EMERGENCY DEPARTMENT EVALUATION AND TREATMENT OF HAND INJURIES

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Venous and Lymphatic Systems

Venous and lymphatic drainage is much more extensive in the subcutaneous dorsal aspect of the hand and fingers. This vascular anatomy, coupled with the laxity of the dorsal skin, contribute to increased swelling and edema on the dorsum of the hand. This is seen even in the presence of palmar infections.

Skin Cover

The dorsal and palmar skin surfaces have different characteristics because they have different functions. The dorsal skin is thin and freely mobile, allowing an extensive range of motion at all

PHALANGEAL AND METACARPAL FRACTURES

Fractures of the hand are the commonest fractures in the body, and roentgenographic evaluation of significant hand injuries is mandatory.2, 21 Specific classification of fractures is often unwieldy and unnecessary. Understanding the potential complications and identifying fractures that may require surgical fixation are both of primary importance in managing hand fractures.

This section focuses on appropriate hand fracture treatment in the emergency department (ED) to include proper splinting,

GAMEKEEPER'S THUMB

The term, gamekeeper's thumb, is generally used for any acute or chronic injury to the thumb ulnar collateral ligament (UCL). It arose from a report of Scottish gamekeepers who had injuries to their ulnar collateral ligaments while breaking the necks of wounded hares, although the article described a chronic laxity rather than acute injury.20 Most of these injuries today are sustained acutely from ski-pole and football injuries because the ligament is damaged by forced extension and abduction

TENDON INJURIES

Tendon injuries to the hand are frequently seen by the practicing emergency physician and require special attention to prevent long-term sequelae. Careful examination of specific tendon function helps to detect these sometimes subtle injuries, but this requires knowledge of the anatomy of the various tendons as they traverse the wrist and hand (see Anatomy section).

To assess for tendon involvement properly, the examiner should first ascertain the position of the hand during the injury, time of

HAND INFECTIONS

The hand is at risk for varying degrees of penetrating trauma because of its inherent role and function. This makes the hand a common site for infection, and because of its unique anatomy, the hand manifests different presentations of these infections.

NAILBED INJURIES

Trauma to the fingertip often results in injuries of the distal phalanx, nail plate, and underlying nail bed. The nail plate is produced by the germinal matrix as well as the entire nail bed and takes approximately 3 to 4 months to regenerate when injured or avulsed (Fig. 20, nailbed anatomy). Significant subungal hematomas are often associated with underlying nail bed lacerations, although their treatment is controversial (Fig. 21). Traditional hand literature supports removing the nail plate

NERVE INJURIES OF THE HAND

Sensation is provided to the hand by the median, radial, and ulnar nerves. Sensation of the median nerve is best by tested at the volar tip of the index finger. Radial nerve sensation is best tested at the dorsal first web space, and ulnar sensation is best tested by at the volar tip of the little finger.

Comparative two-point discrimination is the most accurate assessment of sensation. Intact digital nerves should be able to distinguish points 2 mm to 5 mm apart at the fingertips and 7 mm to 12

HIGH-PRESSURE INJECTION INJURIES TO THE HAND

The development of high-pressure injection guns and their increasing use in the work place and at home have increased both productivity as a society as well as injury to individual members. Specifically, the use of high-pressure injection grease guns and paint guns have caused an increased number of high-compression injection hand injuries. Three main factors affect the severity of the injury: the pounds per square inch of force, the specific agent injected, and time to seeking treatment.

The

CONCLUSION

Human hands are composed of a complex anatomy that works in precision to allow us to perform everyday tasks efficiently and flexibly. This article focuses on some of the injuries and infections that patients commonly present with to the ED or primary care setting. Although the topics are not all inclusive, it is hoped that this review provides a systematic and logical approach for evaluation and management of hand emergencies. The successful management of hand emergencies rests with the

ACKNOWLEDGMENT

The authors extend their appreciation for the significant time and effort put forth by Lyn D. Ward, MD, as the medical illustrator of this article.

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