Triquetral small flake # best seen on the lateral Hyperextension of the wrist. Full function usually restored Futura splint or POP for pain relief Discharge with patient info leaflet or Fracture clinic if given POP Lunate dislocation Fall on outstretched hand High speed RTC (e.g. motorbike) May be missed. Suspect when significant swelling but no fracture seen at first. Splint or POP for pain relief Immediate referral to ortho - needs reduction and internal fixation 1st Metacarpal Base – Bennett’s # May extend into the joint Longitudinal blow – e.g. boxing or forced abduction Often unstable if joint involved and may require fixation POP if no joint extension. Ensure adequate position and no extension into joint with a check X-Ray in cast Next available hand clinic Refer immediately if extends into joint or displaced Ulnar collateral ligament (Gamekeeper’s/ Skier’s thumb) Forcible abduction Suspect if tender in this region. Test for abnormal ‘give’ on stressing the UCL. Significant permanent disability possible if missed Scaphoid backslab (not elastoplast spica) If avulsion on XR or obvious laxity then refer immediately Refer to hand clinic if less clear at presentation 5th Metacarpal neck (Boxer’s #) Punch injury Tooth injury (Fight Bite) 1. Closed - angulation up to 400 is acceptable. Buddy strap and analgesia 2. Open/bite injury –Washout. antibiotics and buddy strap 1. Discharge with patient info leaflet 2. Immediate referral to ortho 5th MC shaft MC shaft POP Hand clinic Other metacarpals Common at all ages from a blow to the hand May cause shortening & Rotation If involving the base of metacarpal obtain true lateral to assess posterior displacement 1. Position acceptable –buddy strap for comfort and encourage early mobilisation. 2. Some displacement or on-going discomfort – POP e.g. ulnar gutter with MCPJs at 90o and interphalangeal joints extended 3.If severe displacement or rotation – buddy strap 1. Fracture clinic 2. Next available hand clinic Immediate referral to ortho Phalanges – proximal & middle phalanx Often simple & undisplaced Occasionally angulated – tends to increase due to intrinsic muscle pull. Beware rotational deformity If >10o angulation correct under ring block. # usually stable in flexion so consider strapping over a rolled bandage or simple buddy strap. Next available hand clinic Terminal phalanx Often a direct blow or laceration Open #, sometimes displaced. Nailbed injury 1. No bony injury 2. Open # - washout and antibiotics. Don’t close the wound. 3. Closed # - buddy strap for comfort 4. Nail bed/ fold injury – clean the wound and replace the nail if possible 1. Discharge 2. Refer immediately to hand surgeon 3. Discharge 4. Immediate referral. Mallet finger (soft tissue injury only) Forcible flexion of an extended finger Dropped fingertip Mallet splint for 6/52 Discharge with leaflet and GP or hand physio FU Mallet Finger (with avulsion: look for bony flake at extensor tendon insertion) Forcible flexion of an extended finger Non-union Mallet splint Hand clinic in 1 week and give advice leaflet. MCP & IP joint dislocations Usually result from hyperextension If one look for others Associated head/neck # Reduce under LA or entonox. Buddy strap and X-Ray post reduction Next available Hand clinic If not reduced then immediate referral Cuts/Wounds Multiple causes Nerve Tendon - careful assessment of movement and direct vision of the tendon Artery Lacerations to the palm of the hand – risk of scar & contracture Document neurological status prior to any LA 1. <1/3 tendon width laceration & normal movement or power – washout, close wound & buddy strap, splint in extension 2. >2/3 tendon width laceration or concerns re. movement or power – washout & non-adherent dressing If does not stop with 5 mins pressure and elevation then it may be a partial arterial laceration – check distal cap refill If nerve injury refer immediately 1. Hand Clinic 2. Immediate referral to ortho If unable to stop bleeding or concerns re. distal ischaemia: Below elbow laceration - Immediate referral to ortho Above elbow laceration - Refer to vascular team. Wounds requiring closure with sutures - discuss with on-call ortho team prior to closure in ED/MIU Bites Infection of deep structure Clean and irrigate Discuss all bites which have broken the skin below the elbows with the on call team Hand fractures and Injuries
INJURY SITE TYPICAL MECHANISM PITFALLS/COMPLICATIONS ED/ MIU/ UCC TREATMENT FOLLOW-UP
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Hand fractures and Injuries
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