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304
ab
cd
Fig. 12.8 (a and b)
Thumb carpometacarpal
arthritis with
accompanying STT
arthritis; arrows point to
the CMC joint
composed of the
trapezium proximally
and metacarpal distally.
Joint space narrowing,
osteophyte formation,
and subchondral
sclerosis are present. (c
and d) The patient
underwent
trapeziectomy and
resection of the proximal
half of the trapezoid to
treat the arthritis in both
joints. Arrows point to
the void left by the
removal of the trapezium
and part of the trapezoid
E. Fakhre and C. M. Henn
joint is treated primarily by trapeziectomy, typically with addition of surgical adjuncts such as
ligament reconstruction, tendon interposition, or
suture suspension. None of these adjuncts have
shown any benet beyond that of trapeziectomy
and a complete trapeziectomy is a key to achieving resolution of symptoms (Fig. 12.8). CMC
fusion can be considered for younger, highly
active patients.
Carpal instability, most often a result of a torn
scapholunate ligament, causes abnormal carpal
motion and loading which can lead to character-
istic patterns of arthritis in the wrist. The most
frequently seen form is the scapholunate
advanced collapse pattern or SLAC wrist. The
sequence begins with a rupture of the scapholunate interosseous ligament causing uncoupling of
the scaphoid and lunate. The scaphoid assumes a
exed posture and rotates within the scaphoid
facet of the radius, which leads to altered loading
and subsequently arthritis in the radioscaphoid
joint initially. This process classically starts in
the radial styloid region (Stage I), then extends to
the entire scaphoid fossa (Stage II), and then to
12 The Hand
305
the midcarpal joint with proximal migration of
the capitate (Stage III) (Fig. 12.9). Eventually
pan-carpal arthritis (Stage IV) develops, though
the radiolunate joint is classically spared, likely
due to the highly congruent lunate and distal
radius. Treatment options depend upon the stage
and include symptomatic treatment initially with
wrist braces, NSAIDs, activity modication, and
steroid injections. After failure of conservative
treatment, Stage II wrists may be treated with
either scaphoid excision and capitate-hamatetriquetral- lunate fusion (four corner fusion) or
proximal row carpectomy, which involves excision of the scaphoid, lunate, and triquetrum.
Stage III can be treated with four corner fusion as
above as well as wrist fusion. Stage IV requires
wrist fusion for symptomatic relief.
Rheumatoid arthritis extensively affects the
hand and wrist. This disease is a systemic inammatory problem affecting nearly all tissues in the
hand including bone, joint, tendon, and vascular
tissues. Despite the advent of disease-modifying
antirheumatic drugs (DMARDs) and the reduc-
tion in the prevalence of severe disease, patients
still often present to a hand surgeon with complaints regarding pain, function, and deformity.
The extensor and exor tendons are often
involved and tenosynovitis, inammation of the
tendon and its sheath, is common. Patients often
present with pain as their chief complaint, but
occasionally patients present with acute loss of
function related to extensor or exor tendon rupture. Other than institution of DMARDs, treatment often includes bracing, NSAIDs and steroid
injections. If pain, swelling, and stiffness persists,
tenosynovectomy may improve symptoms as well
as prevent tendon rupture. The distal radioulnar
joint is frequently involved, which can cause
instability and dorsally prominent distal ulna. The
prominent ulnar head can then abrade the overlying extensor tendons and lead to extensor tendon
rupture(s). This is called a Vaughn–Jackson
Syndrome. Surgical treatment of this problem
includes resection or fusion of the distal ulna with
removal of overlying osteophytes in addition to
reconstruction of the affected tendons.
