Guidelines Summary

The American College of Radiology (ACR) guidelines for imaging acute hand and wrist trauma includes the following key recommendations^[18]:

Radiographs of the area of interest are usually appropriate for the initial imaging of adults with acute blunt or penetrating trauma to the hand or wrist.
If initial radiographs are negative or equivocal, repeat radiographs in 10-14 days, MRI without IV contrast, or CT without IV contrast are usually appropriate as the next imaging study.
If radiographs show acute wrist fracture and tendon or ligament trauma is suspected, MR arthrography of the wrist, MRI of the wrist without IV contrast, CT arthrography of the wrist, or ultrasonography of the wrist are usually appropriate as the next imaging study.
If the initial radiographs show distal radioulnar joint or carpal malalignment in the absence of fracture, CT of both wrists without IV contrast, MRI of the wrist without IV contrast, or MR arthrography of the wrist are usually appropriate as the next imaging study.
If radiographs show acute hand fracture and tendon or ligament trauma is suspected, MRI of the hand without IV contrast or ultrasonography of the hand are usually appropriate as the next imaging study.
If the initial radiographs show metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joint malalignment in the absence of fracture, MRI of the hand without IV contrast, or ultrasonography of the hand, is usually appropriate as the next imaging study.

Hegge T, Neumeister MW. Mutilated hand injuries. Clin Plast Surg. 2011 Oct. 38(4):543-50. [QxMD MEDLINE Link].
Lalonde DH, Kozin S. Tendon disorders of the hand. Plast Reconstr Surg. 2011 Jul. 128(1):1e-14e. [QxMD MEDLINE Link].
Carty MJ, Blazar PE. Complex flexor and extensor tendon injuries. Hand Clin. 2013 May. 29(2):283-93. [QxMD MEDLINE Link].
Wenzinger E, Rivera-Barrios A, Gonzalez G, Herrera F. Trends in Upper Extremity Injuries Presenting to US Emergency Departments. Hand (N Y). 2019 May. 14 (3):408-412. [QxMD MEDLINE Link].
Woo A, Bakri K, Moran SL. Management of ulnar nerve injuries. J Hand Surg Am. 2015 Jan. 40 (1):173-81. [QxMD MEDLINE Link].
Drake DB, Tilt AC, Degeorge BR. Acellular Flexor Tendon Allografts: A New Horizon for Tendon Reconstruction. J Hand Surg Am. 2013 May 24. [QxMD MEDLINE Link].
Altobelli GG, Conneely S, Haufler C, Walsh M, Ruchelsman DE. Outcomes of Digital Zone IV and V and Thumb Zone TI to TIV Extensor Tendon Repairs Using a Running Interlocking Horizontal Mattress Technique. J Hand Surg Am. 2013 Jun. 38(6):1079-83. [QxMD MEDLINE Link].
Farnebo S, Chang J. Practical management of tendon disorders in the hand. Plast Reconstr Surg. 2013 Nov. 132 (5):841e-853e. [QxMD MEDLINE Link].
Scalcione LR, Pathria MN, Chung CB. The athlete's hand: ligament and tendon injury. Semin Musculoskelet Radiol. 2012 Sep. 16 (4):338-49. [QxMD MEDLINE Link].
Makhlouf VM, Deek NA. Surgical treatment of chronic mallet finger. Ann Plast Surg. 2011 Jun. 66(6):670-2. [QxMD MEDLINE Link].
Martinoli C, Perez MM, Bignotti B, Airaldi S, Molfetta L, Klauser A, et al. Imaging finger joint instability with ultrasound. Semin Musculoskelet Radiol. 2013 Nov. 17 (5):466-76. [QxMD MEDLINE Link].
Melville DM, Jacobson JA, Fessell DP. Ultrasound of the thumb ulnar collateral ligament: technique and pathology. AJR Am J Roentgenol. 2014 Feb. 202 (2):W168. [QxMD MEDLINE Link].
Allen GM, Drakonaki EE, Tan ML, et al. High-resolution ultrasound in the diagnosis of upper limb disorders: a tertiary referral centre experience. Ann Plast Surg. 2008 Sep. 61(3):259-64. [QxMD MEDLINE Link].
Teefey SA, Middleton WD, Patel V, et al. The accuracy of high-resolution ultrasound for evaluating focal lesions of the hand and wrist. J Hand Surg [Am]. 2004 May. 29(3):393-9. [QxMD MEDLINE Link].
Lahiri A. Managing Mutilating Hand Injuries. Clin Plast Surg. 2019 Jul. 46 (3):351-357. [QxMD MEDLINE Link]. [Full Text].
Krieger Y, Bogdanov-Berezovsky A, Gurfinkel R, Silberstein E, Sagi A, Rosenberg L. Efficacy of enzymatic debridement of deeply burned hands. Burns. 2011 Nov 18. [QxMD MEDLINE Link].
Patel J, Couli R, Harris PA, et al. Hand lacerations. An audit of clinical examination. J Hand Surg [Br]. 1998 Aug. 23(4):482-4. [QxMD MEDLINE Link].
[Guideline] Expert Panel on Musculoskeletal Imaging:., Torabi M, Lenchik L, Beaman FD, Wessell DE, Bussell JK, et al. ACR Appropriateness Criteria^® Acute Hand and Wrist Trauma. J Am Coll Radiol. 2019 May. 16 (5S):S7-S17. [QxMD MEDLINE Link]. [Full Text].
Dias JJ, Garcia-Elias M. Hand injury costs. Injury. 2006 Nov. 37(11):1071-7. [QxMD MEDLINE Link].
Antosia RE, Lyn L. The hand. Emergency Medicine: Concepts and Clinical Practice. 4th ed. 1998. 625-68.
Chick LR, Lister GD. Emergency management of thermal, electrical, and chemical burns. Occupational Hand and Upper Extremity Injuries and Diseases. 1991.
Chuinard RG, Friermood TG, Lipscomb PR. The 'suicide' wrist: epidemiologic study of the injury. Orthopaedics. 1979. 2:499-502.
Cooney WP 3rd, Dobyns JH, Linscheid RL. Complications of Colles' fractures. J Bone Joint Surg Am. 1980. 62(4):613-9. [QxMD MEDLINE Link].
Cowen NJ, Loftus JM. Distraction augmentation manoplasty technique for lengthening digits of hands. Orthopedic Rev. 1978. 7:45-53.
Damert HG, Altmann S, Schneider W. [The potential of high-resolution sonography in the follow-up of surgically treated flexor tendons]. Handchir Mikrochir Plast Chir. 2006 Apr. 38(2):109-12. [QxMD MEDLINE Link].
Greenspan A. Orthopedic Radiology: A Practical Approach. 1992. 2.
Hergan K, Mittler C, Oser W. Pitfalls in sonography of the Gamekeeper's thumb. Eur Radiol. 1997. 7(1):65-9. [QxMD MEDLINE Link].
Idler RS, et al. The Hand: Examination and Diagnosis. American Society for Surgery of the Hand; 1990. 3.
Koslowsky TC, Mader K, Gausepohl T, et al. Ultrasonographic stress test of the metacarpophalangeal joint of the thumb. Clin Orthop Relat Res. 2004 Oct. 115-9. [QxMD MEDLINE Link].
Kuschner SH, Ebramzadeh E, Johnson D, et al. Tinel's sign and Phalen's test in carpal tunnel syndrome. Orthopedics. 1992 Nov. 15(11):1297-302. [QxMD MEDLINE Link].
Lister G. Undefined. The Hand: Diagnosis and Indications. 1993. 3.
Louis DS. Barton's and Smith's fractures. Hand Clin. 1988 Aug. 4(3):399-402. [QxMD MEDLINE Link].
Mehara AK, Rastogi S, Bhan S, et al. Classification and treatment of volar Barton fractures. Injury. 1993. 24(1):55-9. [QxMD MEDLINE Link].
Moore KL. Undefined. Clinically Oriented Anatomy. 1992. III:591-607.
O'Brien ET. Fractures and dislocations of the wrist region. Fractures in Children. 1991. 3.
Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg [Am]. 1981 Mar. 6(2):153-62. [QxMD MEDLINE Link].
Salisbury RE. Soft tissue injuries of the hand. Hand Clin. 1986 Feb. 2(1):25-32. [QxMD MEDLINE Link].
Schnur DP, DeLone FX, McClellan RM, et al. Ultrasound: a powerful tool in the diagnosis of ulnar collateral ligament injuries of the thumb. Ann Plast Surg. 2002 Jul. 49(1):19-22; discussion 22-3. [QxMD MEDLINE Link].
Simon RR, Slobodkin D. Injuries to the wrist and hand. Emergency Medicine: A Comprehensive Study Guide. 1996. Vol 4: 1217-35.
Skandalakis JE, Colborn GL, Skandalakis PN, et al. The carpal tunnel syndrome: Part I. Am Surg. 1992 Jan. 58(1):72-6. [QxMD MEDLINE Link].

