History should include occupation 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 evaluation 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, bone injuries, and the presence of foreign bodies, debris, or bacterial contamination.
Table 12-1 Motor Testing of the Peripheral Nerves in the Upper Extremity |Favorite Table|Download (.pdf)
Table 12-1 Motor Testing of the Peripheral Nerves in the Upper Extremity
|Radial||Dorsiflexion of wrist|
|Median||Thumb abduction away from the palm|
|Thumb interphalangeal joint flexion|
|Ulnar||Adduction/abduction of digits|
Table 12-2 Sensory Testing of Peripheral Nerves in the Upper Extremity |Favorite Table|Download (.pdf)
Table 12-2 Sensory Testing of Peripheral Nerves in the Upper Extremity
|Sensory Nerve||Area of Test|
|Radial||First dorsal web space|
|Median||Volar tip of index finger|
|Ulnar||Volar tip of little finger|
A bloodless field is needed to achieve adequate visualization. If a proximal tourniquet is needed, a Penrose drain can be used for distal finger injures and a manual blood pressure cuff for more proximal injures. Once adequate visualization is obtained, examine the wound for foreign bodies and tendon and joint capsule injuries. Examine the hand and arm 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 penetration are suspected.
All wounds require scrupulous cleaning and irrigation after adequate anesthesia.
Provide tetanus prophylaxis as indicated (see Chapter 16).
Consult a plastic or hand surgeon for complex or extensive injuries, injuries requiring skin grafting, injuries requiring technically demanding skills, or when the hand is vital to patient's career (eg, a professional musician).
See below for additional care instructions of specific injuries.
Forearm and Wrist Lacerations
Injury over the wrist raises the possibility of a suicide attempt. Question the patient about intent and a history of depression.
Injuries that involve more than 1 parallel laceration, classic for suicide attempts, may require horizontal mattress sutures to cross all lacerations to prevent compromising the vascular supply of the island of skin located between incisions (Fig. 12-1).
Examine tendons and distal nerves individually. (see Tables 12-3 and 12-4)
Horizontal mattress sutures for multiple parallel lacerations.
Table 12-3 Extensor Compartments in the Forearm