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The Painful Hand and Wrist: Causes and Care
With a refresher course on the musculoskeletal neurologic, and vascular anatomy of the hand and wrist as background, the authors highlight key clinical features of afflictions ranging from Colles fracture to carpal tunnel syndrome.
By Brett A. Miller, MD, Lorraine Brady, MD, and Raymond G. Hart, MD, MPH
Injuries and pain to the hand and wrist are extremely common complaints in the emergency department. Overall, hand injuries represent approximately 5% to 10% of all emergency department visits annually. Early evaluation, recognition, and therapy are essential to positive patient outcomes. Failure to properly recognize threatening conditions and initiate timely treatment could have disastrous results.
In this article, we will review the anatomy of the hand, common fractures of the hand and wrist, and carpal tunnel syndrome. Other types of injuries, such as nail bed and nerve injuries, as well as burns, cold injuries, and infections of the hand will be discussed.
ANATOMY OF THE HAND
Understanding the anatomy of the hand begins with identification of the basic landmarks and anatomic terminology. The palmar (volar) surface is opposite the dorsal surface (back of the hand). There is a radial (lateral border) and ulnar (medial border) aspect to the hand and each digit. The digits are identified as the thumb, index, middle, ring, and little fingers, or digits one through five, respectively. Each finger has a distal, middle, and proximal phalanx. The thumb has only a distal and proximal phalanx.
The joints are referred to as the distal interphalangeal (DIP), proximal interphalangeal (PIP), metacarpophalangeal (MCP), and carpometacarpal (CMC). The thenar eminence is located on the palmar surface at the base of the thumb. The hypothenar eminence is the opposite prominence at the base of the little finger. The creases of the palm are identified as digital, palmar, and wrist.
The hand and wrist consist of 27 bones. These are further broken down into 14 phalangeal bones, 5 metacarpal bones, and 8 carpal bones. The carpal bones that make up the wrist are arranged in two rows. The proximal row from the radial side contains the scaphoid, lunate, triquetrum, and pisiform bones; the distal row from the radial side contains the trapezium, trapezoid, capitate, and hamate bones.
The metacarpal bones articulate with the irregular border of the distal carpal row through the CMC joint and with the phalanges through the MCP joint. The 14 phalanges in each hand articulate with one another through the PIP joint and the DIP joint.
TENDONS OF THE HAND
There are nine flexor tendons that cross the wrist volarly. Flexion of the digits is supplied by the flexor digitorum profundus (FDP) and superficialis (FDS). The FDS bifurcates at the base of the proximal phalanx and at each slip inserts at the proximal aspect of the middle phalanx. The FDP lies deep to the FDS and inserts at the base of the distal phalanx. Both tendons are enclosed in a synovial sheath distal to the MCP joint, making them prone to deep space infections. The flexor pollicis longus of the thumb inserts at the base of the distal phalanx. The volar surface of the carpal bones is bridged by the flexor retinaculum, forming the carpal tunnel, through which the median nerve and the nine flexor tendons of the fingers pass.
The flexor carpi radialis, flexor carpi ulnaris, and palmaris longus provide flexion at the wrist. There are also nine hand extensor tendons that cross the wrist dorsally, where they are separated into six compartments. In the hand, the extensors digitorum communis are connected by juncture. In the finger, the extensor expansion divides into a central slip that attaches to the middle phalanx and two lateral bands, joining with the tendons and muscles attaching to the base of the distal phalanx.
ARTERY, NERVE, AND MUSCLE ANATOMY
The hand’s blood supply is provided by both the radial and ulnar arteries, which form the deep and superficial palmar arches in the proximal hand. The digits are supplied by common digital arteries, main branches of the superficial arch.
The radial, ulnar, and median nerves innervate the hand. The ulnar and median nerves provide both motor and sensory function in the hand. The ulnar nerve supplies sensory function to the little finger and half of the ring finger and motor function to the hypothenar muscles, the ulnar two lumbricals and interossei, the adductor pollicis, and the deep head of the flexor pollicis longus. The median nerve supplies sensory function to the thumb, index, and middle fingers, and the radial half of the ring finger, and motor function to the abductor pollicis brevis, the superficial head of the flexor pollicis brevis, and the opponens pollicis. The digital nerves are relatively superficial structures that are often injured in palmar lacerations.
