Chapter 29. Hand Trauma

Hand injuries are one of the more common reasons for emergency department visits. Hand injuries may be isolated or part of multiple trauma. These injuries are seldom life-threatening but can result in significant disability, threatening a patient's livelihood and lifestyle. These injuries can have significant economic impact with possible loss of occupation and lost time from work. Systematic examination and initial care has a direct effect on the ultimate consequence of any hand injury. Overall, it is far better to under treat and refer than to over treat and cause avoidable iatrogenic injury or disability. The course of recovery depends on initial management.

Position the Patient

A hand-injured patient may be examined while they are sitting but the environment should be calm and controlled. That does not apply to a patient with hand lacerations. It is best to examine the injured patient with a hand laceration while supine. The hand should be extended on a hand table next to the bed. The area should be clean, sterile, and have excellent lighting and all essential instruments available. It is best to have an assistant if possible for helping with lighting, positioning, and repair. There is a tendency in EM to see hand patients in hallways, chairs, and less than ideal circumstances. This must be avoided at all costs.

Control Bleeding

Bleeding is controlled by direct pressure with sterile gauze packs, elevation, and, if necessary, an arterial tourniquet (eg, blood pressure cuff inflated above systolic blood pressure). Do not use clamps unless all other measures fail. Blind clamping of vessels can lead to further injury.

Obtain History

Current Injuries

Ascertain the mechanism of injury by questioning the patient or others. An exact description of how the injury occurred will help determine the need for X-ray, antibiotics, urgent consultation in the ED, or in a follow-up visit. It is important to document the mechanism of injury, the time at which it occurred, and the environment in which it occurred. Ask about the following details associated with the mechanism of injury:

• Type of injury—crush, exploding, or simple amputation.
• Lacerations—exactly what device was involved and how the lacerations were caused.
• Position of the hand at the time of the injury (ie, fingers extended or flexed).
• Presence of pain, numbness, paresthesias, weakness, discoloration, coldness, clumsiness or poor coordination, or crepitus.
• Circumstances surrounding open wounds—environment, whether inflicted in a dirty environment (ie, sewer or barnyard) or in a specific situation (ie, fight-clenched fist).

Relevant History

• History of prior or existing hand or upper extremity injuries or disorders. Dupuytren's fasciitis, arthritis, and benign tumors are the most common nontraumatic problems noted.
• Bleeding disorders likely to influence hemostasis (eg, hemophilia).
• Factors that might impair wound healing (eg, use of corticosteroids).
• Tetanus immunization status (Chapter 30).
• Any allergies.
• General state ...