89 - Hand and Wrist Injuries

When assessing hand injuries, the history should focus on the mechanism of the injury, hand position at the time of the insult, perceived resultant functional impairment, and the time elapsed since the injury. Some mechanisms yield classic injury patterns, such as the jersey finger and mallet finger. Other injury patterns are known for their poor outcomes, such as fight bites or high-pressure injection injuries, and require specific managements. Some wounds are more prone to infection, such as crush injuries and grossly contaminated wounds. During the history the patient’s hand dominance and career should also be ascertained and documented. Factors that may compromise wound healing, such as smoking, drug use, or an immunocompromised state, are important to document. Tetanus status should be verified. Despite its complicated nature, the hand can be examined adequately in a short period. Developing a rapid, reproducible hand examination strategy and performing it regularly will decrease the chance of missing subtle injuries. Even when a specific injury is obvious, it is important to examine the entire hand to avoid overlooking less obvious, coincident injuries. Box 89.1 lists one approach to comprehensive assessment of the hand. Assuming that no active bleeding is occurring and requires immediate attention, examination of the hand begins with inspection. All rings, watches, and other potentially constricting devices should be removed immediately. Lacerations and other disruptions in skin integrity are usually recognized easily; erythema, soft tissue swelling, and ecchymoses should also be noted. It is important to compare the general position of the hand with that of the unaffected side inasmuch as many fractures or tendon disruptions will cause characteristic deformities that are recognizable on inspection. Vascular integrity should be determined by comparing skin temperature with that of the opposite hand, feeling for ulnar and radial pulses, and documenting intact and symmetric distal capillary refill. • Irrigation is the greatest ally in preventing wound infections. • The final step in the management of almost all hand and wrist injuries is effective splinting. • All but the most minor hand and wrist injuries merit scheduled follow-up. KEY POINTS