The intrinsic muscles of the hand consist of the interossei, the lumbricals, the thenar and hypothenar eminence muscles, and the adductor pollicis. The thenar muscles consist of the abductor pollicis brevis, the opponens pollicis, and the flexor pollicis brevis, all innervated by the median nerve. The adductor pollicis is innervated by the ulnar nerve. The hypothenar group includes the opponens digiti minimi, the flexor digiti minimi, and the abductor digiti minimi. There are seven interossei—three palmar and four dorsal—lying between the metacarpal bones and innervated by the ulnar nerve. The interosseous muscles abduct the fingers away from the midline. There are four lumbricals that contribute to extension of the interphalangeal joints. The median nerve innervates the radial two lumbricals and the ulnar nerve innervates the ulnar two lumbricals.
COMMON FRACTURES
Common fractures involving the hand and wrist include boxer’s, Bennett, Rolando, Colles, and scaphoid fractures.
Boxer’s fracture. A boxer’s fracture is a fracture of the neck of the fourth or fifth metacarpal with volar displacement of the metacarpal head (see top image, below). Metacarpal neck fractures are among the most common hand fractures encountered in the emergency department. They account for approximately 10% of all hand fractures. The mechanism of injury is a direct force with a closed hand (punching someone or something). In patients with a boxer’s fracture, the dorsum of the hand is swollen and bony tenderness is found over the fractured metacarpal. Significant tenderness or ecchymosis on the palmar bony surfaces is highly suggestive of fracture.
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| Boxer's and Bennett fractures. The mechanism of injury in both boxer's (top, arrow) and Bennett (bottom, arrow) fractures is usually a direct force with a closed hand, such as punching someone or something. |
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Management of these fractures is based on displacement.Nondisplaced fractures are treated with elevation, analgesia, and immobilization with a gutter splint. New studies are beginning to show that early mobilization of isolated fifth metacarpal fractures improves functionality. Displaced or angulated fractures require reduction prior to immobilization with a gutter splint. Care must be taken when applying splints. The MCP joint should be immobilized in flexion to prevent shortening of the collateral ligaments and subsequent loss of motor function. Appropriate follow-up with a hand surgeon is necessary.
Bennett fracture. A Bennett fracture is a fracture of the thumb at the base of the metacarpal with associated subluxation of the CMC joint (see bottom image, above). The resultant instability causes the metacarpal shaft to displace proximally and radially because of the pull caused by the fracture on the abductor pollicis longus tendon. The mechanism of injury usually is axial force to a flexed metacarpal (punching with a closed fist). Initial reduction of the fracture is required; however, this is difficult because of the resultant ligamentous disruption. Early appropriate treatment is mandatory for this type of fracture, because if the fracture is not reduced and held, the consequence may be an adducted thumb without good function as well as a painful joint.
Further treatment includes immobilization with a thumb spica splint, pain control, ice, and elevation. Early referral to a hand surgeon is essential because although these fractures are relatively uncommon, they require open reduction and pinning.
Rolando fracture. A Rolando fracture is similar to a Bennett fracture in that both typically occur by the same mechanism and involve the base of the thumb metacarpal. This is a comminuted fracture at the carpometacarpal joint, typically in a Y-shaped pattern. It has also been described as a double-Bennett fracture in which two basilar fragments are intra-articular. This fracture is unstable and usually has a much worse outcome than a Bennett fracture. Immobilization, ice, elevation, and pain control are the initial treatments, but surgical repair is the definitive intervention. Therefore, early referral to a hand surgeon is essential.
Colles fracture. A Colles fracture is a fracture of the distal radius with dorsal displacement, possibly accompanied by ulnar styloid fractures (see images, below). The resultant deformity is termed “silver fork” or “dinner fork.” A Colles fracture is the most common wrist fracture seen in adults today. Classically, the mechanism of injury is a fall onto an outstretched hand with the wrist in mild dorsiflexion. There are multiple classifications of these fractures, each based on the site of fracture, ulnar styloid involvement, or further joint involvement. Examination reveals pain on palpation with associated swelling of the dorsum of the wrist. A focused neurovascular exam is critical because associated median nerve injuries are highly possible with this type of injury due to compression from edema within the carpal tunnel.
