Assessment of Acute Hand Injuries: Part I

Ramirez, Elda G. PhD, RN, FNP-BC, ENP-BC, FAANP, FAEN; Hoyt, K. Sue PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN

Section Editor(s): Ramponi, Denise DNP, NP-C, FAEN, CEN, FAANP; Column Editor

Advanced Emergency Nursing Journal:
doi: 10.1097/TME.0000000000000001
Imaging
Abstract

More than 140,000 hand injuries occur yearly, and an estimated 5 days of loss of work per patient occurs (Bureau of Labor Statistics, 2012). Advanced practice registered nurses (APRNs) are responsible for managing many of these injuries in primary and emergency care settings. Hand injuries are responsible for approximately 10% of all emergency department visits annually (P. Shayne, S. H. Plantz, & F. Talavera, 2012). This article reviews approaches to the assessment of the patient with a hand injury and establishes a process for basic identification of the hand structures and function. Approaches to history taking and specific evaluations for the hand will be discussed and examples of the assessments will be provided. Diagnostic approaches to support physical findings will be discussed, and methods of radiologic assessment will support the audience in making appropriate diagnosis in relation to hand injuries. This is Part I of a three-part series that will validate the approaches to hand assessment for adults and children and identify specific injuries and their management for the APRN.

Author Information

Emergency/Trauma NP Specialty, The University of Texas Health Science Center at Houston (Dr Ramirez) and St. Mary Medical Center, Long Beach, California (Dr Sue Hoyt).

Corresponding Author: Elda G. Ramirez, PhD, RN, FNP-BC, ENP-BC, FAANP, FAEN, Emergency/Trauma NP Specialty, The University of Texas Health Science Center at Houston, 7000 Fannin, Ste 1200, Houston, TX 77030 (Elda.G.Ramirez@uth.tmc.edu).

Disclosure: The author reports no conflicts of interest.

Article Outline

ADVANCED PRACTICE registered nurses (APRNs) are rapidly becoming frontline providers in emergency and ambulatory care settings that manage and treat hand injuries. These settings are frequented by patients of all ages with hand injuries. More than 140,000 hand injuries occur yearly, and an estimated 5 days of loss of work per patient occurs (Bureau of Labor Statistics, 2012). Hand injuries are responsible for approximately 10% of all emergency department (ED) visits annually (Shayne, Plantz, & Talavera, 2012).

In this three-part series, Part I of this article reviews approaches to the assessment of the patient with a hand injury and establishes a process for basic identification of the hand structures and function. Part II discusses the clinical presentations of selected hand injuries including clinical presentation, diagnosis, medical decision making, and management on the basis of physical examination (PE) and radiographic findings. Part III discusses pediatric hand injuries. Finally, a dictation/documentation template will be provided.

Back to Top | Article Outline

PATIENT PRESENTATION AND LEVEL OF ACUITY

Patients with hand injuries present with a history of blunt and/or penetrating trauma. Patients with blunt trauma comprise up to 50% of presentations with hand injuries. These patients may present to the ED with a crush injury, smashing finger in a door or might be trying to hammer a nail and injures their finger instead with a hammer (Shayne, Plantz, & Talavera, 2013).

Patients with a penetrating injury make up 25% of hand injuries. These injuries include knife lacerations and puncture wounds with ice picks to name a few. The classifications of common hand injuries include lacerations, puncture wounds, avulsions, crush injuries, high pressure injuries, fractures, dislocations, soft tissue injuries/amputations, nail injuries, foreign bodies, burns, bites, and infections (Shayne et al., 2012).

The initial approach to any patient with a hand injury is to first assess for level of acuity. A patient with a hand injury involving a life-threatening injury (e.g., injury with severe blood loss, sepsis) or a patient with neurovascular compromise (e.g., crush injury, compartment syndrome) requires immediate attention.

Back to Top | Article Outline

A-B-C-Ds

It is the responsibility of the APRN to perform a thorough PE. Begin with general resuscitation as needed: airway, breathing, and circulation (ABCs). If there is excessive bleeding (e.g., amputation), provide hemorrhage control with blood pressure cuff or tourniquet use in life-saving situations, which is now recognized as appropriate care if performed properly (Kragh et al., 2009). Extensive bleeding should be controlled with a tourniquet that is approximately 2–3 in. above the bleeding extremity and should occlude the arterial pulse (White, 2011). The tourniquet should be visible at all times, and the patients must be transported to a medical facility immediately for definitive management (White, 2011). Splint all fractures for hemorrhage and pain control. Dress all wounds with saline gauze. Major disabilities such as neurological injuries (e.g., nerve injury of the hand) must all be addressed during this phase of care.

