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Image courtesy of Nicole Cimino-Fiallos, MD.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

The above image shows comminuted/displaced fractures of the second proximal phalanx and the second, third, and fourth metacarpals. The patient sustained these injuries while changing a tire on a tractor-trailer.

Hand injuries are a common presenting problem in emergency departments (EDs) as well as in primary care settings.[1,2] They are typically grouped into the following six broad categories[3]:

  • Lacerations
  • Crush injuries and amputations
  • Infections
  • Fractures/dislocations
  • High-pressure (injection) injuries
  • Burns (not discussed in this slideshow)

Rapid evaluation and treatment of hand injuries is essential to the prevention of significant short- and long-term disability.[1-3]

Images from Kennedy CD, Huang JI, Hanel DP. Clin Orthop Relat Res. 2016 Jan;474(1):280-4. PMID: 26022113, PMCID: PMC4686527.[4]

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Pyogenic Flexor Tenosynovitis

Pyogenic flexor tenosynovitis (shown) is an infection of a digit's flexor tendon sheath. It often results from penetrating trauma (but less commonly may occur in the absence of trauma).

Immunocompromising conditions such as diabetes mellitus are a significant risk factor for flexor tenosynovitis.[4] Skin flora is the most common bacterial culprit, with both methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S aureus (MRSA) being commonly isolated in culture.

Patients with flexor tenosynovitis should be admitted for inpatient care, with hand surgeon evaluation and intravenous (IV) antibiotics. Surgical incision and drainage has also been a standard of care, but studies and experience suggest that some patients may recover with antibiotic therapy alone, without surgical intervention.[4,5]

Images from Fujioka M, Hayashida K. J Trauma Manag Outcomes. 2015 Oct 27;9:7. PMID: 26512296, PMCID: PMC4624359.[6]

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Traumatic Finger Amputations

The above images show an incomplete amputation at the level of the proximal interphalangeal (PIP) joint of four fingers, with significant soft tissue damage and proximal phalanx fractures.

Traumatic partial or full finger amputations must be rapidly addressed, as they may otherwise result in significant long-term disability as well as serious infections. A hand surgeon can provide reimplantation or, if that is not feasible, minimize disfigurement and optimize function and prosthetic fitting.[7]

As with any significant hand injury, assessment of sensory, motor, and circulatory function distal to the injury is essential. This can provide valuable information to hand surgeons in guiding the surgical approach and determining whether a digit is salvageable.

Images courtesy of Medscape/Oliver Mayorga, MD, FACEP; Bristow IR et al[8] (left inset); and Nicole Cimino-Fiallos, MD (right inset).

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Subungual Hematomas

Subungual hematomas, a common occurrence, result when trauma to the distal phalanx causes venous hemorrhage under the nail bed. They typically produce significant, throbbing pain due to increased pressure under the nail.[9]

Removal of the nail plate, though previously a recommended practice, is unnecessary if the nail plate is intact (not fractured or displaced) and at least partially attached to the nail bed and if removal of the plate may lead to a poor cosmetic and functional outcome.[10] Instead, a small hole in the nail plate can be created using a cautery device (bottom image) or even a heated paper clip. This allows the hematoma to drain, which relieves the pressure and in most cases rapidly reduces patient discomfort.

Image courtesy of Medscape.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Nail Bed Lacerations

Nail bed lacerations (shown) can result from penetrating or crush injuries to the distal phalanx.[10,11] These injuries should be repaired to allow for optimal healing and nail regrowth.

Numb the finger with a digital block and apply a tourniquet to the base of the finger to create a bloodless field.[10,11] Pull the nail back to the eponychial fold to expose, irrigate, and inspect the nail bed. Close lacerations with 6-0 chromic gut or other absorbable sutures. Good outcomes have also been reported with skin adhesive, although further research is required.[12] For significant injuries (ie, those that include a displaced phalanx fracture, infection, concomitant tendon injuries, or a large soft-tissue defect), provide patients with follow-up with a hand surgeon.

Images courtesy of Medscape (left) and Eroglu O et al[13] (right).

