Hand fractures and Injuries

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

1^st 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

5^th 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

5^th 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 90^o 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 >10^o 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