ab
Fig. 12.9 (a) AP radiograph of the wrist demonstrating a
Stage II SLAC wrist with involvement of the entire
radioscaphoid joint signied by the line arrow. Note that
the cartilage of the capitate is maintained as indicated by
the normal capitolunate joint (designated by the block
arrow). If this joint were involved this would be a Stage III
SLAC wrist. (b) AP radiograph of the same wrist after
treatment with a proximal row carpectomy. After removal
of the scaphoid, lunate, and triquetrum the capitate
migrates proximally to articulate with the lunate facet of
the radius as shown in the radiograph. The capitate is designated by the arrow
306
ab
E. Fakhre and C. M. Henn
Osteophytes on the distal pole of the scaphoid
volarly can cause attritional rupture of the exor
pollicis longus tendon within the carpal tunnel;
this is called a Mannerfelt lesion. The remainder
of the carpus can develop extensive erosions, frequently causing volar and ulnar subluxation of
the carpus on the radius and a radial deviation
deformity of the wrist. The thumb CMC joint
often erodes and dislocates, pushing the thumb
into an adduction deformity. The metacarpophalangeal (MP) joint of the thumb is also frequently
involved. The MP joints of the remaining digits
usually drift into an ulnar deviation deformity,
further compromising hand function. The PIP
joints develop severe synovitis that can lead to
either a boutonnière or swan-neck deformity. The
DIP joints are usually spared (Fig.12.10).
In the early phases of the disease, treatment is
focused on medical management. Accompanying
therapy and splinting can be useful adjuncts for
maintaining strength and slowing the progress of
deformity. As the disease progresses, the individual problems that develop must be addressed.
Rheumatoid destruction of the wrist itself is
usually addressed with a wrist fusion. Wrist arthroplasty is also an option and newer versions have
shown promise as reliable long-term solutions that
maintain some wrist range of motion. The thumb
CMC joint is usually addressed with a trapeziectomy with or without ligament reconstruction. The
MP joint of the thumb is usually fused when necessary, and MP joints of the other digits are either
fused or replaced with Silastic or other implant
arthroplasties. Fusions and replacements are available for the PIP joints, and DIP jointsare typically
fused. Complex and diverse pathology caused by
rheumatoid arthritis requires an experienced hand
surgeon who understands how various interventions and pathologic processes interact in affecting
function, comfort, and deformity.
Nerve Compression Syndromes
Compressive neuropathies of the upper extremity
are common problems that can cause signicant
disability and pain. Carpal tunnel syndrome is by
far the most common of these problems. Carpal
tunnel syndrome is caused by compression of the
median nerve at the wrist underneath the transverse carpal ligament. The hallmark symptoms
include numbness, tingling, and paresthesias in
the median nerve distribution (the thumb, index,
middle and radial half of the ring nger), loss of
dexterity in the hand, and discomfort. Symptoms
are typically worse at night, during prolonged
wrist exion or extension, or gripping for long
periods of time. In more-advanced stages,
patients may develop weakness of the hand and
dropping of objects, pain radiating to the elbow
Fig. 12.10 Rheumatoid arthritis. (a and b) Severe ero-
sive destruction of carpal bones with dorsal dislocation of
distal radioulnar joint. Severe involvement of the MCP
joints and thumb CMC joints. This patient had undergone
a fusion of the right thumb MCP and a silicone arthroplasty of the right small nger MCP
12 The Hand
307
or even the shoulder, or atrophy of the thenar
musculature.
The underlying cause of carpal tunnel syndrome is often unknown in most patients. Patients
with metabolic diseases such as hypothyroidism,
diabetes, and renal failure are at much higher risk
for developing this disease than patients without
these diseases. The relationship of repetitive
motion tasks, especially keyboarding, with carpal
tunnel syndrome is controversial, but most
patients attribute their symptoms to computer or
smartphone use. However, carpal tunnel syndrome was very common prior to the development and widespread use of computers and smart
phones, so a direct causal relationship is unlikely.
