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HAND INJURIES

What are hand injuries?

Intricate in design and function, the hand is an amazing work of anatomic engineering. Form follows function in the hand; therefore, any injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical evaluation. The goal with injuries to the hand is a rapid and accurate initial evaluation and treatment. In other words, once an injury occurs, the doctor strives to begin medical treatment quickly so the short- and long-term effects on the hand can be minimized.

The hand consists of 27 bones (including the 8 bones of the wrist). When the other associated structures (nerves, arteries, veins, muscles, tendons, ligaments, joint cartilage, and fingernails) are considered, the potential for a variety of injuries exists when trauma involves the hand. The most common cause of the injuries was blunt trauma, followed by injury from a sharp object.

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What are the symptoms of hand injuries?

The symptoms of hand injuries can vary depending on the type of injury, how the injury occurred (the mechanism), depth, severity, and location. Common symptoms of hand injuries may include:

  • Lacerations: tenderness (pain), bleeding, numbness, decreased range of motion (difficulty moving), weakness and pallor (pale or bloodless).

  • Fractures and dislocations: tenderness, deformity, swelling and discolouration, decrease range of motion. numbness, weakness and bleeding.

  • Soft tissue injuries and amputations: tenderness, deformity (with or without tissue and bone loss), swelling and discolouration, bleeding, weakness and numbness.

  • Infections: tenderness, local warmth, redness, swelling, fever (rare in hand infections), deformity and decreased range of motion.

  • Burns: tenderness or complete numbness, deformity, discolouration, loss of tissue, change in the texture of the skin, redness, blistering and black areas of tissue.

  • High-pressure injuries: pain, swelling, occasional skin discolouration.

When to seek medical care for hand injuries?

Anyone with a hand injury should consider calling a doctor or seeking medical attention. The potential for devastating injuries increases greatly when medical attention is delayed. Even the smallest cut or seemingly innocent hand injury could require advanced treatment to prevent infection or significant loss of function.

Any cut or laceration, which may require stitches to repair, warrants a medical evaluation. If a person is in doubt about whether the cut they have needs stitches, they should call the doctor for guidance. Minor burns do not require immediate medical evaluation; however, call a health care professional if there is any doubt.

Injuries to the hand causing the following symptoms generally require emergency medical attention at a hospital's emergency department: severe bleeding, numbness, loss of motion or strength, severe pain, obvious deformity or amputation, any of the signs of infection, such as tenderness, local warmth, redness, swelling, pus, or fever and exposure of underlying structures, such as tendons, bones, joints, arteries, veins, or nerves. Seek emergency medical care in these situations:

  • Fractures, dislocations, high-pressure injuries, and amputations require immediate care.

  • Any deep, gaping (open), or dirty cut requires prompt medical care.

  • Wounds due to an animal or human bite (including lacerations from striking a tooth during an assault), because a rapidly progressing infection may occur.

  • Burns: if the skin is disrupted or if the burn goes completely around a finger, hand, or wrist, seek immediate medical care.

How hand injuries are diagnosed?

Upon arriving at the emergency department or clinic, a medical evaluation may include a medical history and physical examination. The doctor may order X-rays after the history and physical exam if warranted. Certain hand injuries will require X-rays to identify fractures or dislocations or to rule out foreign bodies.

Medical history questions include past medical history, hand dominance, mechanism of injury and occupation, extracurricular activities, and hobbies. Physical examination involves visual inspection (look at the injury), sensory nerve exam (feeling), vascular exam (circulation of blood supply), muscular and tendon exam (movement and strength), and bone exam (broken bones or dislocated joints).

What is hand injuries medical treatment?

Lacerations (cuts) medical treatment

  • Evaluation of the depth of involvement of nerves, arteries, muscles, and tendons.

  • Local anaesthesia (numb the area) and wound preparation - cleansing and irrigation, reexamination. Cleaning and removal of dead tissue.

  • Wound repair or closure. Hand wounds that have not been treated six to eight hours after initial injury may not need sutures.

  • Dressing and splinting if necessary to keep the hand from moving.