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| Colles fracture. These lateral and posteroanterior views illustrate a Colles fracture (arrows). Classically, Colles fractures are caused by a fall onto an outstretched hand with wrist in mild dorsiflexion. |
Closed reduction should be attempted in the emergency department. If successful reduction is accomplished with no neurovascular compromise, cast immobilization with orthopedic follow-up is appropriate. The cast should be kept in place for six weeks, followed by two weeks in a palmar wrist splint. Rehabilitation should start after the six weeks of cast placement to increase flexibility of the wrist. Failed reduction or any signs of neurovascular compromise should prompt early orthopedic consultation for possible surgical intervention.
Scaphoid fracture. A scaphoid fracture is the most common fracture of the carpal bones seen in the emergency department, and the second most common fracture of the wrist after a distal radius fracture. The typical mechanism of injury is a fall onto an outstretched, dorsiflexed hand.
Scaphoid fractures can be further broken down into four categories: tubercle, horizontal oblique, transverse, or vertical oblique. Two thirds of these fractures occur in the middle third of the bone, and these are divided equally between transverse and oblique fractures. Classically, the patient presents complaining of pain in the extreme lateral aspect of the wrist in the area of the dorsal radius. Physical examination will reveal tenderness to palpation within the anatomic snuff-box, with decreased range of motion of the wrist and thumb. Clinically, there is no obvious wrist deformity other than swelling on the radial side.
The diagnosis of a scaphoid fracture should not be made based on radiographic evidence alone because many of these fractures can be missed on early x-rays. Splinting is necessary for an improved outcome. Patients with negative x-rays but highly suspicious physical exam findings should be immobilized with a thumb spica splint and referred to a hand surgeon for follow-up x-rays in 10 to 14 days. Nondisplaced fractures require immobilization with a thumb spica splint and orthopedic follow-up. Displaced fractures require orthopedic consultation for possible open reduction and internal fixation in the operating room, since the majority are unstable. Quite often, when these fractures fail to heal, a posttraumatic arthritis can develop. Therefore, scaphoid fractures need to be recognized and treated promptly and appropriately.
CARPAL TUNNEL SYNDROME
Carpal tunnel syndrome is a symptom complex comprising nocturnal paresthesias, burning pain, sensory changes in the fingers innervated by the median nerve, and diminished dexterity. A common cause is hypertrophy of the synovial tissue surrounding the median nerve in the proximal palm, resulting in diminished blood flow to the nerve and gradual nerve irritation. Hypertrophy of the synovial tissue may develop in response to the increased demands of repetitive work. The carpal tunnel is a static-volume structure, and increasing pressure within it will be transferred to the relatively soft median nerve. Diagnosis can be guided by nerve conduction studies showing the slowing of conduction across the carpal tunnel with elevated nerve sensory or motor latency. In the emergency department setting, it is best to stick with a diagnosis of numbness of the hand until a nerve conduction test is positive with objective findings.
Initial treatment of carpal tunnel syndrome includes cessation of the repetitive activity that precipitated the problem, wrist splinting, elevation, and a nonsteroidal anti-inflammatory drug (NSAID). Referral from the emergency department is best made to the patient’s primary care provider, rather than to a hand surgeon, for further testing and nonsurgical treatment options.
TENDONITIS AND TRIGGER FINGER AND THUMB
De Quervain’s disease, sometimes referred to as stenosing tenosynovitis or first compartment tendonitis, will present with pain, swelling, and tenderness on the radial side of the wrist that increases with ulnar-directed movement of the thumb and wrist. Chronic overuse is usually the cause, but the problem can occur after an acute traumatic event such as a contusion or laceration.
Physical examination demonstrates tenderness to palpation over the radial styloid. The Finkelstein testis performed by having the patient flex the thumb and then wrap the fingers around the thumb. The examiner then moves the hand in an ulnar direction while keeping the forearm immobile. With this maneuver, pain will be elicited near the radial styloid, which is also the point of tenderness.
