HAND RELATED PITFALLS IN THE EMERGENCY ROOMThis article is intentionally brief, written to present 10 hand related pitfalls in the Emergency Room. It expresses the opinion of the author on these conditions, and as such is Level 5 evidence, i.e. evidence based on clinical experience and a knowledge of the current literature. There naturally is variation in the way some things are treated. Each pitfall is worthy of discussion in itself and will only be brushed upon here. This article will hopefully increase your comfort zone when treating some of these problems, or may help to better identify situations which require referral to a hand surgeon. I elected to not discuss injuries proximal to the metacarpals or to discuss burms of the hands. 1) SPLINTING AND MOBILIZATION OF HANDS - This may be the most important topic of all. It is important to splint a hand, when able, in the so called "safe" position. This involves extension of the wrist about 30 degrees, flexion of the MCP joints to 90 degrees with the PIP and DIP joints fully extended. It is difficult to attain this position perfectly but one should strive for it when splinting the hand. Plaster slabs, I find, often work better than casts, or malleable or premade splints. Immobilization rarely requires more than 3-4 weeks duration, after which the hand becomes extremely stiff. Older patients cannot tolerate immobilization as well as younger patients and often 2 weeks is sufficient for this group. Early ambulation is very important and should be performed aggressively as soon as possible, naturally keeping in mind the injury involved and the initial rest period required. Home therapy may suffice, in conjunction with hot soaks, etc., but patients need to be pushed often to put their hand through range of motion exercises in the face of swelling, pain, and stiffness. 2) EXAMINATION SETUP - Emergency Rooms are often busy and crowded but a good hand examination requires time and space. If an exploration of a wound is to be performed, an arm board or side table is most advantageous. I often, after providing anaesthesia, strip the hand with a readily available wide elastic wrap such as an Esmarch and inflate an air tourniquet or blood pressure cuff at the proximal forearm level to 250 mm of mercury to give me a bloodless field. Patients can often tolerate this for 20 to 30 minutes, allowing me to both diagnose and often treat a problem within that time frame. Stripping of the hand should not be performed in the face of infection. A penrose drain can serve the same purpose for isolated mid-to-distal finger injuries. 3) FRACTURES a) Bennett's Fracture: This intra-articular fracture of the base of the thumb metacarpal is an inherently unstable fracture due to the traction effect of the abductor pollicus longus tendon to the metacarpal (not the fracture fragment), causing a step deformity of the joint surface and subsequent arthritis. These fractures require percutaneous fixation or open reduction and internal fixation (ORIF) and should be performed within a few days of injury. b) Boxer's Fracture: These are metacarpal neck fractures, usually involving the 4th or 5th metacarpals. Malunion is the concern here, not nonunion. Closed reduction is usually all that is required as the initial angular deformity can often be improved to an acceptable level. General splinting time, using an ulnar gutter Plaster of Paris splint 12.5 cm wide, with the hand in the safe position encompassing the ulnar 2-3 digits, is 3 weeks (assuming the fracture is on the ulnar side of the hand). Acceptable angulations, following closed reduction, are 15 degrees for the index and middle metacarpals, 40 degrees for the ring metacarpal, and 50 degrees for the small metacarpal. Otherwise, consultation is necessary for possible pinning. c) Many fractures of the hand can be treated conservatively but fractures of the metacarpals or phalanges that are oblique or spiral are generally unstable and require referral. Likewise, fractures that have significant displacement or angulation require referral, as do multiple or intra-articular fractures. d) Fractures across the growth plate in children (usually Salter type 11 fractures) generally can be treated with realignment by longitudinal traction (performed under metacarpal or digital block in the ER) and subsequent buddy taping to an adjoining finger for 2 to 3 weeks. Dorsal aluminum splints (leaving the wrist free) can be added for comfort. Post-reduction x-rays should be performed to ensure acceptable reduction. e) It is common to see car door or other types of crush injuries to the distal phalanx and nail bed region with a resultant fracture of the distal phalanx. Most of these do not impair flexion or extension of the finger tip. Nail bed and skin repair will often significantly reduce the fracture fragments to an acceptable degree. If not, badly displaced fractures may require referral and K-wire fixation. 