Physical examination ndings include a positive Tinel’s sign, in which tapping over the
median nerve at the wrist crease elicits paresthesias inthe median nerve distribution. A positive
Phalen’s sign occurs when symptoms are reproduced by holding maximal exion of the wrist for
a minute or less. The carpal tunnel compression
test is positive if pressure directly over the carpal
tunnel applied by the examiner elicits symptoms
within 30 s or less. Thumb palmar abduction
strength should be tested, and a sensory evaluation should be documented. When patients have
an atypical presentation or physical examination,
an electromyograph (EMG) and a nerve conduction study as well as X-rays can be very helpful to
look for other causes of the patient’s symptoms,
including proximal nerve compression, cervical
radiculopathy, or peripheral neuropathy.
Carpal tunnel syndrome can be treated initially by splinting the wrist in neutral position.
Anti-inammatory medications may also be
helpful if patient’s have acute ares of symptoms.
If this does not help, a corticosteroid injection
into the carpal tunnel gives relief in nearly 80%
of patients with carpal tunnel syndrome, but only
22% of patients will still have symptom relief
1 year following the injection. When conservative measures have failed and the patient has persistent symptoms, surgical release of the
transverse carpal ligament is indicated. This
operation can be done through an open technique
or through an endoscopic technique. Overall
results are excellent with both methods.
Cubital tunnel syndrome, or compression of
the ulnar nerve at the elbow, is the second-most
common compressive neuropathy. Patients present with numbness and tingling in the small nger
and the ulnar half of the ring nger and frequently
complain of medial elbow pain. Symptoms are
often worse at night or after long periods in which
the elbow has been exed. Physical examination
ndings include a positive Tinel’s sign over the
ulnar nerve behind the medial epicondyle, a positive elbow exion test in which full exion of the
elbow for more than 30seconds reproduces symptoms, and in some cases subluxation of the ulnar
nerve over the medial epicondyle when exing
the elbow. There is often decreased sensation in
an ulnar nerve distribution in the ring and small
ngers. In advanced cases, weakness to nger
abduction or even intrinsic atrophy can be present. Froment’s test, in which the patient is asked
to pinch a card between the thumb and index nger, is positive when the patient either cannot
strongly pinch the card or collapses into a exed
IP joint position and hyperextended MP joint
position of the thumb (Fig.12.11). The main differential diagnosis includes cervical radiculopathy, thoracic outlet syndrome (i.e., brachial plexus
compression in the region from the scalenes to the
clavicle), and ulnar nerve compression at the
Fig. 12.11 Clinical photograph demonstrating Froment’s
test. Weakness with thumb adduction leads to exion of
the thumb when trying to grip. The right thumb is the
affected thumb in this case while the left demonstrates
normal ulnar nerve function
308
E. Fakhre and C. M. Henn
wrist. An EMG and nerve conduction study can
be helpful to differentiate between these sites, but
these are often negative even in moderately
advanced stages of cubital tunnel syndrome.
Treatment usually starts with extension splinting,
activity modication, and anti-inammatory
medication. If symptoms do not resolve with conservative management or patients develop constant numbness or signicant atrophy, operative
treatment is indicated. Surgical options primarily
include in situ ulnar nerve decompression versus
decompression with nerve transposition.
Outcomes are equivalent between the two techniques; however, a subluxating ulnar nerve on
preoperative examination would be an indication
to perform transposition.
Tendon Disorders
Stenosing tenosynovitis is the most common
acquired tendon disorder affecting the hand and
wrist. As the name implies, the underlying
pathology is characterized by narrowing of the
tunnel the tendons normally glide through,
which then leads to inammation and thickening
of the tendon and its sheath. The inammation
and thickening then exacerbates the mismatch in
size of the tendon and the tunnel it glides
through. Once the tendon cannot glide smoothly
within the sheath, the patient then experiences
frank catching, or triggering, of the tendon as it
passes through its retinacular housing. As the
disorder worsens, then the patient cannot pull the
tendon through its tunnel, which leads to exion
contractures and/or inability to fully extend the
digit. The underlying etiology is frequently
unknown but diabetes and renal failure are associated with these disorders. Occasionally there is
an inciting event, such as trauma or overuse, that
can create initial swelling of the tendon or its
sheath. This can then initiate a viscous cycle of
the swelling causing a mismatch in size of the
tendon and its tunnel leading to more tendon
inammation and swelling, resulting in worsening of the mismatch.
