Hand Fracture Management in the ED Clinical Presentation

Updated: Mar 18, 2020
  • Author: Erik D Schraga, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

History

Hand fractures usually are not difficult to diagnose. Most patients provide a history of preceding trauma. Physicians who initially evaluate injuries should elicit details of the trauma, as this may benefit the hand surgeon. If an industrial injury is the cause, details may help prevent injury to others. Document the following important details in ED records:

  • Hand dominance of patient

  • Hand that is injured

  • Occupation and hobbies requiring dexterity

Questions regarding the mechanism of injury include the following:

  • Did injury occur in a clean or dirty environment?

  • Were crush injuries sustained?

  • What was the position of the hand at time of injury?

  • Was injury the result of high-pressure grease, water, air, or paint injection?

  • Did a thermal, electric, or chemical injury occur?

  • Was patient wearing any type of jewelry on fingers? If so, has it been removed?

Questions regarding the injury as the result of an assault include the following:

  • Was hand open or fist clenched?

  • Are lacerations present, particularly overlying the metacarpophalangeal (MCP) joint (may indicate significant tendon injury)?

  • Did the patient's fist contact mouth or teeth?

Note subjective motor or sensory deficits. Note length of time since initial injury. Document number of years since last tetanus immunization if lacerations or abrasions were sustained.

Obtain significant medical history. Include documentation of disorders that may compromise healing and record previous hand injury or disability.

Record medication and allergy history.

Note other risk factors that may preclude adequate healing, such as tobacco or cocaine use.

Next:

Physical

Physical examination is of vital importance in evaluating the injured hand. Develop a comprehensive routine for examining all hand injuries regardless of mechanism of injury.

Hand structure

Five metacarpal bones are joined to the wrist, articulating with the distal carpal row.

(Metacarpophalangeal anatomy is depicted in the illustrations below.)

Metacarpophalangeal musculoskeletal structure. Metacarpophalangeal musculoskeletal structure.
Metacarpophalangeal ligaments. Metacarpophalangeal ligaments.

The thumb articulates chiefly with the trapezium, creating a freely movable joint. Remaining metacarpals articulate with the trapezoid, capitate, and hamate, from radial to ulnar direction. The ring and little fingers have about 20-25° of mobility at articulation in the anteroposterior (AP) plane. Index and middle fingers have no flexion or extension capability at articulation.

The thumb consists of proximal and distal phalanges. The remaining fingers consist of proximal, middle, and distal phalanges. The proximal interphalangeal (PIP) joints allow flexion and extension and minimal abduction and adduction.

Terminology

The palm of the hand is referred to as the volar or palmar surface.

The back of the hand is referred to as the dorsal surface.

The borders of the hand are referred to as radial or ulnar.

The anatomic position of the hand is with the palms facing forward.

Fingers often are counted by roman numerals, with the thumb as I, but most clinicians prefer to use common names (ie, thumb, index finger, middle finger, ring finger, little finger) to avoid potential confusion.

Fingers are divided into segments by distal and proximal interphalangeal creases and digital creases. These segments correspond to underlying phalanges. Volar creases may not overlie corresponding joints precisely.

Description of function

Rotation of the hand from neutral position to palm-up position is termed supination. Rotation to palm down position is termed pronation.

Radial and ulnar deviation correspond to movement of the hand to a stated direction from anatomic position.

Extension of hand refers to dorsal movement, and flexion refers to volar movement.

Flexion and extension of fingers correspond to dorsal and volar movements.

Abduction of fingers refers to movement of fingers away from an imaginary line drawn through the middle of the third finger. Adduction refers to movement toward this midline.

The carpometacarpal joint of the thumb is capable of palmar adduction or flexion (toward midline), palmar abduction (away from palmar surface), radial abduction, retroposition (extension) adduction, and opposition. The interphalangeal joint of the thumb can flex and extend only.

Hand examination

Start a hand examination by comparing the injured hand to the uninjured hand.

Note skin and soft tissue changes, such as edema, erythema, cyanosis, ecchymosis, lacerations, and abrasions.

Abnormal positioning, especially of the fingers, may indicate fracture or tendon injury. Identification of rotational malalignment is critical.

(Assessment of rotational deformity is described in the image below.)

Assessment of the hand for rotational deformities Assessment of the hand for rotational deformities of the fingers or metacarpals is essential, as such deformities, if untreated, may result in significant functional compromise. With fingers flexed at the metacarpophalangeal and proximal interphalangeal joints and extended at the distal interphalangeal joints, fingers should all point toward the scaphoid bone (see image).

Categorize location of the injury as ulnar, radial, volar, or dorsal.

Check vascular status by noting capillary refill at nail ridge. If fracture is more proximal, radial and ulnar artery pulsation should be noted. If bleeding is present, do not clamp or ligate a vessel blindly, as nerves closely follow blood vessels.

Neurologic examination

Remember to assess nerve integrity prior to instillation of anesthetics.

The 3 major nerves of the hand are the radial, median, and ulnar nerves.

Sensory examination

Loss of sweating is apparent if sensory nerves are injured. In an uncooperative patient, the hand may be immersed in hot water for 10 minutes. Skin distal to nerve injury will not wrinkle.

Two-point discrimination testing using a bent paper clip is easy and reliable. Ability to discriminate at less than 5 mm on the fingertip is normal. If the patient has abnormal discrimination, always test in relation to uninjured hand, as sensitivity is variable.

Although anatomic variation is possible, generally the sensory distribution is as follows:

  • The ulnar nerve supplies the fifth finger and the medial aspect of the fourth finger.

  • The median nerve supplies the volar aspect of the first through third fingers, as well as the lateral aspect of the volar surface of the fourth finger.

  • The radial nerve supplies the dorsal surface of the entire hand except for the fifth finger.

Motor examination

The radial nerve extends the wrist and the fingers.

The ulnar nerve allows adduction of the fourth and fifth fingers and adduction of the thumb.

The median nerve adducts the second and third fingers and allows opposition of the thumb to the fifth finger.

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