Hand Injury

Aka: Hand Injury, Hand Trauma

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II. History

  1. Background
    1. Hand dominance
    2. Occupation and hobbies
  2. Mechanism
    1. Fall on Outstretched Hand
    2. High Pressure Injection Wound
    3. Boxer's Fracture
    4. Fight Bite
    5. Jammed Finger
  3. Past medical history
    1. Last tetanus Immunization
    2. Prior Hand Injuries
    3. Medications and Allergies

III. Exam: General

  1. See Hand Exam
  2. See Wrist Injury and Wrist Exam
  3. Hand Position of Function
    1. OrthoHandPositionOfFunction.jpg
    2. Inability to perform is a red flag
    3. Observe for isolated finger flexion (extensor Tendon Injury)
      1. OrthoHandExtensorTendonInjury.jpg
    4. Observe for isolated finger extension (flexor Tendon Injury)
      1. OrthoHandFlexorTendonInjury.jpg
  4. Flex fingers against palm
    1. OrthoHandPositionFistToScaphoid.jpg
    2. Finger tips should align to Scaphoid
  5. Skin changes
    1. Capillary Refill should be <2 seconds
    2. Anhidrosis, blanching, hyperemia of involved finger
  6. Tendon evaluation
    1. Extend DIP joint of affected finger only
    2. Flex PIP joint of affected finger only
    3. Flex DIP joint of affected finger only
  7. Neurologic Exam
    1. Sensory: Two Point Discrimination: <6 mm is normal
      1. Ulnar Nerve
      2. Median Nerve distribution
        1. NeuroMedianNerve.jpg
      3. Radial Nerve distribution
        1. NeuroRadialNerve.jpg
    2. Motor Exam (against resistance)
      1. Finger abduction (Ulnar Nerve)
      2. Oppose thumb to index finger (Median Nerve)
      3. Wrist extension (Radial Nerve)

IV. Exam: Specific Findings

  1. Interphalangeal Dislocation
    1. Dorsal PIP Dislocation
    2. Lateral PIP Dislocation
    3. Volar PIP Dislocation
    4. DIP Dislocation
    5. IP Joint Dislocation at Thumb
    6. Metacarpal-Phalangeal Dislocation
  2. Fractures
    1. See Scaphoid Fracture
    2. See Metacarpal Fracture
    3. Loss of 4th or 5th MCP knuckle prominence
      1. Boxer's Fracture
    4. Phalangeal Fractures
      1. Distal Phalanx Fracture
      2. Middle Phalanx Fracture
      3. Proximal Phalanx Fracture
  3. Tendon Avulsions and Injuries
    1. Flexed DIP
      1. DIP Extensor Tendon Avulsion (Drop Finger, Mallet Finger, Baseball Finger)
    2. Hyperextended DIP (especially ring finger)
      1. DIP Flexor Tendon Avulsion (Jersey Finger)
    3. Swollen PIP with dorsal tenderness
      1. Extensor Tendon Injury at the PIP Joint (PIP Central Slip Dislocation)
      2. Complication: Boutonniere Deformity
    4. Swollen PIP with volar tenderness
      1. Flexor Surface Injury at the PIP Joint (PIP Joint Volar Plate Injury)
      2. Complication: Extension deformity
    5. Game Keeper's Thumb
      1. Thumb Ulnar Collateral Ligament Rupture

V. References

  1. Hori (2015) Crit Dec Emerg Med 29(3): 2-7

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