GENERAL MANAGEMENT PRINCIPLES
Specific concerns relative to wounds and lacerations of the arm and hand include potential injury to the arteries, nerves, and tendons that lie close to the skin and the impact of these injuries on the use of the hands in daily and occupational life. Injuries may be classified as either isolated or combinations of closed crush, simple lacerations, open crush, partial amputation, and complete amputation.
Specific considerations in the history include patient age, occupation, mechanism of injury, and hand dominance. Age is important because the potential for bony injury increases with decreasing bone density, and the likelihood for healing and functional recovery decreases with age due to loss of elasticity. Mechanism of injury identifies wounds that are more prone to infection or injury to deeper structures. Note the time from injury to repair; there is no distinct threshold for infection from time of injury to closure, but wounds sutured >12 hours after injury could be more prone to infection (see Chapter 39, “Wound Evaluation”). (See Videos: Hand Exam and Digital Nerve Block.)
Video 43-1: Hand Exam
Used with permission from Aaron Hexdall; Jorma Mueller and Moira Davenport, Bellevue Hospital Center, New York University School of Medicine.
Video 43-2: Digital Nerve Block
Used with permission from Aaron Hexdall; Jorma Mueller and Moira Davenport, Bellevue Hospital Center, New York.
Observe the position and stance of the arm, hand, and digits. Identify exposed tendon or bone and note the location of the wound relative to major arteries, nerves, and tendons. Inspect the wound carefully for possible foreign body, debris, or other visible contaminants. Note significant soft tissue avulsion or loss of length of the injured part, as these findings may be indications for operative repair. Remove rings from the affected arm. (See Video: Ring Removal.)
Video 43-3: Ring Removal
Used with permission from Moira Davenport; Moira Davenport and Carly Tarr, Department of Emergency Medicine, Allegheny General Hospital Medical.
Evaluate active motion and resistance to passive movement. Patients with a painful injury may be unwilling to move the affected extremity. After checking sensory function, local anesthesia may be required to obtain an adequate motor exam. The belief that a local anesthetic with epinephrine should not be used for digital nerve blocks is without evidence, and clinical observation studies have found agents containing epinephrine safe for digital nerve blocks.1,2
The most distal pure motor function of each major nerve should be tested against resistance (Table 43-1).
TABLE 43-1Motor Testing of the Peripheral Nerves of ...