Orthopedics

Traumatic Injuries of the Hand

1. Synopsis
   • Traumatic injury to hand may occur through various mechanisms
   • Injuries can occur to all age groups
   • May occur at home, at work, during physical activity, etc
   • Can affect bones, tendons, ligaments, and muscles of the hand(s)

1. Mechanism
   • High-pressure hand injury has 3 phases
     • 1: Direct mechanical impact injection
       • Pressure-induced neurovascular compromise
       • Edema
       • Possible compartment syndrome
     • 2: Inflammatory sequela/chemical interaction of injected media w/ biologic substrates
     • 3: Secondary microbial infection from direct bacterial inoculation
       • Potentially intensified necrosis precipitated by phases 1 and 2
       • Rare phase and often polymicrobial
   • Penetrating trauma
     • Foreign object piercing the skin
       • Damages the underlying tissues and results in an open wound
2. Etiology/Risk Factors
   • In contact w/ high pressure injecting system
     • Paint gun
     • Air compressor
   • Penetrating injury to hand
     • Sharp object
   • Industrial laborers
   • Hand gunshot wounds
   • Digital amputation
3. Epidemiology
   • Incidence/Prevalence
     • Hand injuries are considered the most frequent body injuries
     • High-pressure injection injuries account for ~ 1 case/600 hand traumas in ED
     • Study of 1091 pts w/ hand injury
       • 84% were male
       • > 50% were < 40 years of age
       • 56.1% resulted in tendon damage, esp to finger flexors (79%) and skin loss (37.8%)
       • 24.1% resulted in amputations
       • 9.6% resulted in fractures
       • 6.1% resulted in nerve damage
       • 5.5% resulted in joint damage
       • HISS-graded injury severity was moderate in 28.6% of cases
       • 25.5% of patients suffered severe injuries
       • 26.5% of patients suffered majored injuries
       • 19.4% of patients suffered minor injuries

Diagnostics

1. History/Symptoms
   • Inquire about
     • Time of injury
     • How injury occurred
     • Any tools/machines used
     • Chemicals involved
   • May complain of hand
     • Swelling
     • Pain
     • Wound
   • Past medical history
     • Diabetes
     • Chronic renal failure
     • Obesity
     • Malnutrition
     • Any use of immunosuppression drugs
       • Chemotherapy meds
2. Physical Exam/Signs
   • Complete neurologic exam
   • Evaluate forearm, elbow, upper arm and axilla
     • To assess proximal extension of injury
   • Range of motion
   • Skin discoloration
   • Pulses
   • Serial examinations of compartments
     • Compartment syndrome may occur hours after initial injury
     • Secondary injury phase leads to further inflammation/edema
3. Labs/Tests
   • CBC +Diff, CMP
     • WBC count
     ESR, CRP
4. Imaging
   • Plain radiographs
     • Rule out foreign body or bone injury
   • CT/MRI
     • Assessment of soft tissue damage
     • Not usually necessary
5. Differential Diagnosis
   • Crush injury to the hand
   • Fractures of hand and digits
   • Compartment syndrome of the hand
   • Localized benign laceration of digit or palm

1. Initial/Prep/Goals
   • ABCs, IV access, monitor
   • Be prepared to treat for
     • Infection
     • Sepsis
     • Compartment syndrome
     • Pain
   • Local anesthesia or block
   • Profuse irrigation with saline under pressure i.e., cath tip syringe, 500-1000 mL total
   • Clean with 1% Povidone-Iodine
   • Tetanus prophylaxis
   • Explore wound for debris/foreign bodies
     • Some unroofing of skin may be necessary for complete wound exploration
     • If extensive debridement or dissection is indicated, specialist consult needed
     • Warn patient that this may be the case before you proceed with initial exploration
   • X-Ray for suspected deep or not easily seen foreign bodies
     • Best for glass and metal, poor for wood
     • Wood and vegetable matter (i.e., thorns) are hard to see in bloody wounds
   • Minor and shallow injuries can usually go home (consider antibiotic)
     • Plan follow-up with specialist for delayed removal
     • More severe/deep injuries with foreign body require prompt removal by specialist if necessary
   • Leave wound open (no sutures), apply antibiotic ointment and gauze dressing
     • Bleeding should be controlled with pressure
     • Arterial injury or severe venous bleeding require surgical in OR (NEVER tie off bleeders in hand)
     • Electrocautery generally should not be used
2. Medical/Pharmaceutical
   • Antibiotics
   • Analgesia
3. Surgical/Procedural
   • Amputation
   • Debridement
4. Complications
   • Loss of range of motion/function
   • Chronic pain
   • Hypersensitivities
   • Paresthesias
   • Motor dysfunction
   • Contractures
   • Missed foreign bodies, tendon injuries, nerve injuries
   • Infections
   • Dehiscence of the wound

Disposition

1. Hand consult if
   • Flexor tendon injury
   • Significant extensor tendon injury
   • Invasion of deep fascial compartments (hand +/- proximal digits - particularly palmar aspect)
     • Allows rapid extension of contamination/infection
     • Can track through carpal tunnel space to forearm
     • Most deep punctures
       • Particularly if foreign body present
       • Suspected that cannot be easily seen without improved hemostasis possible in OR
       • Deep foreign bodies that are difficult to remove (e.g., splinters, pencil lead, staples, pins, shards of glass)
2. Indications for prophylactic antibiotics for 5-7 days
   • Dirty wounds, deep wounds, suspected bone or joint capsule involvement
   • Antibiotics recommended (ADD single IM dose of anti-Pseudomonal cephalosporin if joint capsule or bone involved)
     • Keflex
     • Dicloxacillin
     • Erythromycin
3. Wound check in 2 days mandatory
   • Elevation for 2-3 days
   • Wound should be cleaned BID with sterile H2O
   • Antibiotic ointment applied and clean gauze dressing placed until wound sealed
4. Warn that pain lasting more than 5-7 days +/- increasing pain may indicate osteomyelitis
   • Requires doctor visit or return to ED for further evaluation
     • X-Ray, possibly bone scan, referral to appropriate specialist

1. Hand High Pressure Injury. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK542210/. [Accessed May 2022]
2. The Burden of Musculoskeletal Diseases in the United States. Penetrating Injuries. Available at: https://www.boneandjointburden.org/fourth-edition/vb23/penetrating-injuries#:~:text=Penetrating%20trauma%20is%20an%20injury,explosive%20devices%2C%20and%20stab%20wounds. [Accessed May 2022]
3. UTSouthwestern Medical Center. Traumatic Hand and Upper Extremity Injuries. Available at: https://utswmed.org/conditions-treatments/traumatic-hand-and-upper-extremity-injuries/. [Accessed May 2022]
4. Debski T, Noszczyk BH. Epidemiology of complex hand injuries treated in the Plastic Surgery Department of a tertiary referral hospital in Warsaw. Eur J Trauma Emerg Surg. 2021;47(5):1607–1612.
5. Laceration. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK545166/. [Accessed May 2022]

Contributor(s)

1. Singh, Ajaydeep, MD