The most common of these tendon disorders is
trigger nger, in which the exor tendons of the
ngers or thumb become entrapped underneath
the A-1 pulley of the exor tendon sheath.
Patients initially develop pain over the A1 pulley,
which can then progress to triggering of the digit
with exion and extension. As the disorder progresses, patient can then experience locking of
the nger in full exion, necessitating manual
passive extension of the digit, which is often
associated with a palpable pop as the nger fully
extends. The problem is typically worse in the
morning, as swelling in the hand from lack of
movement overnight can exacerbate the problem.
Then as the day progresses and swelling subsides, the problem and symptoms improve.
Patients will often be able to demonstrate the
triggering and nearly all will exhibit tenderness
over the A1 pulley. Initial treatment with corticosteroid injections has very high success rates, and
often leads to permanent resolution of the problem. If symptoms recur or do not resolve, a surgical release of the A-1 pulley is indicated, which
also has a very high success rate. Prompt recognition and treatment of this disorder prevents the
primary complication from it, which would be
the development of stiffness in the interphalangeal joints as a result of untreated trigger nger.
Another very common stenosing tenosynovitis is de Quervain’s tenosynovitis, in which the
abductor pollicis longus and extensor pollicis
brevis tendons become constricted under the
extensor retinaculum at the rst dorsal compartment of the wrist. Patients with this disorder can
often develop signicant pain over the rst dorsal
compartment at the radial styloid and can reliably
point directly at the rst dorsal compartment as
the source of the problem. The etiology is also
often unclear, but this disorder is particularly
prevalent in new mothers, and especially nursing
mothers. Triggering or locking is much less common in de Quervain’s than in trigger nger.
Hallmark physical ndings are signicant tenderness over the rst dorsal compartment at the
radial styloid and lack of tenderness over the
remainder of the wrist or thumb. Finkelstein’sor
Eichoff’s test can be used to conrm the diagnosis and involves forcefully maneuvering the
patient’s thumb and wrist into adduction and
ulnar deviation, respectively (Fig.12.12). A posi-
12 The Hand
Fig. 12.12 Clinical photograph demonstrating Eichoff’s
test involving wrapping the digits around the thumb and
forceful ulnar deviation of the wrist. A positive test is pain
at the radial aspect of the wrist in the area of the rst dorsal compartment indicating Dequervain’s tenosynovitis
tive test reproduces the patient’s pain. Treatment
of de Quervain’s tenosynovitis begins with nonsteroidal anti-inammatory medications, bracing
(which must include the thumb and wrist),
and corticosteroid injections. If pain persists or
recurs, surgical release of the rst dorsal compartment reliably resolves the pain.
Tenosynovitis can also develop in other less
common locations in the wrist, including the
exor carpi radialis (FCR), extensor carpi ulnaris (ECU), and extensor pollicis longus (EPL).
Intersection syndrome is stenosing tenosynovitis
of the second dorsal compartment tendons, the
extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL), where the rst
dorsal compartment musculature crosses over
them ve centimeters proximal to the radiocarpal joint. Treatment of these conditions proceeds
in a similar fashion to that of de Quervain’s
tenosynovitis.
Dupuytren’s Contracture
Dupuytren’s contracture is characterized by the
gradual development of typically painless nodules and cords in the palm and digitsthat can then
prevent full digital extension. It is a disease of the
palmar fascia, which normally serves to tether
the palmar skin to the underlying skeleton, facili-
309
tating grasp. As the disease progresses the normal
fascial bands become thickened nodules and
cords, which pull the digits into exion and cause
web space narrowing. The diseased tissue can
also pathologically tether the skin, leading to visible pits, which are pathognomonic of
Dupuytren’s contracture. As the disease progress,
the contractures can lead to signicant functional
impairment, including making glove wear impossible or preventing the patient from putting their
hand in a pocket. The disease can affect one or
both hands and can also involve thickening of the
plantar fascia in the foot and/or of the fascia of
the penis, which is called Peyronie’s Disease.
