Professional Documents
Culture Documents
June 2011
Volume 13, Number 6
The Emergency Clinicians Authors
Aaron Andrade, MD
Evidence-Based Approach
Emergency Medicine Physician, Alameda County Medical Center,
Highland General Hospital, Oakland, CA
H.Gene Hern, MD, MS, FACEP, FAAEM
Residency Director, Alameda County Medical Center, Highland
At the start of your Saturday afternoon shift, you are not surprised to see General Hospital, Oakland, CA
that several patients are waiting to be seen for physical injuries. The first Peer Reviewers
patient is a 34-year-old woman who sustained injury to her hand while
Stephen Cantrill, MD, FACEP
skiing, 2 hours prior to her arrival. She reports falling with her hand still Emergency Medicine Physician, Denver Health Medical Center,
tethered to the poles grip, landing on her outstretched right hand. She felt a Denver, CO
painful snap in her right thumb, which still hurts, but otherwise she did not Mark Silverberg, MD, FACEP
Associate Residency Director and Assistant Professor, SUNY
sustain any other trauma. Her only complaint currently is pain at the base Downstate and Kings County Hospital, Brooklyn, NY
of the right thumb. The patient is otherwise completely healthy, has no past
CME Objectives
medical or surgical history, and takes no medications. Upon examination,
Upon completion of this article, you should be able to:
the affected hand appears to be surprisingly normal except for mild tender-
1. Perform an appropriate and complete history and physical
ness and swelling over the ulnar aspect of her first metacarpophalangeal examination of traumatic hand injury patients.
joint and mildly decreased strength in her pincher grasp. X-ray reveals no 2. Discuss the utility of different imaging modalities.
fracture. You wonder if there is additional testing that should be done to 3. Describe the physical findings and management strategies of a
evaluate this injury. wide array of hand injuries.
4. Identify limb-threatening conditions that require immediate
You move on to a second patient, a 24-year-old man who cut his ring hand surgical consultation.
finger knuckle when he punched a wall 2 days ago. Physical examination
reveals a small puncture wound over the IV metacarpophalangeal joint with Date of original release: June 1, 2011
Date of most recent review: May 10, 2011
mild swelling, erythema, warmth, and decreased range of motion secondary Termination date: June 1, 2014
to pain. X-ray reveals no fracture, but theres something suspicious about Medium: Print and Online
Method of participation: Print or online answer form and evaluation
this case. Prior to beginning this activity, see Physician CME Information on
A third patient is a 37-year-old industrial worker whose finger con- the back page.
Editor-in-Chief Professor, UT College of Medicine, Shkelzen Hoxhaj, MD, MPH, MBA Scott Silvers, MD, FACEP Giorgio Carbone, MD
Andy Jagoda, MD, FACEP Chattanooga, TN Chief of Emergency Medicine, Baylor Chair, Department of Emergency Chief, Department of Emergency
Professor and Chair, Department of College of Medicine, Houston, TX Medicine, Mayo Clinic, Jacksonville, FL Medicine Ospedale Gradenigo,
Nicholas Genes, MD, PhD Torino, Italy
Emergency Medicine, Mount Sinai Assistant Professor, Department of Keith A. Marill, MD Corey M. Slovis, MD, FACP, FACEP
School of Medicine; Medical Director, Emergency Medicine, Mount Sinai Assistant Professor, Department of Professor and Chair, Department Amin Antoine Kazzi, MD, FAAEM
Mount Sinai Hospital, New York, NY School of Medicine, New York, NY Emergency Medicine, Massachusetts of Emergency Medicine, Vanderbilt Associate Professor and Vice Chair,
General Hospital, Harvard Medical University Medical Center; Medical Department of Emergency Medicine,
Editorial Board Michael A. Gibbs, MD, FACEP School, Boston, MA Director, Nashville Fire Department and University of California, Irvine;
William J. Brady, MD Professor and Chief, Department of International Airport, Nashville, TN American University, Beirut, Lebanon
Emergency Medicine, Maine Medical Charles V. Pollack, Jr., MA, MD,
Professor of Emergency Medicine FACEP Hugo Peralta, MD
Center, Portland, ME; Tufts University Jenny Walker, MD, MPH, MSW
and Medicine Chair, Resuscitation Chairman, Department of Emergency Chair of Emergency Services, Hospital