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

High-Pressure Injection Injuries

The above images show a puncture wound from high-pressure injection (left) and a dorsal hand injury caused by a grease gun (right).

High-pressure injection devices, such as grease or paint guns, are capable of injecting a substance into the deep tissues of the hand. The injected contents spread along fascial planes, tendon sheaths, and neurovascular bundles and can cause significant damage.[14,15]

Extensive surgical debridement and decompression of the compartments of the hand are usually required and should ideally be performed within 6 hours of the injury; this may reduce the need for amputation.[15]

Adapted image from Medscape.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Reverse Bite Injury

A reverse bite injury, also known as a closed fist injury or a "fight bite," typically occurs during a fistfight when a combatant punches an opponent in the mouth and traumatizes the clenched hand, usually at the metacarpophalangeal (MCP) joint, on the opponent's teeth.[16,17] Because this type of laceration results in a crush injury of the soft tissues of the hand and the introduction of oral bacteria into multiple tissue layers, the wound is at high risk for infection, especially along the extensor tendon sheath or in the MCP joint.[18] Tendon laceration may also result. If left untreated, reverse bite injuries can quickly progress to osteomyelitis, tenosynovitis, or septic arthritis.[16]

Image courtesy of Flickr/Brett Spangler.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Animal Bites

The image shows a dog bite wound.

Animal bites are most often sustained on the hands and upper extremities. The majority of domestic animal bites are caused by dogs,[19-21] which, due to their blunt teeth and powerful jaws, typically produce crush injuries. Cat teeth, in contrast, are sharp and pointed and thus produce puncture wounds; these injuries have a higher risk for infection due to the inoculation of bacteria into deep tissue spaces.[19]

All animal bites to the hand, however, may result in deep tissue infections, causing such disorders as flexor tenosynovitis, septic arthritis, and osteoarthritis.[22]

All bite wounds should be explored for foreign bodies and irrigated with copious amounts of saline. Tetanus immunization, if not up-to-date, should be provided. Rabies immunization should be considered if the animal's vaccination status is unknown or if the animal is unavailable for observation.[19,21]

Images from Sbai MA, Dabloun S, Benzarti S, Khechimi M, Jenzeri A, Maalla R. Pan Afr Med J. 2015 Jul 20;21:206. PMID: 26421101, PMCID: PMC4575703.[23]

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Compartment Syndrome

The above images are from a middle-aged woman who had right acute carpal tunnel syndrome associated with compartment syndrome, 6 days after sustaining a cat bite on her right thumb. Significant edema of the right hand is apparent (top and bottom left), with flexion of the fingers and associated paresthesias along the distribution of the median nerve (palmar surface of the hand). Fasciotomy of the four muscular compartments of the hand was performed (top and bottom right).[23]

Crush injuries and circumferential burns of the distal upper extremity commonly result in compartment syndrome, in which elevated tissue fluid pressure in an osseofascial compartment may cause ischemia and subsequent muscle and nerve death.[23,24]

Compartment syndrome is treated with fasciotomy and compartment release.[25]

Image courtesy of Nicole Cimino-Fiallos, MD.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Paronychia

Paronychia (arrow) is an infection of the folds of the lateral aspect of the nail, where the nail implants into the fingertip.[26] The infection frequently occurs after trauma to the paronychium and is characterized by pain around the nail, swelling, erythema, and warmth. Paronychia in nail biters is especially common.

Treatment of acute paronychia varies according to its severity.[26] Uncomplicated cases may resolve with soaks and warm compresses. If an abscess is present, incision and drainage are appropriate. Consider antibiotics in patients with evidence of significant soft tissue infections or cellulitis and in those at risk for severe infections, including patients with diabetes or immunosuppression.