Back to Top | Article Outline
Compartment Syndrome

Patients with suspected compartment syndrome need immediate assessment for increased compartment pressure. The hand has 10 compartments, and the pressures in the compartments should not exceed within 20 mmHg of a patient's diastolic pressure or within 30 mmHg of the mean arterial pressure. Anything in theses ranges of elevated pressure should be considered for emergent surgical intervention (Olson & Glasgow, 2005). Obtain vital signs including pulse oximetry. Once the APRN has established the immediate acuity of the injury and it is not life or limb threatening, the provider may proceed with the examination. Check the pulses and capillary refill in the affected extremity and compare with opposite noninjured extremity.

Then, the history of present illness (HPI), medical history, and PE of the patient are simultaneously important considerations in the overall care of a patient with a hand injury.

Back to Top | Article Outline

HISTORY OF PRESENT ILLNESS

History of present illness includes a chief complaint stated in the patient's own words and an HPI primarily to identify the level of care the patient needs. The patients' medical history is important in relation to comorbidities that may affect healing of injuries and can potentiate infection. A thorough history of hand injury would include some of the following questions identified in Table 1.

Advanced practice registered nurses may receive patients with hand injuries from triage with concurrent environmental situations such as nonaccidental trauma (e.g., child maltreatment) and domestic violence. These conditions may alter the management plan for the patient. Performing a thorough HPI along with family, social, allergy, and medication history is obligatory. The through history will prepare the APRN to approach the injury with knowledge that will enhance the PE and direct differential diagnosis.

Back to Top | Article Outline

MEDICAL HISTORY

Hand Dominance

Comorbidities: Does the patient have any comorbidities including but not limited to diabetes, cancer, human immunodeficiency virus (HIV), and/or hepatitis?

Social history: Does the patient use substances such as alcohol, tobacco, or recreational drugs?

Past surgeries: Has the patient had a previous upper extremity injury, previous surgical intervention, or previous illness?

Family history: Is there a hand anomaly?

Medications: Is the patient taking Coumadin (warfarin), or is the patient currently on any antibiotics for another infection?

Allergies: Are there known allergies to medications, foods, or latex?

Immunizations: Tetanus status. Inquire about recent tetanus status. These guidelines will be discussed in depth in Part II of this series.

Finally, inquire about recent food intake in the event that the patient will need operative intervention.

Back to Top | Article Outline

PHYSICAL EXAMINATION

Bones. It is important to appreciate the anatomy of the hand. Describing the palmar (volar) surface anatomy (see Figure 1; Wolfson et al., 2005) is important to describe direction and imagery of the hand when describing either in documentation or on consultation. There are 27 bones in the hand: five metacarpals, five proximal phalanges, four middle phalanges, five distal phalanges, and the eight carpal bones. These bones work together with 12 extensor and 12 flexor tendons that make up the hand and allow it the ability to oppose and grip (Daniels, Zook, & Lynch, 2004).

Flexor tendons. Flexor tendon examination is critical to perform. To assess flexor digitorum profundus, hold middle phalanx in complete extension and evaluate strength of flexion of the distal phalanx (see Figure 2). Repeat for each digit. To assess flexor digitorum superficialis, hold nonaffected digits in complete extension and evaluate strength of flexion of the midphalanx (proximal interphalangeal (PIP) joint; see Figure 3). It is important to eliminate use of intrinsic palmar muscles in order to isolate the flexor tendon.

Extensor tendons. Extensor tendon examination is also critical to perform. To assess abductor pollicis longus and extensor pollicis brevis, the patient must be able to abduct thumb from other fingers. For extensor carpi radialis longus and extensor carpi radialis brevis, the patient must be able to make fist and extend hand at the wrist. For extensor pollicis longus with the palm down, the patient should be able to raise the thumb. For extensor carpi ulnaris, there should be ulnar deviation and intact extension of digits against resistance. There should also be adequate movement of the ulnar collateral ligament of thumb with strong opposition (see Figure 4, Wolfson et al., 2005).

Nerves. The ability to identify the potential for motor and/or nerve and/or sensory function of the hand is imperative (see Figure 5 Wolfson et al., 2005) to depict the specific motor and sensory nerve distribution of the median, radial, and ulnar nerves. The ulnar, median, and radial nerves innervate the hand and support its many functions. Each digit has two neurovascular bundles close to the palmer surface of the hand that include the digital artery, dorsal and palmar digital nerves, and vein (Bickley, 2009; Daniels et al., 2004). A thorough assessment of the hand will include inspection, palpation, and range of motion. The patient should be able to perform the following functions.

Ulnar nerve: abduct fingers against resistance, sensation on ulnar surface little finger.

