Medication Summary
Drugs used for injuries involving the hand include various analgesics. Near-immediate pain relief can be provided when the patient receives an injection of a local anesthetic along the path of the digital nerve (digital, web-space, or palmar block). Of course, the digital block must be preceded by a very thorough neurosensory examination and (when indicated) discussion with the hand specialist.
Oral medications should be prescribed for the patient who is being discharged from the emergency department (ED).
Analgesics
Class Summary
Pain control is essential to quality patient care: It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Analgesic agents are used for pain relief. Acetaminophen is used in patients with mild pain, especially those with a contraindication to NSAID use; narcotics are used in those with moderate to severe pain. Many analgesics have sedating properties that benefit patients who have sustained injuries.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
Acetaminophen is the drug of choice for mild pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper gastrointestinal (GI) disease, or those who are taking oral anticoagulants.
Codeine and acetaminophen (Tylenol With Codeine)
This drug combination is indicated for the treatment of mild to moderate pain.
Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lorcet Plus, Lortab)
This drug combination is indicated for the relief of moderate to severe pain.
Oxycodone and acetaminophen (Percocet, Endocet, Tylox)
This drug combination is indicated for the relief of moderately severe to severe pain. It is the agent of choice for aspirin-hypersensitive patients. Different strengths are available.
Oxycodone and aspirin (Percodan, Endodan)
This drug combination is indicated for the relief of moderately severe to severe pain.
Antianxiety Agents
Class Summary
Patients with painful injuries usually experience significant anxiety. Administration of anxiolytics allows the clinician to achieve the same degree of pain relief with a smaller analgesic dose.
Lorazepam (Ativan)
Lorazepam is a sedative-hypnotic of the benzodiazepine class that has a rapid onset of effect and a relatively long half-life. By increasing the action of gamma-aminobutyric acid (GABA), a major inhibitory neurotransmitter, it may depress all levels of the central nervous system (CNS), including the limbic system and reticular formations. Lorazepam is excellent for patients who need to be sedated for longer than 24 hours.
Diazepam (Valium, Diastat)
Diazepam depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. It is considered second-line therapy for seizures.
Local Anesthetics
Class Summary
Local anesthetic agents are used for digital block to facilitate reduction or examination of fingers.
Lidocaine (Anestafoam, Xylocaine, Lidoderm, Topicaine)
Lidocaine is an amide local anesthetic used in 1-2% concentration. The 1% preparation contains 10 mg of lidocaine for each 1 mL of solution; the 2% preparation contains 20 mg of lidocaine for each 1 mL of solution. Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. For a digital block, lidocaine must not be used with epinephrine; 1% lidocaine without epinephrine is the drug of choice.
To improve local anesthetic injection, cool the skin with ethyl chloride before injection. Use smaller-gauge needles (eg, 27 gauge or 30 gauge). Make sure the solution is at body temperature. Infiltrate very slowly to minimize the pain. The time from administration to onset of action is 2-5 minutes, and the effect lasts for 1.5-2 hours.
Buffering the solution helps reduce the pain of local lidocaine injection. Sodium bicarbonate can be added to injectable lidocaine vials (1 part bicarbonate to 9 parts lidocaine) to produce buffered lidocaine. The shelf-life of buffered lidocaine is approximately 1 week at room temperature. All vials should be marked "buffered," labeled with the time and date, and signed by the person who created the buffered mixture.
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Carpometacarpal joint dislocation.
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Carpometacarpal joint dislocation.
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Volar proximal interphalangeal (PIP) joint dislocation.
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Dorsal thumb interphalangeal dislocation.
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Dorsal thumb interphalangeal dislocation.
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Aluminum foam splints.
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Hand dislocation. Dorsal aluminum foam splint.
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Buddy taping.
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Acute dorsal proximal interphalangeal joint fracture-dislocation.
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Acute dorsal proximal interphalangeal fracture-dislocation. A concentric reduction could not be maintained in a splint.
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Complex second metacarpophalangeal dislocation in a skeletally immature patient (same patient as in the next 2 images). Note the position of the finger and dimpling of skin on volar hand.
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Radiograph of the hand of a patient with complex second metacarpophalangeal dislocation (same patient as in the previous and next images).
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Intraoperative photo of the second metacarpophalangeal joint (same patient as in the previous 2 images). Note the displaced volar plate between the metacarpal head and the proximal phalanx.
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Boutonniere deformity.
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Normal lateral band location, dorsal to the axis of rotation of the proximal interphalangeal joint.
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After central slip disruption, lateral bands migrate volar to the axis of rotation of the proximal interphalangeal joint.
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Lateral view of relevant finger anatomy.
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Anteroposterior radiograph displaying a gamekeeper's fracture.
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Lateral radiograph displaying a gamekeeper's fracture.
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Ruptured ulnar collateral ligament.
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Completed UCL repair using suture anchors for fixation (same patient as in the image above).
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Radiograph displaying a stress test of a torn ulnar collateral ligament.
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Complex unstable fracture of the proximal phalanx.
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Displaced fourth and fifth metacarpal fractures, anteroposterior view.
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Displaced fourth and fifth metacarpal fractures, lateral view.
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Fourth and fifth metacarpal fractures, oblique view.
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Fourth and fifth metacarpal fractures after intramedullary pinning, anteroposterior view.
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Fourth and fifth metacarpals after intramedullary pinning, lateral view.
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Digital block.
Tables
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Acute Phase: Closed Reduction and Traction
- Acute Phase: Physical and Occupational Therapy
- Acute Phase: Open Reduction, Fixation, and Surgical Repair
- Recovery Phase for Hand Dislocation
- Maintenance Phase for Hand Dislocation
- Prevention
- Activity
- Consultations for Hand Dislocation
- Long-Term Monitoring
- Show All
- Medication
- Media Gallery
- References
