When I saw the construction worker being wheeled into the Emergency Department with his hand wrapped in a large blood-soaked dressing, I suspected that his injury was serious. “Are all my fingers still there?” He screamed in absolute panic, his arm high in the air with blood everywhere. As I removed the large bloody dressing, I was suspecting the worst. The paramedics stated that the patient was involved in a car crash. His left hand had been crushed. His arm and hand were hanging out of the window. Witnesses at the scene saw the vehicle roll over three times before coming to rest on the drivers’ side. The patient required extraction from his vehicle. “They’re all here,” I said, while I reassured both him and his family.

While trauma to the hand may not be life-threatening, it often results in incapacitating lifestyle changes. Loss of function to the dominant hand can be cumbersome, frustrating, and may require subsequent reconstructive surgeries and long-term rehabilitation to regain function. Long-term functional outcomes may not be fully assessed during the initial acute phase of injury.¹ Another factor related to hand trauma is that alcohol-related hand injuries cost twice as much for treatment.²

According to the National Safety Council in 2006, some 521,300 cases of arm/hand/finger injury were reported in the US. The average cost of a hand/finger/arm injury was in the tens of thousands of dollars for all the medical care required. Disabling and combined injury in upper extremity trauma increases morbidity and mortality and costs billions of dollars in medical expenses, loss of wages, and productivity for society.³

The hand is an intricate and organized system of structures that enables the distinction of position sense (proprioception) and feeling/sensation (sensibility). The thumb adds 40% to the power of the hand because of its ability to aid in pinching and grasping. Writing, eating, or brushing the teeth or hair would be extremely difficult without the gripping strength of the thumb.

Anatomical structures in the hand include bones, blood vessels, nerves, ligaments, and tendons. These structures work in an organized and coordinated fashion in order for the hand to perform its many functions. For example, if a flexor or extensor tendon is lacerated, function of the affected finger can be severely compromised. The major nerves innervating the hand — the radial, median, and ulnar — are equally important to function. If the radial nerve is severed, the hand loses one-half to three quarters of its power. If the median or ulnar nerves are injured, the finite and precision pinching ability of the hand is interrupted. In essence, fracture, infection, and trauma not only alter the anatomy and physiology of the hand, but its capacity to work properly as well.

Examining the injured hand

Accurately assessing and describing injured parts is important to the health care provider, not only for purposes of documentation and communication to physicians, but so that proper treatment can be instituted. Of course, before beginning detailed questioning and assessment, control active bleeding by applying direct pressure and elevating the traumatized arm/hand. Remember that a tourniquet or hemostat is never applied to a digit or underlying structures because it will increase the potential for creating more tissue injury and potentially prolonging treatment and tissue healing.^4,5 If bleeding or hemorrhaging continues or progresses, the patient may have a pneumatic-inflated arm tourniquet applied in the ED/Trauma center. Application of this type of tourniquet is physician supervised for amount of pressure in mmHg and length of time that the tourniquet is applied.⁵

In assessing hand trauma, thorough physical and occupational histories can provide much of the information that is needed to make a diagnosis. In addition to routine queries including history of present illness or trauma, pertinent past medical history, current medications, allergies, smoking, drug/alcohol use, and significant family history, be sure to find out:

1. What was the mechanism of injury?
2. What time did the injury occur?
3. What is the estimated blood loss?
4. Does the patient have allergies to medications?
5. When was the last tetanus shot?
6. Where is the pain — severity, location, and pattern?
7. Can you see edema/swelling around the wound? Is it ascending or descending? Does swelling interfere with hand or digit functioning?
8. Is there numbness, paraesthesia, or weakness? What is the degree of functional sensory disability?
9. What treatment was rendered prior to the patient’s arrival at the treatment center?

Understanding the mechanism of injury

With any trauma, understanding the biomechanical forces related to the injury can assist with the triage process and can provide insight into needed treatment. Mechanisms of injury include amputation, blunt injury, crushing, degloving, blast/explosive injury, and penetrating trauma.^6,7,8

Blunt injury occurs when the skin surface is struck with a flat, dull, rounded, or unpointed object. As a result, excessive bleeding into and around soft tissue structures occur; sprains and strains of tendon-ligamentous attachments commonly occur.⁵ Extensive contusions caused by blunt trauma may be so severe as to cause vascular compromise. Repetitive strain trauma from vibrating tools or forceful repetitive movements can precipitate what is called cumulative trauma disorder (CTD), repetitive strain injury (RSI), or work-related musculoskeletal disorders (WRMD), such as carpal tunnel syndrome or DeQuervain’s tenosynovitis. Other diagnoses related to CTD are bursitis, tendonitis, ganglion cyst, mononeuropathy (single nerve dysfunction), and Raynaud’s phenomena.⁷ Blunt injury directly over bone may also cause fracture to underlying osseous structures.

