Initial Trauma Management

INITIAL MANAGEMENT OF HAND INJURIES

The HAND is one of the most specialised structures in the human body with a highly complex anatomy. Seemingly “simple” open wounds can hide injuries to vital structures that are not clinically obvious
Such unrecognised injuries can result in chronic debility and functional compromise
The hand is also extremely vascular, and even small open wounds can cause a considerable amount of bleeding which can be alarming to the injured person and those around them

DO’S

Contact your specialist hand surgeon or emergency services early
Emotional stress from the injury can cause the development of light-headedness or even fainting. If necessary, ask the patient to lie down.
Remove all gross contamination
Apply a non-adhesive dressing – jelonet or saline soaked gauze and a bandage
If excessive bleeding – apply direct pressure with a firm bandage
Do not disturb the dressing once bleeding has stopped
Early control of blood loss will prevent the unlikely development of physiological shock
Remove any rings or jewellery from the injured hand. Subsequent swelling can cause serious complications – nerve compression and/or digital ischaemia
Immobilise the hand – instruct patient not to move and apply a splint if available
Elevate the hand – use a sling if available
Review tetanus status
Keep the injured person fasted until specialist review

DON’TS

Apply a digital tourniquet – digital ischaemia is a well recognised complication
Attempt to explore the wound – likely to miss vital injuries OR cause more harm
Blindly clamp bleeding vessels

Dismiss an injury as only “minor”

Most experienced hand surgeons would advise that all open hand wounds be explored. Also, completely normal finger flexion and extension does not exclude a significant tendon injury! If you are confident that the injury does not require specialist review, then treat as deemed appropriate.

Injuries to be very suspicious of are:

Any open wound overlying the extensor aspect of a joint. Complications from unrecognised tendon injuries and/or the develpoment of septic arthritis are devastating and unfortunately not uncommon late presentations of these open wounds
Lacerations secondary to glass, sheet metal or power tools
Any open wound that has pain associated with finger/thumb movement. This may suggest a partial tendon injury or joint pathology
Bite wounds
Any closed wound that has significant pain, swelling and difficulty associated with movement
Finger-tip crush injuries with subungual haematomas

IF IN DOUBT