Median nerve: oppose thumb and little finger, sensation enervates palmar surface of thumb, index, middle, and half of the ring finger

Radial nerve: extend wrist and fingers against resistance, sensation on dorsal web space between thumb and index finger

Nails and their structures/function. It is also important to check the nails for nail avulsions. Check for tissue avulsion, partial/complete amputation, and subungual hematoma. Assess for local erythema, exudate, diffuse soft tissue swelling, fingertip swelling, bony step-off, crepitus, deformity, normal cascade of fingers, and any irregular angulation of the digits. Evaluation of the nail bed, eponychium, and distal interphalangeal joint is critical due to edema and pain masking hidden injuries (see Figure 6; Wolfson et al., 2005). Consider flexor tendon involvement in any trauma to forearm, palm, or digits.

The examination of the proximal extremity and its joints is standard of care: head, neck, shoulder, elbow, and wrist.

Neck. For a C6 involved injury, there will be decreased use of the palmar surface of thumb, index, and half of the third finger. If C7 is involved, there is decreased use of the palmar surface of the third finger, and for a C8, there will be decreased use of the palmar surface of the fourth and fifth fingers.

A step-by-step examination of the hand can be found in Table 2 of this document. The following pneumonic is also a support to providers when completing a thorough hand examination.

Back to Top | Article Outline

8 P MNEMONIC

Inspection of the hand involves evaluating in resting position and through range of motion. Both the dorsal and palmar surfaces and each individual joint must be inspected, put through range of motion, and palpated. (Bickley, 2009).

Palpation may be limited because of pain; yet, having a painful joint or tender area anywhere on the hand is what leads the APRN to the differential diagnosis. Range of motion and altered sensation are the final components of the examination. The following pneumonic has been developed for the APRN to have a customized process in evaluation of the hand so that components of the examination are not overlooked:

Pain: Tenderness to palpation

Position: Obvious deformity/crepitus, hand position

Pallor: Color, temperature, moisture, surface trauma, ecchymosis, open wound/bleeding, erythema, warmth

Pulse: Quality of pulses; distal neurovascular status, cap refill digits

Paralysis: Range of motion of all five digits

Paresthesia: Sensation to light touch

Puffiness: Soft tissue swelling, mass

Pressure: Tenseness, compartment syndrome (Shea & Hoyt, 2012)

Back to Top | Article Outline

RADIOGRAPHIC EVALUATION OF THE HAND

Ordering Plain Films

It is important for the APRN to order the appropriate radiograph of the patient's hand. Bandages and splints must be completely removed with appropriate support so that the injury can be examined properly.

An APRN responsible for management of hand injuries should identify the need for radiographic assessment of the injured hand. Intuitively, a provider assessing a hand or wrist that has tenderness, even without acute injury, should use radiography as form of assessment. In EDs across the nation due to overcrowding, many radiographic orders for extremity injuries are carried out prior to the patient being evaluated by a provider. Triage nurses follow a protocol for hand injuries that should include primary radiography.

There should be three views performed: anterior–posterior, lateral, and oblique of the hand, and each digit should be visible when performing basic radiography. The positioning of the hand and the quality of the radiograph are the role of the technician. Each provider must be able to identify whether a film does not elicit a clear representation of the extremity to reach a definitive diagnosis.

Back to Top | Article Outline
Imaging

Computed tomography (CT) can be included by the APRN if there is question of intra-articular injury and magnetic resonance imaging (MRI) can be included if there is ligamentous injury (Hammert Boyer, Bozentka, & Calfee, 2010). Magnetic resonance imaging is utilized to identify soft tissue injuries, occult fractures, osteonecrosis, and ligamentous injuries (Hammert et al., 2010). The practice of ordering CT or MRI in the ED is not common for simple, isolated hand and wrist injuries. If the injury is stable and consultation is initiated with an orthopedist or hand surgeon, these time-consuming, nonemergent studies can be done on an outpatient basis managed by the specialist.

Back to Top | Article Outline
Radiographic Identification

Basic radiographic imaging identifies varying density of the area being examined. As a refresher, the four basic radiographic classifications include air and fat that are black, water is gray, and metal or bone is white (Erkonen & Wilbur, 2010). In evaluating a hand, initially the provider should systematically begin with making sure that the image is of the patient who is being evaluated. A common potentially disastrous mistake is to make clinical decisions on the basis of an examination belonging to another patient. The image is then evaluated for fracture or abnormality of each bone, each joint for smoothness, and fracture or dislocation, and soft tissue for swelling (Erkonen & Wilbur, 2010) and foreign bodies. Foreign bodies may be present over a bone, so multiple views are critical to identifying an object that is camouflaged by the whiteness of bone. Always consider that the organic foreign body may not be visible in radiograph, and glass is identified only in some cases on the basis of the type of glass and size of the object (see Table 3).

