Synopsis
Examine hand wounds before anaesthesia, identify rotational fracture deformity and flexor or extensor discontinuity, protect bites and open joints, and coordinate stable splintage, repair and early hand therapy.
- Remove rings before swelling progresses and record hand dominance, occupation, contamination, timing and exact finger position at injury.
- Examine before local anaesthetic: resting posture, tenodesis, digital cascade, active flexion and extension, two-point sensation and capillary refill.
- Test flexor digitorum profundus by holding the PIP extended and asking for DIP flexion; test superficialis while adjacent fingers are held extended.
- Test extensor function at each joint against gentle resistance and use Elson testing when a central-slip injury is suspected.
- Ask the patient to flex all fingers toward the scaphoid; scissoring identifies rotation and is not corrected by accepting greater angulation.
- Obtain AP, oblique and lateral hand or finger radiographs and image for foreign body when mechanism indicates.
- Stable extra-articular fractures without rotation often use buddy support or an intrinsic-plus splint with early movement and defined review.
- Open, intra-articular, malrotated, unstable or multiple fractures and tendon, nerve or vessel injuries need early hand-surgery management.
- Treat a fight bite as deep contamination: explore with the hand in the injury position, irrigate appropriately, give antibiotic prophylaxis and arrange surgical review.
- A mallet injury usually needs uninterrupted DIP-extension splintage, while suspected jersey finger requires urgent flexor-tendon referral.
- Rehabilitation instructions must name which joints move and which remain protected; generic rest creates stiffness or repair failure.
Key red flags
A clenched-fist wound over a metacarpophalangeal joint is a human bite with possible tendon and joint inoculation until proved otherwise.
A pale digit, absent capillary refill, severe crush or ring avulsion requires immediate revascularisation-level hand assessment.
Loss of isolated flexor or extensor function, digital sensory loss or a deep laceration near tendon and nerve requires early surgical exploration planning.
Finger malrotation, overlap or scissoring during flexion is functionally unacceptable even when angular deformity appears small.
Fusiform swelling, flexed posture, sheath tenderness and passive-extension pain suggests flexor-sheath infection, an emergency covered separately in infection care.
The injured finger overlaps or scissors beneath a neighbour when the patient flexes toward the scaphoid.
Abnormal resting extension, disrupted tenodesis and loss of isolated DIP or PIP flexion follows a palmar wound.
A dorsal laceration or drooping joint with inability to extend suggests tendon division, mallet or central-slip injury.
A small dorsal MCP wound after punching teeth may inoculate extensor tendon, joint and bone.
Two-point sensory loss, pale digit or delayed refill after laceration or crush requires urgent hand assessment.
Investigation priorities
Define fracture, dislocation, joint involvement and radiopaque foreign body.
Management branches
A fracture, wound or tendon injury is suspected.
- Remove rings, control bleeding and record cascade, tenodesis, isolated tendons, sensation and perfusion.
- Expose and photograph wounds, identify bite or contamination and obtain appropriate radiographs.
- Give analgesia, cover and splint in a safe functional position and refer according to structural injury.
The closed fracture is stable, extra-articular and has no rotation or tendon deficit.
- Use buddy support or an intrinsic-plus splint matched to location and check skin and rotation.
- Begin movement of unprotected joints early and provide elevation and analgesia.
- Review alignment and hand function and escalate scissoring, displacement or failure to progress.