School of Medicine, Boston, MA Assistant Professor, Departments of
Committee & Medical Director, Medicine, Pennsylvania Hospital, Italiano, Buenos Aires, Argentina
Preventive Medicine, Pediatrics, and
Emergency Preparedness and Steven A. Godwin, MD, FACEP University of Pennsylvania Health Medicine Course Director, Mount Dhanadol Rojanasarntikul, MD
Response, University of Virginia Associate Professor, Associate Chair System, Philadelphia, PA Sinai Medical Center, New York, NY Attending Physician, Emergency
Health System Operational and Chief of Service, Department
Medical Director, Charlottesville- of Emergency Medicine, Assistant Michael S. Radeos, MD, MPH Ron M. Walls, MD Medicine, King Chulalongkorn
Albemarle Rescue Squad & Dean, Simulation Education, Assistant Professor of Emergency Professor and Chair, Department of Memorial Hospital, Thai Red Cross,
Albemarle County Fire Rescue, University of Florida COM- Medicine, Weill Medical College Emergency Medicine, Brigham and Thailand; Faculty of Medicine,
Charlottesville, VA Jacksonville, Jacksonville, FL of Cornell University, New York; Womens Hospital, Harvard Medical Chulalongkorn University, Thailand
Research Director, Department of School, Boston, MA Maarten Simons, MD, PhD
Peter DeBlieux, MD Gregory L. Henry, MD, FACEP Emergency Medicine, New York Emergency Medicine Residency
Louisiana State University Health CEO, Medical Practice Risk Hospital Queens, Flushing, New York Scott Weingart, MD, FACEP Director, OLVG Hospital, Amsterdam,
Science Center Professor of Clinical Assessment, Inc.; Clinical Professor Assistant Professor of Emergency
Medicine, LSUHSC Interim Public of Emergency Medicine, University of Robert L. Rogers, MD, FACEP, Medicine, Mount Sinai School of The Netherlands
Hospital Director of Emergency Michigan, Ann Arbor, MI FAAEM, FACP Medicine; Director of Emergency Senior Research Editor
Medicine Services, LSUHSC Assistant Professor of Emergency Critical Care, Elmhurst Hospital
John M. Howell, MD, FACEP Joseph D. Toscano, MD
Emergency Medicine Director of Medicine, The University of Center, New York, NY
Clinical Professor of Emergency Emergency Physician, Department
Faculty and Resident Development Maryland School of Medicine,
Medicine, The George Washington of Emergency Medicine, San Ramon
Wyatt W. Decker, MD
Baltimore, MD International Editors Regional Medical Center, San
University, Washington, DC; Director
Professor of Emergency Medicine, of Academic Affairs, Best Practices, Alfred Sacchetti, MD, FACEP Peter Cameron, MD Ramon, CA
Mayo Clinic College of Medicine, Inc, Inova Fairfax Hospital, Falls Assistant Clinical Professor, Academic Director, The Alfred
Department of Emergency Medicine, Emergency and Trauma Centre, Research Editor
Rochester, MN Church, VA
Thomas Jefferson University, Monash University, Melbourne, Matt Friedman, MD
Francis M. Fesmire, MD, FACEP Philadelphia, PA Australia Emergency Medicine Residency,
Director, Heart-Stroke Center, Mount Sinai School of Medicine,
Erlanger Medical Center; Assistant New York, NY
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Andrade, Dr. Hern, Dr. Cantrill, Dr. Silverberg, Dr.
Jagoda and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
reveals a small puncture wound over the volar proximal significantly to unemployment and loss of produc-
interphalangeal joint of his left long finger, mild tender- tive work hours.
ness to palpation over the area, and slight decreased range Hand trauma presents with such a wide variety
of motion secondary to pain. You wonder if the injury is of conditions with differing outcomes that a com-
as benign as it looks. manding knowledge of hand trauma and anatomy
is essential to any practicing emergency clinician.
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasound.
Immediately Limb-Threatening
Compartment syndrome Phalanges Distal Phalange
Crush injuries
High-pressure injections Medial Phalange
Vascular injuries
Proximal Phalange
Injuries Requiring Rapid ED Assessment/Intervention
Dislocations
Amputations
Metacarpal
Not Immediately Limb-Threatening Bones
Nerve injuries
Fractures Carpal
Lacerations Bones
Tendon injury
Ligamentous injury Ulna
Radius
Fingertip/fingernail injury
A B C
A B C
Ulnar, medial, and radial nerves are shown by the arrow across the bottom of the images. Arrowheads show arteries, A (ulnar), B (medial), and C
(radial).