As identified, there are 27 bones in the hand: five metacarpals, five proximal phalanges, four middle phalanges, five distal phalanges, and the eight carpal bones (Bickley, 2009). The hand radiographs in Figures 7A and B illustrating oblique and posterior–anterior (PA) views of the hand identify the bone and joint anatomical presentations of the hand. Figure 7B illustrates the lateral view and identifies the lateral hand bones and distal anatomy of the radius and the ulna. Figure 7C depicts the PA view of the hand and clarifies bone anatomically. Figure 8 illustrates the lateral view of the hand identifying the bones that make up the hand. Each of these views serves a specific purpose in allowing clear identification of significant anatomy of the skeletal presentation. The providers should approach the visualization of the image the same way every time they view a radiographic image. One method is to begin by following the contour of each bone to look for deformity, then soft tissue edema, and finally foreign body. It is common for providers to glance at an image and quickly identify a large deformity and yet err by missing a misalignment or subtle finding that will potentially affect functionality when missed. It is imperative that the provider returns to the patient and reevaluates the hand physically to correlate with radiographic findings. In some cases, the image will show no fracture or significant finding, but the patient is still in significant discomfort or may have dramatic soft tissue injury. The provider should treat the injury as if there is a fracture or underlying injury by appropriately splinting and following up for occult fracture.

Back to Top | Article Outline

PEDIATRIC HAND INJURIES

In the ED, patients of all ages present with hand injuries, and it is imperative to identify the anatomical findings in children who may not have fully formed bones. The identification, differentiation, and definition of children's fractures are beyond the scope of this basic assessment article but will be discussed in Part III of this article in an upcoming issue.

Back to Top | Article Outline

SUMMARY

The purpose this article was to review approaches to assessment and examination of the acute hand and establish a process for basic radiographic identification of the skeletal anatomy of the hand. Often, the APRN's early identification of such an injury can change the outcome of a patient's long-term functionality. At times, a patient will present with a hand injury but fail to inform the APRN of previous injury or disease to the hand and its limited function. Any aberrant finding must be evaluated for acuity and relation to presenting injury. Some red flags in hand assessment are tendon injury missed by not placing hand in position during the injury, such as a fist position. Vascular injuries may seem to be obvious, but if there is no clot formation, and change in position occurs, the clot detaches and the arterial injury is identified. Compartment syndrome can develop in any compartment and the hand has many fascial planes; when initially identifying the mechanism of the injury and the present damage, compartment syndrome may be anticipated and early intervention may save potential disastrous outcome. High-pressure penetration is often not considered when taking a history. Any high-pressure injury classification is considered a potential loss of limb injury until proven otherwise. Part II of this series will discuss specific hand injuries' radiologic and laboratory findings, procedures, and treatment modalities for the injury.

Back to Top | Article Outline

REFERENCES

Bickley L. S. (2009). Bates guide to physical exam & history (10th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott Williams & Wilkins.
Daniels J. M., Zook E. G., Lynch J. M. (2004). Hand and wrist injuries: Part I. Nonemergent evaluation. American Family Physician, 15 69(8), 1941–1948.
Erkonen E. E., Wilbur L. S. (2010). Radiology 101: The basics and fundamentals of imaging (3rd ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott Williams & Wilkins.
Hammert W. C., Boyer M. I., Bozentka D. J., Calfee R. P. (2010). ASSH manual of hand surgery (1st ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott Williams & Wilkins.
Kragh J. F., Walters T. J., Baer D. G., Fox C. J., Wade C. E., Salinas J., Holcomb J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 249(1), 1–7.
Olson S. A., Glasgow R. R. (2005). Acute compartment syndrome in lower extremity musculoskeletal trauma. The Journal of the American Academy of Orthopedic Surgeons, 13, 436.
Shayne P., Plantz S. H., Talavera F. (2012). Hand injuries. emedicinehealth WebMD. Retrieved from http://www.emedicinehealth.com/hand_injuries/article_em.htm
Shayne P., Plantz S. H., Talavera F. (2013). Hand injuries. emedicinehealth. Retrieved from http://www.emedicinehealth.com/hand_injuries/article_em.htm
Shea S. S., Hoyt K. S. (2012). Emergency NP/PA pocket reference guide. San Diego, CA: EmergeEd.
U.S. Department of Labor—Bureau of Labor Statistics. (2012). Nonfatal occupational injuries and illnesses requiring days away from work. Retrieved 2011, from http://www.bls.gov/news.release/archives/osh2_11082012.pdf
White D. (2011). Tourniquets in EMS: Our EMS systems learn invaluable lessons from the horrible price our soldiers pay. Retrieved from http://www.ems1.com/trauma/articles/1001613-Tourniquets-in-EMS/
Wolfson A. B., Hendey G. W., Hendry P. L., Linden C. H., Rosen C. L., Schaider J. J., Suchard J. R. (2005). Harwood-Nuss' clinical practice of emergency medicine (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

acute hand injuries; advanced practice registered nurse; emergency; hand assessment; hand injury

Copyright © Wolters Kluwer Health, Inc. All rights reserved.