Initial treatment consists of rest, a soft thumb spica splint, NSAIDs, and avoidance of the precipitatingactivity. If symptoms have persisted for several weeks, a local steroid injection of 1 ml of betamethasone with 1 ml of plain lidocaine may be indicated. First compartment syndrome must be differentiated from degenerative arthritis at the thumb’s CMC joint.
Trigger finger or trigger thumb is a condition characterized by a catching or snapping sensation in the finger or thumb that is relieved when the digit is moved from a fixed flexed position to an extended posture. It is associated with pain in the palm, caused by inflammation of the tenosynovium in the tendon sheath. Treatment consists of rest, NSAIDs, and steroid injection. Patients can find relief by wearing a splint over the affected PIP and DIP joints.
NAIL BED AND FINGERTIP INJURIES
The fingertip is defined as the area distal to the insertion of the FDP and extensor tendons. The tuft of the distal phalanx is the well-padded area on the volar surface of the finger. The nail lies on the surface of the dorsal surface of the fingertip. The sides of the nail fold are the paronychium; the base fold is the eponychium; between the nail fold and the nail bed is the nail groove; and at the distal end under the edge of the nail is the hyponychium. The dermis of the nail bed is directly attached to the periosteum of the distal phalanx, deriving its blood supply from a rich capillary bed.
A careful history of a nail bed injury should include the time elapsed since the injury, what occurred at the injury site, and the posture of the hand at the time of the injury. Careful inspection of the fingertip for color and swelling or deformity should be done. Sensation should be assessed by two-point discrimination. Anesthesia, in most cases achieved with a transthecal or digital nerve block, is usually necessary prior to irrigation and inspection. The wound should be copiously irrigated to remove debris, reduce bacterial contamination, and lessen the risk of subsequent infection. An 18-gauge needle attached to a 60-ml syringe will provide adequate pressure to dislodge foreign material, using at least 250 to 500 ml of normal saline.
Nail bed lacerations should be repaired to minimize deformity and the duration of functional impairment. Following placement of a digital block for anesthesia, the nail overlying the injured nail bed can be removed by spreading a small pair of scissors or hemostat beneath the nail, carefully separating the eponychium from the nail edges. The nail bed laceration can then be repaired using a 6-0 or 7-0 absorbable suture. After the removed nail is cleansed with normal saline, a 5-0 nylon suture can be placed through the proximal end of the nail plate and then through the center of the eponychial fold, avoiding the nail bed. This returns the nail to its anatomic position; it also acts as a natural splint to the distal phalanx and protects the sensitive nail bed. A separate hole should be placed through the center of the nail to allow drainage from the subungual area.
If a nail is too damaged or lost to be repaired, a piece of aluminum used in suture packaging or a piece of lubricated gauze can be inserted into the eponychium to maintain an open nail fold that will allow for new nail growth. This also helps prevent formation of synechiae and scarring. The fingertip can then be placed in a nonadherent gauze and volar splint.
Wound care should include hand elevation, neurovascular checks, and adequate analgesia. The dressing should remain untouched for five to seven days, unless there are signs of obvious purulence. The suture attached to the nail may be removed after three weeks. New nail growth may take one to three months.
An avulsion of the nail often includes pieces of the nail bed attached to the undersurface of the nail. In these cases, optimal results are obtained if the nail is replaced as accurately as possible onto the avulsion site. If the tissue is not available and the defect is small, it will heal well by secondary intention. If the defect is large, a hand surgery consult should be obtained because grafting may be needed.
Subungual hematomas result from blunt trauma or crush injuries to the nail bed and present with red-to-black discoloration. An x-ray should be obtained to identify a possible associated fracture. Treatment is based on the percentage of nail bed discoloration. If the hematoma covers less than 50% of the area under the nail, adequate decompression can be achieved by trephination, which is the creation of a hole, or by a scalpel, 18-gauge needle, or electrocautery. Anesthesia is usually unnecessary, and the digit should be splinted in cases with associated fracture.
If more than 50% of the nail bed area is involved, the nail may be removed to evaluate the nail bed and repair any lacerations. There is a 60% incidence of nail bed lacerations involving more than half of the nail bed and an incidence of 95% with an associated fracture. However, about 85% of patients can be adequately treated with trephination alone, regardless of hematoma size.