Media Gallery

Metacarpophalangeal joints of the digits
Volar tendons at the wrist. These can be used as landmarks for injections.
Sagittal section of extensor compartments
Superficial volar sensation of the hand
Superficial dorsal sensation of the hand
Boutonnière deformity due to closed central tendon rupture
Boutonnière deformity
Mallet finger due to loss of central extensor tendon to the distal phalanx
This image shows an ultrasound of the flexor tendon of a finger with the structures labeled. It was performed using a water bath with the water as the conduction agent. (Image courtesy of Dr. Christopher Moore and Dr. Michael Osborne.)

of 9

Author

Andrea B Lese, MD Assistant Professor, Department of Orthopedics, West Virginia University School of Medicine

Andrea B Lese, MD is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth R Chuang, MD Attending Physician, Emergency Department, Long Beach Memorial Medical Center and Miller Children's Hospital

Disclosure: Nothing to disclose.

Wyatt Decker, MD Vice President and Chief Executive Officer, Mayo Clinic Campus, Arizona

Wyatt Decker, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Kahill Glenn, MD, to the development and writing of this article.

Sections Soft Tissue Injuries of the Hand
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Media Gallery
References

Soft Tissue Injuries of the Hand Guidelines

Guidelines Summary

References

Tables

Contributor Information and Disclosures

What would you like to print?