Liebmann O, Price D, Mills C et al. Ann Emerg Med. 2006;48(5)558-562. Used with permission of Mosby, Inc.
Zone I II III
Zone I II III
Left arrow notes a tuft fracture of digit IV. Right arrow notes a shaft
fracture of the distal phalanx of digit III.
Used with permission of John D. Lubahn, MD. 2001. Renee L. Cannon. Used with permission.
Used with permission of Aaron Andrade, MD. Used with permission of Aaron Andrade, MD.
Used with permission of Aaron Andrade, MD. Used with permission, Aaron Andrade, MD.
METACARPAL FRACTURES
Thumb MC fractures (Bennett, Rolando, etc) Thumb spica; early referral if operative repair required
(Class II)
FINGER FRACTURES
Displaced intra-articular, unstable, or angulated fractures Splint and refer (Class III)
Surgical consult from ED to discuss timing of repair (Class III)
OPEN FRACTURES
DISLOCATIONS/LIGAMENT INJURIES
Thumb UCL (skiers thumb) or RCL injury Thumb spica and refer (Class II)
Abbreviations: CMC, carpometacarpal; ED, emergency department; IP, interphalangeal; MC, metacarpal; MP, metacarpophalangeal; RCL, radial col-
lateral ligament; UCL, ulnar collateral ligament.
TENDON INJURIES
FLEXOR TENDONS
Closed FDP avulsion (jersey finger) Splint; early referral for operative repair (Class II-III)
Open flexor tendon laceration Surgical consult for timing of repair (Class III)
Close skin and splint, if referring (Class II)
EXTENSOR TENDONS
Closed injury (mallet, PIP, or extensor digitorum injury, Splint appropriately and refer (Class II)
acute boutonniere)
Open uncontaminated laceration Consider repair of zone II-IV lacerations in ED (Class III)
Close skin and splint, if referring early (Class II)
Abbreviations: ED, emergency department; FDP, flexor digitorum profundus; IV, intravenous; PIP, proximal interphalangeal joint.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2011 EB Practice, LLC d.b.a. EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of
EB Practice, LLC d.b.a. EB Medicine.
Volar migration of the lateral bands From Rhee S, Cobiella C. Trauma. 2007;9:163-170, copyright 2007
by Sage Publications. Reprinted by permission of SAGE.
Special Circumstances
High-Pressure Injection Injuries
High-pressure injection injuries are very uncommon,
so strong evidence regarding their management
is lacking. They tend to occur in the nondominant
hands of industrial workers.95 While paints and
oils are the most common materials involved, the
literature is filled with case reports of incidents
involving water, air, solvents, and even molten metal
and cement.96-103 Superficial signs of injury can be
deceptively minimal, as in the third clinical vignette
patient, and even imaging may misrepresent the full
extent of tissue damage. (See Figure 16.) Regardless Radiograph (left) and intraoperative photograph (right) showing the
of the material injected, these injuries are associ- extent of tissue involvement in a high-pressure injection of paint.
ated with a high risk of infection and amputation, Used with permission of New Zealand Journal of Medicine.
1. I couldnt see all the way to the base of the 6. The pressurized injection injury looked like
laceration, but Im sure there is no glass inside. a very small red dot on the finger, so I sent the
Lacerations caused by glass and other brittle patient home with pain medications
materials are at high risk for retained foreign body. High-pressure injection injuries can look
Inability to explore the laceration completely to its deceptively minor on physical examination. All
base or a patient having the sensation of foreign cases require x-rays to better visualize the extent
body should prompt multiple-view radiographs of injury. Due to the high risk of amputation and
prior to laceration repair. permanent functional impairment, every case
should be admitted for IV antibiotics and likely
2. A patient with a sutured laceration came back surgical debridement.
for a wound check with signs of infection, so I
prescribed antibiotics and asked the patient to 7. I cleared the patient as fit for incarceration
return in a few days for suture removal. because all he had was a bite mark on his
While antibiotic treatment is reasonable in this knuckle.