  • Pain medication and antibiotics. Tetanus shot if indicated.

Internal damage: Lacerations that involve tendons can be treated at a later date with positive results. Therefore, an emergency department doctor may clean and close a hand laceration, then recommend tendon repair to Dr Ricardo at a later date.

Deep cuts: Some injuries require immediate treatment in the emergency department or are surgically repaired. If a large artery is cut, there is the possibility of massive blood loss.

Bites: The main complication of bite wounds is infection. To help prevent infection bites (human bites or animal bites) require thorough cleansing and irrigation (washing out the wound). Puncture wounds (such as cat bites) and wounds where tissue is crushed (such as human bites and dog bites) are particularly likely to become infected. The risk of infection increases when these wounds are stitched closed, so most bite wounds need to be allowed to heal without stitches. Most bite wounds require antibiotics and close follow-up to assure healing.

A common cause of a human bite wound is a fight in which a punch results in a cut on the hand caused by striking the opponent's teeth. When this "fight bite" is over a joint (usually the knuckle), cleaning the joint in the operating room may be necessary. This type of injury may appear minor but can lead to severe infections with significant deformity or disability, even when appropriately treated.

Dislocations and fractures medical treatment

Dislocations are the result of injuries to the ligaments around joints. In a dislocation, a bone is displaced out of its normal position resulting in obvious deformity, pain, and decreased mobility. When a dislocation occurs, the injury will be evaluated to ensure there are no fractures. Dislocated bones must be put back in place. This process is called reduction, which is the realignment of dislocated or broken bones. The reduction can be accomplished by external manipulation of the injured area (closed reduction) or by surgery (open reduction). All require follow-up care after a period of immobilization, usually with a splint or cast. The goal of treatment is to preserve the function and stability of the joint.

Splinting describes any method used to keep the injured hand or finger from moving. Dr Ricardo may place an injured hand or finger against a solid, stiff object but not inside a cast. A cast does not allow for swelling, so the injury may be cast a few days after swelling has decreased. Buddy taping is a procedure where an injured finger is taped to an adjacent finger to keep the injured finger from moving. The other finger becomes a splint.

Fractures (broken bones) of the hand and wrist are fairly common. Most fractures heal well if treated in a timely and appropriate manner. Some injuries may require a series of X-rays over one to two weeks. The small bones and complex structure of the hand make some fractures difficult to detect. The treatment of fractures depends on several factors including the severity of the crack or break, whether joints are involved, the location of the specific bone injured, the amount of deformity (displacement), and if there is a laceration (cut) associated with the fracture.

Children's bones are still growing and so are susceptible to fractures involving the soft areas where the bone growth is occurring (growth plate). Some of these growth plate injuries are difficult to diagnose because they do not show up on X-rays. Injuries near the growth plate areas of a child's hand, therefore, may need to be treated as fractures (breaks) even with normal X-rays.

Fractures and other injuries that require immobilization are often splinted on one side to prevent compression injuries from a cast that covers the entire hand. A splint allows room for the swelling associated with acute injuries, which may prevent the loss of adequate circulation or nerve injury. Splinting does not eliminate the possibility of this complication. Anyone who experiences numbness, colour change, or the feeling of tightness after splint application should return to Dr Ricardo immediately or go to the emergency department.

Soft tissue injuries, amputations, infections, burns, cold and high-pressure injuries medical treatment

Soft tissue injuries and amputations can be devastating to the hand and the patient. Reattaching (replantation) is difficult, and even if successful may, cause long-term complications with pain and infection. Situations, when Dr Ricardo may attempt replantation, are amputation involving a child, thumb amputation, or amputation of multiple fingers or the entire hand.

Always retrieve the amputated body part (if possible). Cover the amputated body part, keep it damp, and place the part near ice to cool. Do not place the body part in direct contact with the ice to prevent freezing.

Crush or tear injuries and prolonged delay before evaluation may make successful replantation impossible. Each injury requires an immediate evaluation because each person's circumstances warrant all possibilities to be considered. The type, location, extent, person's wishes, and time of injury all contribute to the treatment plan. Some injuries will require immediate surgery for replantation. Others will require little medical intervention beyond cleansing, bandaging, and allowing the injury to heal.

