch for severe injuries, glucose for diabetics, etc.

 

D. Initial Treatment

The first step in initial treatment is accurate assessment using history and physical examination and then x-ray. All patients with open hand injuries require a Tetanus prophylaxis. Most significant hand injuries should be treated with antibiotics prophylactically and in the case of significant farm and industrial injuries therapeutically. Most hand injuries should be treated initially with débribement and irrigation in the Emergency Room. Severe injuries can go directly to the Operating Room and have this done under initial general anesthetic. The selection of dressings for transfer would probably be saline-soaked gauze in most cases. The dressing after hand injury treatment in the Emergency Room would usually be Jelonet and gauze. Most hand injuries would benefit from an initial period of splinting. However, splinting always causes some degree of stiffness in the hands and should be minimized. In cases of significant hand injury or specific types of hand injury, a referral to a hand surgeon should be considered.

Author: Dr. SF Morris