Hand Injuries

Picture of the bones in the hand

• 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.
• Most hand injuries will heal without significant loss of function if evaluated by a doctor soon after the injury.

Hand injuries can be divided into six general categories:

1. lacerations (cuts),
2. fractures and dislocations,
3. soft tissue injuries and amputations,
4. infections,
5. burns, and
6. high-pressure injuries (grease and paint guns).

Other common hand injuries include

• nail injuries,
• finger injuries,
• finger infection,
• wrist injuries, and
• broken hand.

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

Common symptoms of hand injuries

Lacerations

• Tenderness (pain)
• Bleeding
• Numbness
• Decrease range of motion (difficulty moving)
• Weakness
• Pallor (pale or bloodless)

Fractures and dislocations

• Tenderness
• Deformity
• Swelling and discoloration
• Decrease range of motion
• Numbness
• Weakness
• Bleeding

Soft tissue injuries and amputations

• Tenderness
• Deformity (with or without tissue and bone loss)
• Swelling and discoloration
• Bleeding
• Weakness
• Numbness

Infections

• Tenderness
• Local warmth
• Redness
• Swelling
• Fever (rare in hand infections)
• Deformity
• Decrease range of motion

Burns

• Tenderness or complete numbness
• Deformity
• Discoloration
• Loss of tissue
• Change in texture of the skin
• Redness
• Blistering
• Black areas of tissue

High-pressure injuries

• Pain
• Swelling
• Occasional skin discoloration

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
• 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.

Upon arriving at the emergency department or clinic, the medical evaluation may include a medical history and physical examination.

Medical history questions

• Past medical history (Does the patient have diabetes or arthritis? Does the patient smoke?)
• Hand dominance (Is the patient right or left-handed?)
• Occupation, extracurricular activities, and hobbies (How does the patient use their hands?)
• Mechanism of injury (How did the injury occur?)

Physical examination

• Visual inspection (look at the injury)
• Sensory nerve exam (feeling)
• Vascular exam (circulation of blood supply)
• Muscular and tendon exam (movement and strength)
• Bone exam (broken bones or dislocated joints)

Tests

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.

After a thorough evaluation, the diagnosis usually falls within one of these common injury categories.

• Lacerations
• Fractures and dislocations
• Soft tissue injuries and amputations
• Infections
• Burns
• Thermal burns
  • First-degree burn: Superficial, involvement of the outermost layer of skin, characterized by pain, redness, swelling
  • Second-degree burn: Partial skin thickness, characterized by blistering
  • Third-degree burn: Extends completely through all skin layers, characterized by a lack of pain and sensation
• Chemical burns
• Electric burns
• Cold injury or frostbite
• Foreign body
• High-pressure infusion (grease gun, paint gun)

Home care for hand injuries initially involves proper first aid techniques. In most cases, serious hand injuries will require medical attention.

Lacerations (cuts)

• Apply pressure to the wound to stop bleeding.
• If possible, wash dirt or debris from the wound.
• Cover the wound to prevent further contamination or injury.
• Do not remove large foreign bodies such as nails, hooks, or knives.
• Seek medical attention.

Fractures (broken bone) and dislocations

• Immobilize or splint the hand, if possible.
• Cover the injury if bone is exposed (open fracture), with a clean towel, cloth, or gauze.
• Ice may help decrease the pain, but never apply ice for more than 20 minutes at one time, and never apply ice directly to skin.
• Seek medical attention.

Soft tissue injuries and amputations

• Apply pressure to stop bleeding.
• Cover the injury with a damp bandage, if possible.
• Elevate the hand above the heart to reduce bleeding.
• Retrieve the amputated body part (if possible). If possible, cover the amputated body part, keep it damp, and place the part (for example, finger or thumb) near ice to cool. Do not place body part in direct contact with ice in order to prevent freezing.
• Seek medical attention.

Infections

• Keep the injury clean and dry.
• Seek medical attention.

Burns

• Thermal (heat) burn: Cool with water, not ice, and then cover the injury.
• Chemical burn: Irrigate with lots of water, then cover the injury.
• Frostbite: Rewarm with warm-water bath or soak, then cover the injury.
• Seek medical attention.

A general sequence of treatment for hand injuries is listed for each type of injury. Many types of injuries can lead to compartment syndrome.

• Compartment syndrome is 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.
• Although each digit has eight compartments, the syndrome rarely occurs in the hands but should be kept in mind as a possible complication of a hand injury.

Lacerations (cuts)

• Evaluation of the depth of involvement of nerves, arteries, muscles, and tendons
• Local anesthesia (numb the area)
• Wound preparation - cleansing and irrigation, reexamination
• Cleaning and removal of dead tissue
• Wound repair or closure
• Dressing and splinting if necessary to keep the hand from moving
• Pain medication
• Antibiotics, particularly for bite and puncture wounds (often a judgment call by the treating doctor)
• Tetanus shot if indicated
• Hand wounds that have not been treated six to eight hours after initial injury may not need sutures. Many health care professionals leave these wounds open since they are sutured (closed) they are more prone to infection.

