December 2014 Evidence-Based Management Volume 16, Number 12 Of Acute Hand Injuries In The Authors W. Talbot Bowen, MBBS Section of Emergency Medicine, Louisiana State University Health Emergency Department Sciences Center, New Orleans, LA Ellen M. Slaven, MD Clinical Associate Professor of Medicine, Section of Emergency Abstract Medicine, Louisiana State University Health Sciences Center, New Orleans, LA Although injuries of the hand are infrequently life-threatening, Peer Reviewers they are common in the emergency department and are associated Makini Chisolm-Straker, MD with significant patient morbidity and medicolegal risk for physi- International Emergency Medicine Fellow, Attending Physician and Instructor of Medicine, Division of Emergency Medicine, Columbia cians. Care of patients with acute hand injury begins with a fo- University Medical Center, New York, NY cused history and physical examination. In most clinical scenarios, Nicholas Genes, MD, PhD, FACEP a diagnosis is achieved clinically or with plain radiographs. While Assistant Professor, Department of Emergency Medicine, Icahn School most patients require straightforward treatment, the emergency of Medicine at Mount Sinai, New York, NY clinician must rapidly identify limb-threatening injuries, obtain CME Objectives critical clinical information, navigate diagnostic uncertainty, and Upon completion of this article, you should be able to: facilitate specialist consultation, when required. This review dis- 1. Perform a focused and complete history and physical cusses the clinical evaluation and management of high-morbidity examination pertinent to acute hand injuries. 2. Discuss the management strategies for a broad range of acute hand injuries in the context of the current evidence. hand injuries. 3. Identify limb-threatening hand injuries that require emergent hand surgery consultation. Prior to beginning this activity, see “Physician CME Information” on the back page. Editor-In-Chief Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, Stephen H. Thomas, MD, MPH Research Editors Andy Jagoda, MD, FACEP Professor and Chair, Department FACEP George Kaiser Family Foundation Michael Guthrie, MD Professor and Chair, Department of of Emergency Medicine, Carolinas Professor and Chair, Department of Professor & Chair, Department of Emergency Medicine Residency, Emergency Medicine, Icahn School Medical Center, University of North Emergency Medicine, Pennsylvania Emergency Medicine, University of Icahn School of Medicine at Mount of Medicine at Mount Sinai, Medical Carolina School of Medicine, Chapel Hospital, Perelman School of Oklahoma School of Community Sinai, New York, NY Director, Mount Sinai Hospital, New Hill, NC Medicine, University of Pennsylvania, Medicine, Tulsa, OK Philadelphia, PA Federica Stella, MD York, NY Steven A. Godwin, MD, FACEP David M. Walker, MD, FACEP, FAAP Emergency Medicine Residency, Professor and Chair, Department Michael S. Radeos, MD, MPH Director, Pediatric Emergency Giovani e Paolo Hospital in Venice, Associate Editor-In-Chief of Emergency Medicine, Assistant Assistant Professor of Emergency Services, Division Chief, Pediatric University of Padua, Italy Kaushal Shah, MD, FACEP Dean, Simulation Education, Medicine, Weill Medical College Emergency Medicine, Elmhurst Associate Professor, Department of University of Florida COM- of Cornell University, New York; Hospital Center, New York, NY International Editors Emergency Medicine, Icahn School Jacksonville, Jacksonville, FL Research Director, Department of of Medicine at Mount Sinai, New Emergency Medicine, New York Ron M. Walls, MD Peter Cameron, MD Gregory L. Henry, MD, FACEP York, NY Hospital Queens, Flushing, NY Professor and Chair, Department of Academic Director, The Alfred Clinical Professor, Department of Emergency Medicine, Brigham and Emergency and Trauma Centre, Editorial Board Emergency Medicine, University Ali S. Raja, MD, MBA, MPH Women's Hospital, Harvard Medical Monash University, Melbourne, of Michigan Medical School; CEO, Vice-Chair, Emergency Medicine, School, Boston, MA Australia William J. Brady, MD Medical Practice Risk Assessment, Massachusetts General Hospital, Professor of Emergency Medicine Inc., Ann Arbor, MI Boston, MA Critical Care Editors Giorgio Carbone, MD and Medicine, Chair, Medical John M. Howell, MD, FACEP Robert L. Rogers, MD, FACEP, Chief, Department of Emergency Emergency Response Committee, William A. Knight, IV, MD, FACEP Medicine Ospedale Gradenigo, Clinical Professor of Emergency FAAEM, FACP Medical Director, Emergency Assistant Professor of Emergency Torino, Italy Management, University of Virginia Medicine, George Washington Assistant Professor of Emergency Medicine and Neurosurgery, Medical Medical Center, Charlottesville, VA