Gary Quick, MD

When you suspect blunt nerve trauma, referral to a hand surgeon is prudent-even without evidence of acute compartment syndrome. The same is true if you discover ischemia in any part of the hand after injury. Try to control hemorrhage with compression and elevation of the involved extremity. If this is unsuccessful, use a short-duration tourniquet. Do not attempt to clamp a bleeding vessel; the risk of causing serious nerve or tendon damage is too high. Avoid exploring wounds in the region distal to the midpalmar crease and proximal to the proximal interphalangeal flexor crease because of the high risk of damaging the flexor tendons and the annular ligaments in this region. Explore more proximal injuries cautiously to determine occult injury to the flexor tendon.

ABSTRACT: To determine the stability of the injury, examine phalangeal and metacarpal fractures for intra-articular involvement. Suspect carpal bone fracture in any patient with wrist pain and tenderness; proper splinting is essential to prevent avascular necrosis of the bone, arthritis, and chronic disability. After successful reduction of a distal or proximal interphalangeal joint dislocation, order follow-up x-ray films. Apply stress testing of the joint space to all injured joints to ensure ligamentous integrity. Carpal and carpometacarpal dislocations require immediate consultation with a hand specialist. Therapy for bite wounds includes copious irrigation, debridement (in the operating room if necessary), and antibiotic prophylaxis. A patient with an infected bite wound requires hospitalization and intravenous antibiotics.

ABSTRACT: Rely on the history and physical findings when you evaluate a hand injury. After you control any active bleeding, test the motor and sensory functions of the radial, ulnar, and medial nerves. Use the rule of the 5 P's-pulses, pallor, pain, paresthesia, and paralysis-to guide the vascular examination. Assess the muscles and tendons by testing their flexion and extension functions against mild resistance. After anesthetizing any wound sites, apply high-pressure saline irrigation to remove debris and reduce bacterial contamination to prevent infection. To repair skin injuries, use a closure method appropriate to the condition of the wound. Infection-prone wounds-such as crush, grossly contaminated, and bite injuries-may require antibiotic prophylaxis and possibly delayed closure.