Chapter 12: Injuries to the Arm, Hand, Fingertip, and Nail

DIAGNOSIS AND DIFFERENTIAL

When taking a history, consider occupation, time and mechanism of injury, and hand dominance. Examination of all arm and hand injuries includes inspection at rest, evaluation of motor, nerve, and tendon functions, evaluation of sensory nerve function, and assessment of perfusion. Examine active motion and resistance to passive motion. (See Tables 12-1 and 12-2.) Examine all wounds for evidence of potential artery, nerve, tendon, or bone injuries, and the possible presence of foreign bodies, debris, or bacterial contamination.

Control bleeding to achieve adequate visualization and assessment of an injury. When necessary, a manual blood pressure cuff can be used as a temporary tourniquet for proximal injuries or a penrose drain can be used for distal finger injuries, taking care to apply for only limited time periods. Once adequate visualization is obtained, examine the wound for foreign bodies and tendon or joint capsule injuries. Examine the hand and arm throughout normal range of motion, including in the position of injury to avoid missing deep structure injuries that may have moved out of the field of view when examined in a neutral position. Obtain anteroposterior and lateral x-rays if bony injuries, retained radiopaque foreign bodies, or joint involvement are suspected.

EMERGENCY DEPARTMENT CARE AND DISPOSITION

1. Clean and irrigate all wounds after appropriate local anesthesia is provided.

2. Provide tetanus prophylaxis as indicated (see Chapter 16).

3. Consider consultation with a hand specialist for complex or extensive injuries, injuries that may require skin grafting, repairs requiring technically demanding skills, or injuries that may impact recovery of function.

4. Prophylactic antibiotics are not routinely needed for uncomplicated hand lacerations.

5. Consider antibiotics for complex wounds such as bites, injuries more than 12-hour old, contaminated wounds, exposed bone, or significant comorbidities.

6. See below for additional care instructions for specific injuries.

Dorsal Forearm, Wrist, and Hand Lacerations

1. Examine tendons and nerves distal to the wound to assess for potential injury.

2. Dorsal forearm and hand skin is often thin without underlying tissue. This can make wound edge approximation challenging.

3. For most lacerations, use 5-0 nonabsorbable sutures for closure. Consider subcuticular sutures with 5-0 absorbable material on the dorsum of the hand.

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