Images from Mahajan M, Rhemrev SJ. Int J Emerg Med. 2013 Aug 12;6(1):31. PMID: 23938194, PMCID: PMC3765347.[27]

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Gamekeeper's/Skier's Thumb

Injury to the ulnar collateral ligament (UCL) of the thumb, commonly known as gamekeeper's or skier's thumb,[27] can present as a chronic injury in patients with rheumatoid arthritis or as an acute injury in skiers or others following a fall on an outstretched hand or a motor vehicle accident. This injury can be associated with a gamekeeper's fracture, which is an avulsion of the bony ligamentous attachment point at the base of the proximal phalanx (left); therefore, evaluation of acute gamekeeper's thumb should include radiographs.[27]

Complete UCL tears must be surgically repaired, but incomplete tears can be managed conservatively with immobilization of the thumb in a spica cast for 4 weeks.[27]

Image from Wikimedia Commons/Clappstar.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Mallet Finger

Mallet finger (shown, middle finger) occurs after an injury to the terminal extensor tendon of the distal phalanx owing to forced flexion of an extended finger at the distal interphalangeal (DIP) joint.[28] This type of injury is most often experienced in participants in "ball sports" (eg, football and baseball) and in elderly women, with the latter typically sustaining the injury during a low-energy activity such as making a bed.[29,30]

Findings on clinical examination include drooping at the DIP joint and an inability to actively extend the distal digit.[28]

Once a mallet finger is identified, it should be splinted in extension for 6 weeks,[30] and patients should follow up with an occupational therapist.

Image courtesy of Nicole Cimino-Fiallos, MD.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Boxer's Fracture

The patient in the above image punched a wall in anger, resulting in a boxer's fracture of the fifth metacarpal.

The injury colloquially known as a "boxer's fracture" is a fracture of the fourth or, more commonly, fifth metacarpal neck, with volar displacement of the distal metacarpal head.[31] These injuries result from punching a hard surface or, less often, from landing on a hard surface with a closed fist.[32]

The management of boxer's fractures is controversial; however, most specialists agree that fractures with greater than 45° angulation or with more than 20° rotation of the finger should prompt external reduction and the involvement of an orthopedic surgeon.[32] For fractures with minimal rotation and angulation, conservative management with functional taping and/or an ulnar gutter splint may be sufficient.[33]

Left image courtesy of Patrick Foye, MD, UMDNJ-NJ Medical School. Right image from Wikimedia Commons/James Heilman, MD.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Scaphoid Fractures

Patients who present with a complaint of pain in the anatomic snuffbox (left image, arrow) after trauma, especially after a fall on an outstretched hand, should be evaluated for a scaphoid fracture (right image, arrow).[34] The risk for nonunion in scaphoid fractures is high, and the scaphoid's vascular anatomy puts its proximal portion at great risk for avascular necrosis after a fracture.

Distal pole fractures can be considered for nonoperative management, whereas proximal and waist fractures almost always must be managed operatively. Nonunion of the scaphoid fracture requires surgery, and many patients will experience at least some loss of function.

Images courtesy of Medscape/Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

High-Energy Wrist Injuries

Lunate dislocations

Lunate dislocations (left) usually result from high-force mechanisms, such as a fall on an outstretched hand or a motor vehicle accident,[35] with the injury typically occurring via ulnar deviation and hyperextension of the wrist.

On an anteroposterior view of the hand, the "Terry Thomas" sign may be present, in which there is a widening of the space between the scaphoid and lunate. On lateral views of the hand, the "spilled tea cup" sign (right) is seen when the lunate is not in line with the radius and capitate.[35] Lunate dislocations are typically managed operatively, so early hand surgeon consultation is critical.

Images courtesy of Medscape/Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR.

14 Can't-Miss Hand Emergencies

Nicole Cimino-Fiallos, MD, FACEP, FAAEM | September 14, 2022 | Contributor Information

Perilunate fracture dislocations

The above lateral (left), anteroposterior (center), and oblique (right) radiographs of the left wrist reveal a perilunate dislocation associated with a fracture of the radial styloid.

Any injury mechanism that results in axial loading and hyperextension of the wrist should prompt clinical suspicion and careful evaluation for perilunate fracture dislocation. This is a potentially devastating injury; moreover, it signals the presence of concomitant injuries, including disruption of the capitolunate joint, dislocation of the lunate, and rupture of the lunotriquetral, radioscaphocapitate, and scapholunate ligaments.[36] Median nerve damage and arterial injury may also occur.

Patients with a perilunate dislocation or fracture dislocation should be evaluated for early surgical management.[36-38]

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