Characteristics

• Included in this group are phalangeal/metacarpal fractures, small-joint subluxation/dislocations and ligament injuries, tendon and nerve injuries.

• Hand injuries are common, e.g. industrial/agricultural trauma, domestic DIY and kitchen-knife injuries, glass injuries, sporting trauma and the ubiquitous road trauma.

• All ages are afflicted by hand injury.

Clinical features

• Swelling, bruising, deformity, reduced range of movement, fracture crepitus and compartment syndrome are possible findings.

• The clinical history and examination should separate soft tissue from bony pathology and also joint from bone injury.

• Comparative examination (with contralateral side) particularly useful in one-side injuries, e.g. normal rotation, capillary refill and sensation.

Radiological features

• AP and lateral view centred on the appropriate bone/joint with adjacent joint essential.

• Look for fractures, including small avulsion fractures indicative of tendon, ligament or volar plate injury.

• Look at alignment – assessing joint subluxation/dislocation – usually obvious on the lateral but look for bony overlap on the AP film.

• Soft-tissue swelling can also be seen on radiograph.

• Assess the articular surface carefully for fractures, depression and loose bodies.

Management

• Assess soft tissues, neurovascular status and (after any reductions) immobilise initially.

• Metacarpal block (‘ring block’) with local anaesthetic into the web space either side of the injured digit, gives good analgesia (up to 8 hours if bupivicaine used) for initial assessment and the emergency treatment of injury.

• Dislocated joints and displaced fractures should be reduced, and stability assessed, and open fractures should be irrigated as soon as possible and a dressing applied.

• Non-operative treatment for undisplaced fractures and stable joints after reduction of a dislocation.

• Operative treatment for displaced or unstable fractures, intra-articular injury with a visible step, recurrent dislocations or subluxation, some missed injuries, e.g. mallet deformity presenting late.

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