The underlying etiology is not known, but the
disease is particularly common in older men of
Celtic and Scandinavian origins, suggesting a
hereditary component to the process, but disease
severity within families is variable.
Surgical excision of the diseased tissue does
not prevent development of further disease either
in the same digit or other digits, and conservative
treatment, including therapy and splinting, has
not been shown to alter disease progression.
Therefore, the treatment of Dupuytren’s contracture is aimed at correcting functionally limiting
contractures. Patients typically present initially
with minimal or no contracture, so initial treatment is often reassurance and observation. As
contractures worsen, though, there are three main
treatment options to correct the contracture.
Needle aponeurotomy is a procedure to percutaneously cut the specic cord causing the contracture, and can be an excellent, minimally invasive
option, especially in very prominent cords in the
palm. Clostridial collagenase is an enzyme that
breaks down the diseased tissue and can be
injected into the specic areas of maximal disease. 24–48h after the injection a manipulation is
then performed to manually disrupt the cord and
passively extend the digit. Perhaps the most
denitive treatment is surgical excision of the
diseased tissue (Fig.12.13). All three treatment
options have advantages and disadvantages, and
the decision of which procedure to use depends
on many factors, including surgeon and patient
preference, the location and severity of disease,
and previous treatment successes or failures. No
310
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c d
E. Fakhre and C. M. Henn
Fig. 12.13 (a and b) Dupuytren’s contracture.
Preoperative photographs of signicant Dupuytren’s contracture with a prominent pretendinous cord causing a
signicant exion contracture of the middle nger. (c)
treatment, though, can fully eradicate the disease
and patients often require multiple treatments
throughout their lives.
Intraoperative photograph following excision of the cord,
allowing full passive extension. (d) 6 weeks postoperatively demonstrating full active extension
(the radius is longer than the ulna) may be more
likely to get the disease, leading to the theory that
altered loading on the lunate leads to osteonecrosis. Early in the disease, radiographs are normal,
but an MRI clearly shows the abnormality in the
Kienböck’s Disease
lunate (Fig.12.14). As the disease progresses, it
can be diagnosed with plain radiographs, which
Kienbock’s disease is idiopathic osteonecrosis of
the lunate. As the osteonecrosis progresses, the
lunate collapses and fragments, often leading to
collapse of the carpus and wrist arthritis. Patients
experience pain, which can be severe, loss of
wrist range of motion and weakness. The disease
most commonly occurs in the second through
fourth decades of life. The underlying etiology is
unclear, but patients with ulnar negative variance
will show a sclerotic lunate with or without fragmentation, collapse, or arthritis. Initial treatment
is typically conservative, including immobilization with either a brace or cast, antiinammatories, and activity modication.
Optimal surgical treatment is debatable, but
potential surgical treatments are determined by
the presence or absence of carpal collapse and the
relative ulnar variance. In patients with ulnar
12 The Hand
311
Fig. 12.14 Kienbock’s
Disease (a) PA
radiograph showing
subtle sclerosis of the
lunate. The arrow points
to the area of sclerosis
(increased density or
“whiteness”) in the
lunate. (b) Coronal MRI
scan of the same wrist
showing obvious
avascular necrosis of the
lunate. This is
designated by the arrow
pointing at the lunate
which appears
hypointense or “dark”
on T1 sequence MRI
a
negative variance and early disease, radial shortening osteotomy is often performed in an attempt
to alter the loading on the lunate and perhaps prevent progression of the disease. Other options for
early disease include drilling of the radius (distal
radial core decompression) or vascularized bone
grafting to the lunate. Once carpal collapse and/
or wrist arthritis has developed salvage surgical
options include intercarpal fusion, proximal row
carpectomy, and, in the case of pan-carpal arthritis, total wrist fusion.