Penetrating injury occurs when a pointed object such as a knife, bullet, or tooth laceration commonly referred to as a “fite bite” penetrates the skin’s surface and enters the underlying tissues. Small, inconsequential-appearing puncture wounds created by high-pressure injection injuries (HPI) caused by tools or equipment can occur when people are working and handling air-compressed tools. Air/pneumatic tools can release 600 pounds to 20,000 pounds of pressure per square inch of tissue mass. Injured persons can be injected with chemicals, grease, oil, paints, and solvents. The blast of air from these tools not only fractures bone, but the various caustic substances travel along tendon sheaths and fascial planes, which cause deep-space tissue infection and contamination of wounds.^5,9,10 Penetrating tissue injury can also precipitate infection to bone (osteomyelitis) and surrounding tissues. Kanavel’s signs (tenderness over a flexor tendon sheath, flexed posture of the digit, severe pain on passive stretch of the digit, and fusiform swelling) indicate serious deep-space tissue infection and/or purulent tenosynovitis of the digit. These signs indicate an orthopaedic emergency and the patient should be treated expeditiously.⁵

Blast injury is caused when firecrackers, combustible materials, or bombs explode on or into tissues. This can lead to an extensive disruption of tissues, causing significant bone and soft tissue damage to biomechanical and neurovascular structures.⁶

Degloving injuries produce significant tearing and detachment of skin and neurovascular structures away from bone in the finger or hand. Lack of sufficient local circulation and sensory innervation generally requires amputation.^4,11

Crushing injuries occur when fingers or hands are crushed between heavy machinery or objects. These injuries cause extensive bleeding. Excessive bleeding into muscle can precipitate compartment syndrome, which is the elevation of tissue pressures within a myofascial compartment.¹¹ Compartment syndrome is also an orthopaedic emergency. An important clue to a nurse regarding compartment syndrome is pain not relieved by narcotic analgesia. To relieve elevated intracompartmental pressures that can cause compartment syndrome, a fasciotomy may be performed.

Amputations demand special considerations. If a partially or completely amputated part has been cooled properly, the chances for revascularization (restoration of blood flow) and replantation (reattachment) of the amputated part are greater. Cooling is best achieved when amputated parts are wrapped in sterile gauze that has been moistened with sterile normal saline solution. The part is then placed in a sterile container and the container is placed on ice. Amputated parts are never put directly into povodine iodine solution, saline, water, or ice. These fluids will cause lysis of cells with destruction of tissue, which will render the part unusable for replantation or grafting.

If an amputated part has not been adequately cooled and managed properly, the tissues react by releasing inflammatory mediators such as prostaglandins and histamine that further decrease tissue viability. This minimizes the opportunity for replantation of the amputated tissue/part.

Assessing the damage

Knowing how the injury occurred provides clues as to the mechanism of injury. Trying to estimate blood loss is also helpful — not just for the purposes of transfusion but also to determine which blood vessels may be involved. Pumping or squirting of blood indicates injury to an artery, while a slower oozing or dripping of blood generally means damage to veins. Blood supply flows from the radial and ulnar arteries (and their branches) along the volar aspect, which is on the palm side of the hand.

The patient’s hand is observed and palpated for capillary refill, color, ecchymosis, deformity, normal sweating (lack of sweating may indicate nerve damage), and warmth. Looking at the symmetry of the structures provides data that may assist with the differential diagnoses of hand trauma. The hand is palpated, assessing for active and passive range of motion (ROM). Palpate for crepitus (crunching/popping sensation), which could indicate that an open fracture where the bone ends has now receded back under the skin surface. Joints above and below the area of injury are examined because concomitant injury may not be obvious and palpating proximal and distal will often detect subtle injury.^5,12,13,14

Each finger joint is put through its range of motion, noting inability to flex or extend the joint. The base of each joint is securely held while the joint being examined is flexed or extended. This ensures that the particular tendon being examined is actually moving the finger joint.

In arterial trauma (vascular inflow), poor arterial circulation presents with a cool, pale, or pallored (white) finger that has poor tissue turgor. In a finger with poor venous circulation (venous outflow), the digit may be cyanotic, congested, edematous, and warm.¹⁵

No matter where on the hand the injury has occurred, a thorough neurovascular assessment is performed. The components of the neurovascular assessment include pulses, sensation, motion, skin temperature, color, and capillary refill.

X-rays are obtained of the amputated tissues and affected parts. Amputated digits are also X-rayed. Two orthogonal (right angle) views, anterior/posterior and lateral, are recommended. However, oblique views and stress views of a joint may be necessary. For injuries caused by excessive forces, the joint above and below the affected part are X-rayed. Radiographs not only show fracture, but they may show the presence of foreign bodies such as metal, glass, or radio-opaque debris. Plain X-rays cannot visualize wood and nonradiopaque plastic. CT or MRI may be warranted; however, these imaging studies are generally not obtained in the emergent setting post hand trauma.¹⁶

After emergency measures — what next?