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

Deep cuts: Some injuries require immediate treatment in the emergency department or are surgically repaired. When an injury to an artery is diagnosed, a surgeon must evaluate for immediate surgical repair. If a large artery is cut, there is the possibility of massive blood loss. Death may result if bleeding is not controlled.

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. The doctor may decide to loosely stitch large bite wounds. 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. Consulting an orthopedic hand surgeon promptly about such bite wounds may benefit the patient.

Some hand lacerations are self-inflicted. After wound treatment, these patients should be referred to a psychiatric specialist.

Dislocations and fractures

Dislocations

• Evaluation to determine the extent of the injury
• Pain relief
• X-ray to rule out fracture and further define an injury
• Local anesthesia
• If there is no fracture or associated laceration, reduction to put the bone back in place is attempted; reduced reduction of bones is painful, so some patients will require pain medication for the procedure.
• Reexamination of the injury
• Immobilization by splinting or budding taping
• X-ray for confirmation of correct alignment
• Follow-up with hand surgeon or orthopedist, usually within 24-48 hours.

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 doctor will evaluate the injury 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. The doctor may place an injured hand or finger against a solid, stiff object but not inside a cast. With a splint, the injured area is immobilized yet still has room to swell. 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 the doctor tapes an injured finger to an adjacent finger to keep the injured finger from moving. The other finger becomes a splint.

Fractures (broken bone)

• Evaluation to determine the extent of the injury
• Pain relief
• X-ray
• Referral for operative repair or acute reduction; some patients will require conscious sedation (anesthesia technique where the patient is not fully sedated but does not require ventilation assistance).
• Referral for failed/inadequate reduction
• Reexamination
• Immobilization by splinting or budding taping
• X-ray for confirmation of correct alignment
• Follow-up with primary care doctor or hand specialist for severe or complicated fractures

Fractures 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. Some doctors will X-ray the opposite uninjured hand to compare with the injured hand to assist with visualizing growth plate fractures or disruptions.

Treatment of a recent fracture rarely includes an enclosed cast. 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, color change, or the feeling of tightness after splint application should return to the doctor immediately or go to the emergency department.

Soft tissue injuries and amputations

• Stabilize the injured person first, and then if possible, preserve the amputated body part.
• Evaluate to determine the extent of the injury
• Pain relief
• X-ray to confirm or rule out fracture and further define the scope of the injury
• Referral to a hand surgeon for repair

These injuries 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 a surgeon may attempt replantation, are amputation involving a child, thumb amputation, or amputation of multiple fingers or the entire hand.

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. In some locations, the doctors and facilities needed for replantation do not exist.

Infections

• X-ray if indicated (especially if gas gangrene is expected)
• Referral to a hand specialist if needed for extensive cleaning of the wound
• Antibiotics for bacterial infection of the tissue; antifungals for fungal infections

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 an evaluation by a hand or burn surgeon. Hospital admission may be required for treatment. Multiple operations including skin grafting may be needed in order to ensure the best outcome.

First-degree burn

• Cool burned area with water, not ice
• Pain relief
• Reevaluation of depth or degree of burn
• Bandage the injured area with antibacterial ointment
• Follow-up in 48-72 hours

Second-degree burn

• Cool burned area with water, not ice
• Pain relief
• 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
• Close follow-up in 48-72 hours

Third-degree burns and deep second-degree burns

• Cool with saline or water, not ice
• Pain relief
• Reevaluation of depth or degree of burn
• Use Sterile dressings with antibacterial ointment on the injured area
• Referral to a doctor skilled in burn treatment for 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 of dead tissue). Some patients, especially those with burns that completely surround the fingers, hand, or wrist, may be admitted to a hospital burn unit because of the potential to develop compartment syndrome.

Chemical burns

• Treatment tailored to the type of chemical, most require lots of irrigation with water
• Certain exposures require immediate debridement. In some burns, water is not used because it further damages the skin, other exposures require systemic treatments so a specialist in burns is good to consult; in addition, the poison control center (1-800-222-1222) can help decide what special emergency treatments may help with certain patients.
• Local wound care

Electrical burns

• Local wound care
• Evaluation for electrical injury to other organ systems
• If severe: IV fluids, cardiac monitoring

Cold injuries

• Rapid rewarming of tissue with warm water (104-08 F or 40-42.2 C) for 15-30 minutes
• Sterile incision of blisters is usually recommended
• Ointment plus sterile dressings over the injured area
• Pain relief
• Consideration for antibiotics
• Local wound care with follow-up in 48-72 hours

High-pressure injuries

• X-rays
• Tetanus booster
• Broad-spectrum antibiotics
• Splint
• Steroids may be considered
• Consult a hand specialist immediately as debridement may be required

• 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.

Most hand injuries will heal without significant loss of function if evaluated by a doctor 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.

• Type of injury
• The severity of 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
• Compliance with treatment plan (keeping appointments, taking medications, and changing dressings as directed, for example) helps to enhance an outcome

After the initial evaluation and treatment, almost all hand injuries will require close follow-up with a hand specialist and a primary care doctor.

• 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.