Infection
The hand is relatively resistant to infection
because of its robust blood supply. However,
hand infections are relatively common due to its
frequent exposure to trauma, particularly lacerations, open fractures, puncture wounds, foreign
body penetration, and paronychial or cuticle injuries. Hand infections can also become severe,
particularly in diabetics and immunocompromised patients, necessitating intravenous antibiotics and often surgical drainage.
Hand cellulitis involves infection of the subcutaneous tissue in the hand without development of a deep space infection or abscess. It
typically develops after an often innocuous skin
injury to the hand. Patients will exhibit classic
signs of cellulitis with erythema, impressive
b
swelling throughout the hand, and occasionally
streaking erythema up the forearm. Treatment
involves prompt administration of antibiotics,
splinting, and elevation. Localized cellulitis in
immunocompetent hosts typically responds to
oral antibiotics. Advanced cellulitis, spreading
erythema up the arm, immunocompromised
hosts, orfailed oral antibiotics all require admission, IV antibiotics, and close observation to rule
out the development of a deep space infection.
Perhaps the most common infection in the
hand is a paronychia, which is an infection that
affects the soft tissues overlying the proximal
nail fold or the lateral edges of the nail. It is usually caused by Staphylococcus and presents as
red, painful swelling overlying the nail fold. Mild
cases in immunocompetent hosts typically
resolve with warm water soaks with or without
oral antibiotics. In more-advanced stages, and
especially when purulence is visible, surgical
drainage is required. This is typically done in the
emergency department, urgent care or the ofce,
and a subsequent course of oral antibiotics
resolves the infection.
A felon is an infection of the pulp of the ngertip. Due to the many brous septae that connect the skin to the underlying skeleton in the
nger pulp, infections generally create abscesses
in the nger pulp. Patients present with a very
swollen, tense, and painful nger pulp
(Fig.12.15). Treatment is prompt surgical drain-
312
a b
Fig. 12.15 (a and b) Clinical photograph of a 10-year-old patient with a felon
E. Fakhre and C. M. Henn
age of the abscess, which must include releasing
all of the septae to fully drain the infection. Oral
or IV antibiotics then supplement surgical drainage in clearing the infection. Delay in surgical
drainage and/or antibiotics, especially in immunocompromised patients, leads to local spread of
the infection to the adjacent distal phalanx, exor
tendon sheath, and/or distal interphalangeal joint.
Infection within the exor tendon sheath is
called purulent or septic exor tenosynovitis.
This is an extremely serious infection that can
result in amputation if not treated emergently and
aggressively. Infection typically is the result of a
penetrating injury to the volar digit, inoculating
bacteria directly into the tendon sheath. The bacteria can then proliferate within the tendon sheath
unchecked by the body’s immune system due to
lack of blood supply within the sheath. As the
infection worsens, the tendons can become ischemic and rupture. If left untreated, it can also lead
directly to digital ischemia and/or spread into the
thenar space, the palmar space, or even the carpal
tunnel, causing a more severe and widespread
infection. The four classic physical exam ndings in patients with exor sheath infections are
called Kanavel’s signs (Fig.12.16). They include
fusiform swelling of the digit, severe tenderness
Kanavel’s Signs
Fusiform swelling of the digit
Tenderness along the flexor tendon sheath
Digit held in slight flexion
Pain with passive extension
Fig. 12.16 Table of the Four Kanavel’s Signs for diagnosis of exor tenosynovitis
over the exor tendon sheath, semi-exed posture of the digit, and severe pain with passive
extension of the digit. The more of these signs the
patient exbibits, the more likely a exor sheath
infection is present. Treatment of this problem
includes urgent surgical drainage of the exor
tendon sheath and culture-directed prolonged IV
followed by oral antibiotics.