High-Pressure Injection Injuries
While an uncommon presentation in emergency departments, high-pressure injection injuries are potentially devastating in terms of future hand function. These types of injuries are associated with a high rate of amputation. Early presentations can be misleading to the examining physician because the injury may appear very benign. However, potentially lethal damage lies beneath the skin, most notably to the flexor tendon sheath if the injection was in the finger.
The mechanism of injury usually involves industrial equipment such as grease or spray guns. There are a number of potentially injectable substances, most notably paint, paint thinner, grease, water, and certain oils. Knowing what substance was injected is critical to proper evaluation and treatment. Damage is inflicted by the pressure, the toxicity of the injected substance, and possibly by heat from an injected hot substance.
If the patient presents early, the complaint may be only mild pain near the injection site. Physical examination may show only a subtle entrance wound or no break at all in the skin, and mild swelling may be apparent. The patient who presents several hours after the injury will have a much different presentation. He will complain of extreme pain in the hand or affected digit. Examination may reveal significant swelling in the affected areas with associated signs of vascular compromise and tissue necrosis. In either case, x-rays of the soft tissues should be obtained to determine the extent of the injection if the material is radio-opaque. Urgent hand surgery consultation is critical because surgical debridement and wound exploration are necessary with these injuries.
The affected area should be immobilized with splinting. Tetanus prophylaxis should be given and intravenous broad-spectrum antibiotics should be started early. Some hand surgeons advocate the use of steroids for these injuries.
Nerve Injury Patterns
Nerve injuries usually result from lacerations, contusions, or puncture injuries to the hand. There are three classifications of nerve injuries: neuropraxia, axonotemesis, and neurotemesis. Neuropraxia is a localized conduction block with intact axons, usually from a contusion injury. Light touch is intact but diminished and usually returns to normal spontaneously within days to weeks. Axonotemesis results from a crushing injury, in which the axon is severed but the endoneurium remains intact. Presentation is similar to that of neuropraxia, but Tinel’s sign is present (light percussion of the nerve proximal to the injury elicits paresthesias distally). Recovery is complete but slow due to axonal regeneration.
Neurotemesis refers to complete transaction of the nerve; recovery is unlikely without formal nerve repair. Radial motor function can be tested by wrist extension, thumb extension, and abduction. Radial sensation includes the dorsal aspect of the hand from the thumb to half of the fourth finger. Ulnar motor function is tested by the patient’s ability to pinch a piece of paper between the thumb and index finger. Ulnar sensation includes both the dorsal and palmar lateral hand from the fifth digit laterally to half of the fourth digit. The median nerve is tested by having the patient oppose the thumb to the index finger, flexion of that finger, and thumb abduction and opposition. Median nerve sensation includes the medial two thirds of the palmar hand as well as the dorsal aspect of the second and third and half of the fourth digits.
BURNS TO THE HAND
Burns can be divided into thermal, chemical, and electrical injuries. Direct heat exposure accounts for up to 50% of all thermal injuries, although scalding injuries occur most commonly in children. Acids cause coagulation necrosis, while alkalis can produce liquefaction necrosis and are generally more severe than burns caused by acids. Electrical burns are classified based on source voltage. High-current injury occurs with sources greater than 600 V. Typical residential power lines in the United States are 7620 V; household current is 110 V and large home appliances require 220 V. Current flow through body areas with a small cross-sectional area, such as the hand, will result in more damage from electricity. Air bag injuries represent a unique mix of frictional, chemical, and thermal burns.
A careful history and documentation of neurovascular and motor exams are important in determining the extent and depth of injury. The digits and hand should be evaluated for circumferential burns, which are associated with a high risk of compartment syndromes. The degree of burns should be determined. First-degree (superficial) burns are limited to the epidermis, present with erythema and pain, and heal well in a short period of time. Second-degree (partial-thickness) burns involve the epidermis and varying amounts of the dermis. These are further divided into superficial and deep partial-thickness burns, depending on their ability to heal within three weeks.
Third-degree (full-thickness) burns involve the epidermis, dermis, and dermal appendages. Patients present with a painless, charred wound. These wounds require debridement and skin grafting. Fourth-degree burns involve the underlying muscle, tendon, and bone and require extensive skin grafting.
