Hand and Wrist Injuries Management

Assessment Refresher

• Physical assessment includes:
  • Look: bruises, bleeding, swelling, deformity
  • Feel: bony tenderness, crepitus, sensation
  • Move: passive, active, resisted
• Special tests include:
  • Hand Examination
  • Tinnels Test and Phalens Test for Carpal Tunnel Syndrome

Common Hand Injuries

FOOSH Injuries

• Scaphoid Fracture:
  • Often not seen on initial x-ray
  • Can be very subtle, minimal swelling and bruising
  • Mechanism and physical examination are key
  • Pain at the anatomical snuffbox
• Colles Fracture:
  • Common FOOSH injury
  • Usually extra articular
  • Impaction of distal radius with dorsal angulation
• Smith's Fracture:
  • Caused by a direct blow
  • Note the volar angulation

Other Hand Injuries

• Boxer's Fracture:
  • Axial loading of the 5th Metacarpal
  • 95% young males
  • Direct blow with a solid surface
• Bennet's Fracture:
  • Caused by forced abduction of the thumb
  • Intra articular fracture
  • Stable non-displaced fractures can be placed in a thumb spica
• Proximal Phalanx Fracture:
  • The most common paediatric hand fracture
  • Caused by forced rotation, hyperextension, or direct trauma
  • Assess for scissoring and numbness
• Tuft Fracture:
  • Due to crush injury
  • Usually stable
  • Can be managed by splinting at the DIPJ
  • Complication: loss of sensation, up to 6 months
• Mallet Finger:
  • No information provided
• Finger Dislocations:
  • Requires reduction
  • Assess collateral ligaments post-reduction
  • Elson's Test can be considered but is complex
• Boutonniere Deformity:
  • Caused by cut to central slip at its attachment to the bone or direct blow to the dorsal aspect of the hand
  • PIPJ bent toward palm, DIPJ is bent back away (hyperextension)
  • May develop up to 3 weeks post-injury

Tendonitis and Sprains

• Thumb Tendonitis:
  • De Quervain's tenosynovitis
  • Active and Resisted Pain on Extension
  • Finklestein Test
• Sprains:
  • Pain on Resisted/Active Movement
  • Absence of Fracture/Bony Tenderness
  • Usually caused by hyper-extension or direct trauma to the area
  • May present or reoccur

Management of Hand and Wrist Injuries

• Fracture Rules:
  • No Ottawa or equivalent for the wrist that are widely used
  • Typically, wrist fractures are overt and follow the pattern of injury
• Sprains: What to Exclude
  • Fracture or dislocation
  • Damage to nerves or circulation
  • Wound penetrating the joint or known bleeding disorder
  • Serious complication such as haemarthrosis or septic arthritis
  • Tendon rupture
  • Complete tear or tear of more than half the muscle belly
  • Large intramuscular haematoma
• Sprains: Standard Soft Tissue Advice
  • P - Protection
  • R - Rest
  • I - Ice
  • C - Compression
  • E - Elevation
• Pharmaceutical Management:
  • Analgesia (Paracetamol, Cocodamol 8/500 OTC)
  • NSAID (Caution over use in 48-hour post-injury, Caution in Elderly, Topical vs Oral, Prescription vs OTC)
• Excersises:
  • Return to normal function as pain allows
  • Consider simple strength building exercises after function returns
• Splinting:
  • Appropriate for most finger injuries/tendon fracture etc
  • Must include circulation check
  • No circumferential taping
  • Give the patient supplies!