Cleansing: Wound edges are cleansed with an antibacterial solution; the wounds are irrigated with normal saline solution. Contaminated wounds (farm accidents, bites, and chemical burns) are cultured first and then cleansed by copious irrigation with a pulsatile lavage system.¹⁷ Surgical scrubbing and debridement of devitalized tissue may require management in the operating room.

PRICEMM Method: PRICEMM is an acronym for protection, rest, ice, compression, elevation, medication, and modalities.⁴ However, if compartment syndrome is suspected, do not apply ice to the fingers/hand. In compartment syndrome, ischemia and edema to the underlying tissues causes the circulation to be compromised. Applying ice will further compromise blood supply to the tissues.

Suturing: Many lacerations require suturing to approximate wound edges. Animal and human bites, however, are generally not sutured closed due to the high incidence of infection.¹¹ Contaminated lacerations are lavaged and often “loosely” closed or left open to close by secondary intention, or may require skin grafting.

Dressings: Hand dressings, while bulky, are supportive. The hand is placed in the position of function (normal physiologic cascade of fingers). This position is important so undue tension is not placed on nerve and tendon repairs, suture lines, and wire/pin insertions. Plaster splints may be used over the top of dressings to further support the hand.

Casting: Fractures to the hand may require casting, splinting, or surgery for open reduction internal fixation. C-wires — tiny wires used for internal fixation — or an external fixator device, such as a Hoffman apparatus may be needed to stabilize the fracture. Generally, due to tissue swelling, acute fractures are splinted and then casted 72 hours to seven days post trauma.

Keeping germs at bay: antibiotic coverage

After the wound is flushed by lavage, contaminated wounds require tetanus prophylaxis as well as antibiotic coverage.^18,19 Depending on the mechanism of injury and where the accident occurred, specific antibiotics will be indicated. A culture and sensitivity test taken before the wound is cleaned will aid in the decision of which antibiotic to use. Antibiotics are also administered when the joint cavity or cortex of the bone has been breached. Cephalosporins are commonly used in hand trauma.

Certain wounds are predictably contaminated. Human and animal bites, lawn mower mishaps, and farm-related injuries are just a few examples.^20,21,22 The sidebar lists common organisms seen in hand infection. Anaerobes that cause tetanus live in animal feces and farm soil. Prophylaxis against tetanus and gas gangrene is essential. Depending on the patient’s tetanus status, Tetanus/diphtheria toxoid 0.5 ccIM and/or Tetanus Immune Globulin (TIG) (Human) 250-500 units IM is administered. Dirty or contaminated wounds require tetanus prophylaxis within the last five years, while clean lacerations, such as a hand cut by a glass while washing dishes, may only need tetanus coverage within the last five to 10 years.

Getting the hand back in shape

Nerves regenerate at a rate of just 1 mm to 2 mm a day, so rehabilitation of a hand injury may be slow and tedious. Physical therapy (PT) and occupational therapy (OT) are crucial in the rehabilitation process. Severe crush injuries, as well as all third degree and some second-degree burns to the hand, require extensive follow-up. Revascularized and replanted digits, as well as traumatic injuries around joints and injuries resulting in excessive scar tissue formation, also need extensive rehabilitation to regain and maintain function.

For complicated hand injuries, the initial phase of rehabilitation includes wound cleansing and dressing to promote healing. PT alleviates muscle atrophy and stiffness, which could lead to excessive scar formation and contracture of essential hand joints. OT fashions movable and stationary hand splints, which are used throughout the acute phase of rehab.

The later part of rehab includes guidance by a vocational rehab therapist, who assists the patient to practice or relearn job and avocation skills. PT at this point is aimed at endurance, flexibility, and strength (referred to as work hardening).

Specialized equipment such as the Engalischiff work simulator is used. This computerized device gauges resistance and repetitive movements and tracks the patient’s progress. Trends in daily and weekly progress can be monitored.

Psychosocial support is a significant part of the emotional healing process for the patient and family. Developing Post Traumatic Stress Disorder (PTSD) after hand trauma is not uncommon. Permanent or temporary loss of a job affects the entire family system. Psychosocial specialists (nurse practitioners, clinical nurse specialists, social workers, and physicians) can assist the patient and family during transitional and stressful periods. Early psychosocial intervention may decrease psychological factors that could impede therapeutic functional outcomes in the patient.^23,24,25

Hand trauma poses many challenges to the patient. Loss of income, self-care, personal independence, and alteration within the family unit can result in long-term commitments placing strain on personal and family relationships.^26,27 The hand is crucial for attending to activities of daily living. While splints and exercise devices are essential in rehab, knowing how to intervene from the minute the patient is injured is the nurse’s best tool.