Edited by Christina Liu and CJ Nessralla - 7/1/2021
Descriptors
Mangled Hand or Wrist
Exam Pearls
Remove field tourniquet on initial evaluation.
Hand exam
Sensory exam prior to blocking. Once determine nerve status, can block/numb hand for more detailed exploration and irrigation
Irrigate and determine structures injured: order of importance:
- Vascular
Only need 1 digital artery per finger Cap refill in finger tip, radial pulse + allen test in wrist Color Pulse ox: >94% O2 on each digit normal If abnormal pulse ox, can doppler digital artery more distally vs palpate if more proximal Needle prick test to finger pulp: brisk red bleeding normal (dark, slow = static venous, no bleeding = devascularized)
- Sensory:
Radial and ulnar digital nerve to EACH digit, full radial/ulnar/median nerve exam
- Tendons:
Eval for lacerations. Isolate FDS (flex at PIP while holding all other digits extended) and FDP (flex at DIP while holding PIP extended) to each digit, examine FPL and extensors.
- Fractures and exposed bone
Workup
Radiographs: AP/lateral hand + AP/lateral/oblique wrist and forearm depending on level of injury
Other imaging: Mangled extremities generally proceed to OR without advanced imaging.
Labs: CBC, BMP, PT-INR, T&S, covid (in anticipation of OR depending on how mangled hand is)
Other: Let fellow know early if injury looks bad and concerned for vascular injury
Management
Need for acute intervention:
Remove field tourniquet on initial evaluation.
Yes, irrigation and exploration of possible injured structures Pressure dressing if arterial injury WTD/iodine-soaked sponge, volar resting splint to temporize until OR
Weight-bearing and range of motion: NWB and no ROM of hand/wrist in volar resting splint
Type of immobilization: Volar resting splint
Admission or discharge status: admission if any vascular repair performed in OR. usually will go emergently vs urgently to OR for exploration and repair of injured structures
Anticoagulation: if vascular repair performed, may require heparin gtt
Antibiotics: IV ancef in ED. Add gentamicin or equivalent at institution for grade 2-3 open fractures. Add penicillin G for soil contamination.
Surgical Indications
Absolute: vascular injury, tendon injury, nerve injury
Relative: NA
Not an indication: NA