4) PROPHYLACTIC ANTIBIOTICS IN HAND INJURIES - The hands are not as resilient from an infection standpoint as the face. Therefore certain wounds should be covered with antibiotics, including the common dirty wound, even though it has been debrided and irrigated well. Staphylococcus and streptococcus remain the main offenders. I believe a first generation cephalosporin such as Keflex is reasonable in most cases, or Clavulin (although it is more expensive). If I'm a bit more worried, I'll use Penicillin and Cloxacillin p.o or I.V. Barnyard and chain saw injuries are notorious for subsequent infection and should have prophylactic antibiotics, with anaerobic coverage for the barnyard insult. Human bites often have a deep inoculum. and require extensive irrigation and debridement, while the hand is in the fist position. Penicillin is the drug of choice against Eikenella corrodens, common in oral flora, and I would also add Cloxacillin or Keflex. Human bites may well result in septic arthritis of an MCP joint. Consultation or close monitoring, at least, is suggested. I would cover not only every human bite but all animal bites to the hand. Cat and dog bites have a high incidence of pasteurella multocida infections. Clavulin is a good choice for all animal bites. The traditional safe method of treating animal bites is to allow healing by secondary intention followed by future revision if required. However, some bites can be excised and treated like an ulcer and be closed giving better functional aesthetic result. Consultation is usually required to make this decision. Marine related wounds have a higher than average incidence of infections (e.g. vibrio) and may require coverage with Minocycline as well. All diabetics with significant hand injuries should be covered with at least oral antibiotics, intravenous antibiotics if worried (Gentamicin, Penicillin and Cloxacillin). 5) ULNAR COLLATERAL LIGAMENT TEARS - The ulnar collateral ligament (UCL) to the MCP joint of the thumb is commonly injured. This is due to a hyperabduction force and may be prompted by some type of fulcrum in the 1st web space (skier's thumb). Incomplete tears of the ulnar collateral ligament are represented by a good end point when testing the integrity (stretching) of the UCL ligament. If one is uncertain, due to pain, whether or not there is a good end point when testing the ligament, local infiltration of an anesthetic such as Xylocaine (without epinephrine) will allow you to test conclusively. I find it useful to draw a straight line down the dorsuin of each thumb to visually compare the degree of abduction possible at the MCP joint when passively testing. Incomplete tears, as represented by a good end point, can be treated in a thumb spica splint for 3 weeks. Complete tears, with no good end point or with significant abduction, require surgical intervention within the first few days of injury. X-rays may be normal in a complete tear or may show avulsion fractures in an incomplete tear, or anything in between. Larger fracture fragments require ORIF. 6) DISLOCATION OR FRACTURES AT THE BASE OF THE METACARPAL - Although fractures at the bases of the 2nd through 5th metacarpals are usually intra-articular, they most commonly are minimally displaced. It has been my experience that closed reduction only is required followed by simple splinting of the hand for 2 weeks thereafter. Significant displacement or dislocation, however, may require percutaneous pinning or ORIF. 7) OPEN FINGER TIP INJURIES WITH SKIN LOSS - For pure soft tissue injuries of the fingertips, primary closure is preferred if possible. When skin loss is greater than 1 square centimetre, a skin graft used to be recommended. There is no question that larger wounds (likely up to 1 1/2 square centimetres) can heal by secondary intention. Exposed distal phalanx can be rongeured back to a level where there is soft tissue coverage (fat) over the bone. These injuries generally take a month or so to heal with the end result at least comparable to graft closure. Skin grafts and small flaps still have their role in finger tip injuries and if in doubt consultation is worthwhile. Note: Preservation of digit length is more important in thumb than finger injuries. 8) EXTENSOR TENDONS INJURIES - Aside from the extensor pollicus longus tendon to the thumb, the extensor tendons of the hand generally can be repaired in the Outpatient Department. This always requires extension of the laceration proximally and distally in a zig-zag (Z) type fashion. The ends of the extensor tendons will not retract too far from each other and can be repaired, with the hand relaxed, using a 3-0 or 4-0 braided synthetic nonabsorbable material such as mersilene or ethibond, or with PDS which slowly absorbs. Splinting (with the hand and wrist in the safe position) for complete lacerations is of 4 weeks duration. Incomplete lacerations require splinting for 2 weeks. 9) HIGH PRESSURE INJECTION INJURIES - Any high pressure injection injury should have a high degree of suspicion of significant underlying injury although the initial presentation may appear quite benign. Even pinpoint entry wounds from hydraulic hoses can cause significant damage as injected material travels down the flexor tendon sheath or a neurovascular bundle. Even injected water can cause significant injury. Consultation is suggested here as most such injuries require emergent surgical intervention. 10) VOLAR PLATE INJURIES - Hyperextension and dorsal dislocation injuries of the MCP and PIP joints involve the collateral ligaments and volar plate. Most injured fingers can be treated using a dorsal splint placing the finger in gentle flexion for 3 to 7 days followed by buddy taping for 2 to 3 weeks. Early and prolonged ambulation is important with these injuries as the joint will stiffen rather quickly and prolonged immobilization extends the recovery period dramatically. Fracture dislocation of these joints involving more than 40 % of the joint surface may require volar plate arthroplasty or ORIF and early consultation is appropriate. Open dislocations should be referred as well. Thanks to Dr. Mihkel Oja, Plastic Surgeon at the Dr. Everett Chalmers Hospital in Fredericton, New Brunswick for reviewing the draft copy of this article. References:
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