Fingertip and nail infections may be treated in the clinic or emergency department with incision and drainage (if indicated), antibiotics, and close follow-up. A major consideration for an infection in the hand is the presence of a fluid collection or an abscess. If the infection is isolated to the skin, known as cellulitis, treatment involves antibiotics and close follow-up. However, an abscess requires drainage (sometimes known as "lancing"). If the abscess is large or near nerves, arteries, ligaments, or tendons surgery may be necessary for treatment. Hand infections have the potential for rapid progression leading to a severe loss of function.

Serious burn injuries to the hand may require a close evaluation. Hospital admission may be required for treatment. Multiple operations including skin grafting may be needed to ensure the best outcome.

First-degree burn: cool burned area with water, not with ice, pain relief, and then reevaluation of depth or degree of burn. Bandage the injured area with antibacterial ointment and follow-up in 48-72 hours.

Second-degree burn: cool burned area with water, not with ice, pain relief, and then reevaluation of depth or degree of burn. Sterile rupture of blisters is recommended by some, but not all health care professionals. Bandage injured area with antibacterial ointment and close follow-up in 48-72 hours.

Third-degree burns and deep second-degree burns: cool burned area with water, not with ice, pain relief, and then reevaluation of depth or degree of burn. Sterile dressings with antibacterial ointment on the injured area. Evaluation and debridement within 24-48 hours of injury (debridement is the process of removing dirt, foreign bodies, and dead tissue from a wound; this procedure could involve washing, scrubbing, and cutting away dead tissue). Some patients, especially those with burns that surround the fingers, hand, or wrist, may be admitted to a hospital burn unit because of the potential to develop compartment syndrome (a condition in which there is swelling and an increase in pressure within a limited space (a compartment) that presses on and compromises blood vessels, nerves, and/or tendons that run through that compartment; and thus may cause the death of all tissue in the compartment and other distal tissue).

Chemical burns: treatment tailored to the type of chemical, most require lots of irrigation with water. Certain exposures require immediate debridement and local wound care.

Electrical burns: local wound care. Evaluation for electrical injury to other organ systems and if severe: IV fluids, cardiac monitoring.

Cold injuries:  rapid rewarming of tissue with warm water (40-42.2 C) for 15-30 minutes. Sterile incision of blisters is usually recommended and ointment plus sterile dressings over the injured area. Relief the pain and consider antibiotic therapy. Local wound care with follow-up in 48-72 hours.

High-pressure injuries: certain injuries will require X-rays. Tetanus booster, broad-spectrum antibiotics, and steroids may be considered. Injuries may require debridement and immobilization.

How is hand injuries follow-up?

After the initial evaluation and treatment, almost all hand injuries will require close follow-up with Dr Ricardo.  Most injuries will need to be checked within one week after the first evaluation and treatment. Some injuries may require a series of office visits or interventions (with tendon lacerations, infections, fractures, second- or third-degree burns) to achieve complete healing while others (simple or shallow cuts, first-degree burns, small fingertip amputations) may only require one or no follow-up visits.

How is hand injuries prevention?

The use of appropriate safety equipment during sports and occupational activities could prevent or limit the extent of fractures, dislocations, cuts, and burns. Normal household safety measures, especially with small children, will also decrease the chances of all injuries, including those to the hands. The key to decreasing the long-term effect of a hand injury is timely medical evaluation and treatment.

What is the prognosis for hand injuries?

Most hand injuries will heal without significant loss of function if evaluated by Dr Ricardo soon after the injury. Almost all hand injuries require a medical evaluation because even the most insignificant hand injuries have the potential for serious or crippling loss of function.

Many factors will play a role in determining how well the injury heals with the least limitation of function, such as type of injury, the severity of the injury; amputations, tissue loss, ligament damage or loss usually have a more guarded outlook, delay of definitive medical evaluation and treatment leads to poorer outcomes and compliance to the treatment plan (keeping appointments, taking medications, and changing dressings as directed, for example) helps to enhance an outcome.

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