Septic arthritis in the IP and MCP joints also
typically arises from direct inoculation from penetrating injuries. Treatment is prompt surgical
drainage and prolonged IV antibiotics in order to
preserve the articular cartilage, which is rapidly
destroyed in the setting of infection. Infections
caused by penetration of a human tooth, such as
when a patient punches another person in the
mouth, deserve special attention. These injuries,
12 The Hand
313
termed clenched-st injuries lead to direct inoculation of the MCP joint with human mouth ora
and subsequent immediate closure of the wound
to the outside air when the patient extends the
digit. An abscess within the joint then rapidly
develops and can cause extensive damage to the
joint. As a result, these wounds should be urgently
surgically opened and drained, and the joint
should be left open to allow continued drainage.
Prolonged IV antibiotics are then often required
and should cover Eikenella corrodens, a common
pathogen found in the human mouth.
Dog and cat bite wounds can also cause signicant hand infections including septic exor
tenosynovitis and septic arthritis. Appropriate
debridement should be performed when necessary and antibiotics should cover Pasteurella
multocida, a pathogen commonly found in these
infections. Infections to the hand and wrist from
fungi, mycobacteria, and other atypical ora are
relatively rare, but should considered in subacute
cases, cases that do not respond appropriately to
routine surgical and medical treatment, and in
immunocompromised patients. A history of
exposure to soil, rose thorn injury, birds, shellsh, or seawater should also raise the clinician’s
suspicion of an atypical infection. These infections often require multiple extensive surgical
debridements and long periods of antibiotic
therapy.
Trauma
The hand is often the human body’s primary and
initial contact point with the environment and
thus subject to high rates of traumatic injuries.
These injuries may include soft tissue injuries,
involving the skin, subcutaneous tissue, tendons,
and neurovascular structures; or they may include
isolated bone or joint injuries; or a combination
of any and all of these structures. They range
from very minor injuries that recover to normal
function with or without treatment, to devastating
mangling injuries, to traumatic amputation.
Many traumatic hand injuries require urgent hand
surgical treatment to optimize functional outcome of the hand, and so basic knowledge of
hand injuries and their treatment are important
for all physicians.
Lacerations
Large, complex lacerations, crush injuries, and
penetrating injuries with obvious tendon, bone,
or neurovascular injury require emergent hand
surgical evaluation and treatment. Simple, isolated lacerations, though, generally can be evaluated and initially or denitively treated in the
emergency room or urgent care. Direct exploration or probing of these wounds is not necessary
but noting obvious tendon injury in the wound
prior to closure can be helpful. A thorough physical exam of the digit before or after closure can
often reliably identify complete injury to the tendons or nerves. Pain with resisted tendon function
or any numbness should raise suspicion that a
partial tendon or nerve injury exists, and surgical
exploration should be recommended to assess the
extent of the presumed partial injury. Capillary
rell should be checked to insure maintenance of
blood supply to the digit. A pale digit without
capillary rell requires emergent hand surgical
evaluation and revascularization. Radiographs
should be obtained in all cases to ensure that no
fracture or residual foreign body is present.
Appropriate tetanus and antibiotic coverage
should be instituted.
If the decision is made to take a wound to the
operating room urgently due to gross contamination, vascular compromise, or severity of the
injury, the wound can be irrigated, dressed, and
splinted to await passage to surgery. If the external wound is minor, but the patient has an obvious tendon or nerve injury that will require repair,
a loose closure can be performed in the emergency room. Splinting is usually initiated, and the
patient can follow-up with the hand surgeon on
an elective basis. Minor lacerations that are clean
and do not have deep tissue involvement should
be denitively closed and dressed in the emergency room. It is important to recognize, though,
that even very small lacerations or puncture
wounds can disrupt tendons and/or nerves and
lead to permanent hand or nger disfunction if