Hand Injuries
Richard Hay
Overview of upper limb anatomy Assessment of upper limb injuries affecting the
hand Common injuries seen in ED
◦ Soft tissue◦ Bones
Other considerations
Hand Injuries
Anatomical terminology◦ Surfaces◦ Movements
Flexor and extensor compartments of the forearm Flexor and extensor retinaculum
◦ Carpal tunnel Hand
Upper limb – forearm and hand
Carpal Tunnel
Extensor retinaculum
Hand
Dorsal expansion
History◦ Hand dominence / ischaemic time / ADT / occupation /
hobbies / conditions affecting peripheral circulation Look Feel Move
◦ Functional assessment of all muscles / tendons◦ Assessment of neural function
Sensory and motor Anaesthetise and explore wounds only after
completing neurological assessment◦ Digital blocks◦ Wrist blocks
Assessment
Lacerations◦ Irrigation with either N/S or tap water
Tendon injuries◦ Surgical repair if >50% (?75% if no triggering)
FB◦ XR / US / CT
Bite wounds◦ Good evidence for the use of prophylactic Abx
Soft tissue injuries
Nerve injuries◦ All motor branches◦ Digital nerves proximal to DIP
Radial aspect IF / MF Ulnar aspect LF Both sides of thumb
Fingertip amputations◦ Different classification systems
Soft tissue injuries
Soft tissue injuries
Nail bed injuries◦ Subungual haematoma
Trephination If significant pain Antibacterial soaking / dressing
◦ When to explore / repair nail bed If nail fold disrupted If nail plate is dislodged from nail bed If nail plate adherent to nail bed then probably does not
require exploration
Soft tissue injuries
Management primarily non-operative◦ Closed reduction and splinting
<2mm articular congruity Accept angulation and rotation that does not interfere with
function or cause significant cosmetic deformity Shaft #s
◦ Acceptable angulation varies with MC involved and location of # Greater deformity acceptable in 4th/5th MC
10° for 2nd/3rd
20° for 4th
30° for 5th
Less angulation if # closer to CMC jts
Metacarpal fractures
Neck #s◦ Acceptable angulation
10-15° for 2nd/3rd
45° for 5th
Immobilisation◦ Forearm based extending to the PIP dorsally and distal
palmar crease on volar aspect (ie allow motion of IP jts) Wrist at 20-30 degrees MCP jts at 70-90 degrees
◦ Can buddy strap for rotational control
Metacarpal fractures