Superficial and superficial partial-thickness burns can be managed with simple care at home and should heal well in 7 to 10 days. All other burns require referral to a specialist. Analgesic agents should be taken for pain relief. Large blisters may be debrided, but intact blisters should be left as a biological dressing. The patient’s tetanus vaccine should be updated. If necessary, a dressing should be fashioned with sterile gauze Xeroform separating the digits and a cock-up wrist splint when the burns are extensive. Systemic antibiotics should not be administered prophylactically in the emergency department, but antibiotic creams such as silver sulfadiazine are generally used on all burns.
Criteria for hospitalization include the following: circumferential hand and finger burns; full-thickness burns involving more than 2% to 3% of the total body area; high-voltage electrical injuries; significant burns of the hands, face, genitalia, perineum, feet, or major joints; and other significant injuries or comorbid conditions. Discharged patients should be instructed to rinse the wound with soap and water, apply antibiotic cream, and then redress the wound once or twice daily. They should also keep the hand elevated and watch for signs of infection, and they should be told that wound drainage is normal. Burns should be rechecked in 24 hours and full-thickness burns should be seen by a specialist within a day or two.
COLD INJURIES
Management of cold injuries is determined by the extent of the injury and the area involved. They are categorized as freezing injuries if ice crystals have formed in the involved tissue and nonfreezing if ice crystals are absent. Nonfreezing injuries require no specific treatment other than rewarming.
Chilblain results from long-term exposure to cold and damp conditions and is characterized by burning, itching, and erythema. Tender blue nodules may appear on rewarming and will resolve spontaneously. Frostnip is a superficial freezing injury without ice crystal formation in the tissue. The involved skin is pale due to intense vasoconstriction. Symptoms resolve on rewarming. Frostbite is the most severe form of freezing injury, characterized by ice crystal formation and often resulting in permanent tissue injury and loss.
Treatment for cold injuries is removal of the patient from further cold exposure and rewarming. Cold, wet, and constrictive clothing must be removed, and the patient should be placed in a warm water bath of 104° to 107.6°F for 10 to 30 minutes with active movement of the hand. Rewarming is often painful and analgesia is usually required. Current recommendations are to debride clear blisters and leave hemorrhagic blisters intact. Aloe vera cream and ibuprofen may be used by the patient at home. Sterile gauze dressings should be applied, and the hand should be kept elevated.
COMMON INFECTIONS OF THE HAND
Infections of the hand, such as paronychia, felon, flexor tenosynovitis, and herpetic whitlow, are common presentations in the emergency department. Most hand infections are “surgical” rather than “medical,” in that most require some type of incision and drainage and often debridement. Care must be taken with these patients to determine which infections should be treated in the emergency department with systemic antibiotics and which require surgical intervention. A careful history is critical and should include the mechanism of injury and any comorbid conditions that might complicate treatment and healing, such as diabetes, chronic steroid use, and other immunocompromised states.
Close monitoring of vital signs is necessary to determine if a systemic inflammatory response or shock is present. Physical examination must include a careful inspection of the entire limb to assess for adenopathy and lymphangitis.
Paronychia. A paronychia is a superficial infection or abscess formation involving the lateral nail folds of individual phalanges. This is the most commonly encountered infection of the hand seen in the emergency department. Patients will present complaining of distal finger pain with obvious swelling, redness, and tenderness involving one or both sides of the lateral nail beds.
Treatment is determined by the stage of the infection. If the infection is a cellulitis prior to abscess formation, antibiotics are indicated. Antistaphylococcal agents are the mainstays of therapy. The patient should also be advised to elevate the hand and apply warm compresses to the affected area. If the infection has progressed to abscess formation, incision and drainage are indicated. If it has spread beneath the nail, removal of all or part of the nail plate may be necessary. This can be accomplished by inserting a closed, straight hemostat directly underneath the affected nail proximally while gently spreading the hemostat to displace the nail from the nail bed. A digital block or wrist block anesthesia will most likely be required.
Although commonly prescribed, antibiotics are not necessarily indicated in a properly drained paronychia. Patients should be advised to avoid further trauma to the soft tissues surrounding the nail beds, which can result from nail biting or, in children, thumb sucking.