University, Washington, DC; Director Medicine, The University of Director, EM Midlevel Provider Amin Antoine Kazzi, MD, FAAEM of Academic Affairs, Best Practices, Maryland School of Medicine, Program, Associate Medical Director, Associate Professor and Vice Chair, Mark Clark, MD Inc, Inova Fairfax Hospital, Falls Baltimore, MD Neuroscience ICU, University of Department of Emergency Medicine, Assistant Professor of Emergency Church, VA University of California, Irvine; Alfred Sacchetti, MD, FACEP Cincinnati, Cincinnati, OH Medicine, Program Director, Shkelzen Hoxhaj, MD, MPH, MBA Assistant Clinical Professor, American University, Beirut, Lebanon Emergency Medicine Residency, Scott D. Weingart, MD, FCCM Chief of Emergency Medicine, Baylor Department of Emergency Medicine, Mount Sinai Saint Luke's, Mount Associate Professor of Emergency Hugo Peralta, MD College of Medicine, Houston, TX Thomas Jefferson University, Sinai Roosevelt, New York, NY Medicine, Director, Division of Chair of Emergency Services, Philadelphia, PA Eric Legome, MD ED Critical Care, Icahn School of Hospital Italiano, Buenos Aires, Peter DeBlieux, MD Chief of Emergency Medicine, Robert Schiller, MD Medicine at Mount Sinai, New Argentina Professor of Clinical Medicine, King’s County Hospital; Professor of Chair, Department of Family Medicine, York, NY Dhanadol Rojanasarntikul, MD Interim Public Hospital Director Clinical Emergency Medicine, SUNY Beth Israel Medical Center; Senior Attending Physician, Emergency of Emergency Medicine Services, Downstate College of Medicine, Faculty, Family Medicine and Senior Research Editors Medicine, King Chulalongkorn Louisiana State University Health Brooklyn, NY Community Health, Icahn School of James Damilini, PharmD, BCPS Memorial Hospital, Thai Red Cross, Science Center, New Orleans, LA Medicine at Mount Sinai, New York, NY Thailand; Faculty of Medicine, Keith A. Marill, MD Clinical Pharmacist, Emergency Nicholas Genes, MD, PhD Research Faculty, Department of Scott Silvers, MD, FACEP Room, St. Joseph’s Hospital and Chulalongkorn University, Thailand Assistant Professor, Department of Emergency Medicine, University Chair, Department of Emergency Medical Center, Phoenix, AZ Suzanne Y.G. Peeters, MD Emergency Medicine, Icahn School of Pittsburgh Medical Center, Medicine, Mayo Clinic, Jacksonville, FL Joseph D. Toscano, MD Emergency Medicine Residency of Medicine at Mount Sinai, New Pittsburgh, PA Chairman, Department of Emergency Director, Haga Teaching Hospital, York, NY Corey M. Slovis, MD, FACP, FACEP The Hague, The Netherlands Professor and Chair, Department Medicine, San Ramon Regional of Emergency Medicine, Vanderbilt Medical Center, San Ramon, CA University Medical Center, Nashville, TN Case Presentations males (male-to-female ratio of occurrence, 1.7:1), and are more common among individuals aged ≥ 18 3,4,5 It’s a busy afternoon in the ED. A 32-year-old man with years. a laceration of his left palm is placed in your next open The United States Bureau of Labor Statistics reports that hand injuries are the second most com- bed. The injury occurred 1 hour prior to arrival as he was 6 using a flat-head screwdriver to open a can of paint. He mon injury resulting in days away from work. complains of pain and swelling at the wound site and Decreasing reimbursement rates, changing inability to flex his fifth digit. The patient is right-handed, perceptions of medicolegal risk, and requirements for works in construction, has a history of hypertension, and the Subspecialty Certificate in Surgery of the Hand has resulted in variable hand surgeon availability his last tetanus shot was 12 years ago. There is a 3-cm 7 laceration of the palmar surface of the base of the fifth in many EDs. Although rarely life-threatening, hand injuries are associated with significant patient digit. He is unable to flex the fifth digit at the PIP joint or 8 DIP joint. You order 3-view hand radiographs, update his morbidity and physician medicolegal risk. A 2010 Tdap vaccine, and prepare for local anesthesia, irrigation, retrospective review by Brown et al of 11,529 closed and wound exploration. You suspect the patient has a malpractice claims from 1985 to 2007 reported that open finger injuries were in the top 10 most common flexor tendon injury. 9 A second patient is brought in by EMS after 911 diagnoses resulting in medical malpractice litigation. was called to a local bar. The patient exhibits confusion, While most hand injuries require straight- dysarthria, ataxia, and nystagmus. The paramedic states, forward treatment, the emergency clinician must “He drank way too much.” The patient’s right hand is rapidly identify limb-threatening injuries, obtain swollen over the fourth and fifth MCP joints and there is specific critical clinical