case, infected lacerations or those that present for Fight bites may look minor on physical
repair later than 12-24 hours after injury should examination, but they carry a high risk of soft
be allowed to heal by secondary intention. In this tissue infection and loss of function. All cases
case, immediate suture removal and irrigation/ require antibiotics and surgical consult for
debridement of the wound is essential. possible debridement and washout. Patients will
often hide the true mechanism of this injury, so
3. I didnt see a fracture on the x-ray. lacerations to the MCP should be considered a
Radiographs are not 100% sensitive for detection fight bite until proven otherwise.
of fracture. To maximize the sensitivity, emergency
clinicians should ensure that multiple views are 8. I wanted to be safe, so I splinted the entire
obtained, including posteroanterior, lateral, and mallet finger from the DIP to the MCP.
oblique. In cases where fracture is highly suspected, Mallet fingers have been shown to heal with
the safest practice is to splint the affected extremity good functional outcomes after DIP splinting in
and refer for outpatient hand specialist follow-up. extension for 6 weeks. Immobilization of more
In cases where formal radiology reads are pending, proximal joints is unnecessary and can lead to
patients should be informed that they may be called undue joint stiffness.
back with additional findings.
9. I couldnt successfully reduce the dislocation,
4. I saw the bleeding artery in the laceration, so so I splinted it and referred the patient for
I clamped it. outpatient follow-up.
Lacerated hand vessels, even when easily Any dislocation or fracture that fails closed
visible, should never be clamped by an reduction warrants immediate surgical
emergency clinician. The risk of causing consultation. In particular, irreducible
further vascular damage, tendon damage, and dislocations often occur due to intra-articular
nerve damage is extremely high. Emergency bone fragments or an entrapped volar
department management should focus on plate. While awaiting surgical consultation,
hemorrhage control with direct pressure and management should focus on pain control and
proximal tourniquet application. Direct repair of splinting in a comfortable position.
vasculature is best left to a surgical specialist.
10. I placed the amputated finger directly in a
5. The child with the severely crushed hand was bucket of ice water to increase viability.
having so much pain and tingling, I had to Direct contact with ice and excessive water can
perform a regional nerve block. cause irreversible damage to amputated limbs.
While rare, compartment syndrome of the hand The proper technique for cooling is to wrap the
does exist. The emergency clinician must be amputated part in saline-moistened gauze and
able to recognize high-risk mechanisms such as place in a sealed plastic bag. This bag is placed
crush injuries and early physical examination into an insulated container with a sealed bag
findings such as increasing pain and paresthesias. of ice. Properly cooled parts can remain viable
Regional nerve blocks are contraindicated in up to 12-24 hours, depending on the tissues
suspected compartment syndrome as they prevent involved.
meaningful repeat physical examinations.
1. Prescribe antibiotics for patients only when and ligamentous injury and should be used in
clinically necessary. The majority of hand inju- cases where complete tears are highly suspected.
ries will not require antibiotic therapy. Impor-
tant exceptions include animal/human bites, 3. Subungual hematomas without disruption of
grossly contaminated wounds, contaminated the nail can be treated with simple nail trephi-
penetrating trauma, high-pressure injection nation, a cheaper and faster alternative to nail
injuries, and amputations. removal and nail bed laceration repair.
Risk management caveat: Immunosuppressed Risk management caveat: Carefully examine the
patients are at higher risk of infectious nail and its margins to be sure that they are
complications. Physicians should have a lower intact. Disruption of these structures warrants
threshold for treating these patients with complete nail removal and direct repair of nail
antibiotics. When not prescribing antibiotics, bed lacerations.
closer and earlier follow-up is warranted.
4. Regional nerve blocks often produce more
2. In the hands of an experienced sonographer, complete and longer-acting anesthesia than
ultrasound can be used as a time- and cost- local anesthesia or enteral and parenteral pain
effective alternative to MRI in diagnosing liga- medications. Patient satisfaction is generally
ment and tendon injuries. higher as well.
Risk management caveat: Keep in mind that the Risk management caveat: Be sure to have a
reliability of ultrasound is user-dependent. high index of suspicion for compartment
Studies have shown that ultrasound has a higher syndrome. Patients with significant crush
specificity than sensitivity in detecting complete injuries, pain out of proportion to mechanism,
tears. Therefore, a complete tear can be ruled in paresthesias, pressure-injection injuries, and
but cannot be ruled out with ultrasound. MRI tense compartments on palpation are at higher
remains the gold standard for detecting tendon risk of developing compartment syndrome.
Regional nerve blocks are contraindicated in
these patients.
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