Felon. A felon is a soft-tissue infection of the pulp of the distal finger or thumb. The most common mechanism of infection is penetrating trauma to the distal finger or thumb with secondary bacterial invasion. This can be a complicated infection to manage because the pulp of the distal finger or thumb is divided into several compartments by vertical septa. The patient may present with redness, swelling, pain, and throbbing in the affected distal finger or thumb. Treatment involves complete incision and drainage of the affected area under digital block anesthesia.
Special care must be taken because of these septal divisions. Incisions should never cross a flexion crease at right angles. A lateral incision to the ulnar aspect of digits two, three, and four is recommended, as is an incision to the radial aspect of digits one and five. The incised wounds should be irrigated and packed. Application of zinc oxide ointment can be very useful to help keep the wound open and draining. Gram stain, culture, and sensitivity must be done for any purulent exudates. Antistaphylococcal antibiotics should be prescribed.
Appropriate follow-up is necessary because of the many potential complications, most notably osteomyelitis of the distal phalanx, that may occur from the infection itself or treatment. If osteomyelitis is suspected, x-rays should be obtained and studied carefully for signs of bony involvement. If it is present, operative debridement with IV antibiotics is mandatory.
Flexor tenosynovitis. Acute synovial infections of the hand usually involve the flexor tendon sheaths, which are covered by the ulnar and radial bursa. Infections of the synovial spaces in the hand tend to spread along these sheaths to the midpalmar, thenar, and lumbrical compartments. Infections are usually caused by penetrating trauma, and the most common organism is Staphylococcus aureus. Clinical features include tenderness along the course of the flexor tendon, symmetric swelling of the finger, pain on passive extension, and a flexed posture of the finger.
Flexor tenosynovitis requires hospital admission and hand consultation. In uncertain cases, the hand should be splinted and elevated and the infection treated with a broad-spectrum penicillin or a cephalosporin, with close follow-up.
Herpetic whitlow. Herpetic whitlow is a relatively frequent presentation in the emergency department, especially in pediatric patients. It is simply a viral infection of the distal finger that can be caused by either type of herpes simplex virus (see image, below). It can be seen in adult patients following an outbreak of genital or gingival herpes. It can also be seen in children with coexistent herpetic gingivostomatitis. Another group particularly at risk is medical and dental professionals because of increased exposure to the patient’s oral cavity and saliva.
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| Herpetic whitlow. A relatively frequent presentation in the emergency department, herpetic whitlow is a viral infection of the distal finger that can be caused by either type of herpes simplex virus. |
The patient with whitlow will present with one or more painful vesicles on or near the fingerpad and will complain ofpainreness around the fingerpad. These vesicles can later coalesce to form an ulcer with a hemorrha gic base. A detailed history should be obtained to determine if the patient has had prior herpetic lesions, either genital or oral. The diagnosis is typically made by the clinical appearance of the affected area, but if the diagnosis is uncertain, it can be confirmed by fluorescent antibody testing. Gram stain and cultures of the lesion will be of little value.
No specific treatment is indicated because these lesions are self-limiting. Incision and drainage should not be performed because of the risk of viral dissemination. Pediatric patients should be instructed to avoid putting the fingers in contact with the mouth, especially by thumb sucking. This will prevent recurrence and further spread of the virus.
Suggested Reading
American Society for Surgery of the Hand: The Hand: Primary Care of Common Problems, 1st ed, Churchill Livingstone, 1985.
Cailliet R: Hand Pain and Impairment, 4th ed, F.A. Davis Company, 1994.
Eiff MP, et al.: Fracture Management for Primary Care, 2nd ed, Saunders, 2003.
Harrison B and Holland P: Diagnosis and management of hand injuries in the ED. Emerg Med Prac 7(2):28, 2005.
Hart RG, et al.: Emergency and Primary Care of the Hand, American College of Emergency Physicians, 2001.
Lester B: The Acute Hand, Prentice Hall, 1999.
Rosen P, et al.: Emergency Medicine, Concepts and Clinical Practice, 5th ed, C.V. Mosby, 2002.
Newmeyer W: Primary Care of Hand Injuries, 1st ed, Lea and Febiger, 1979.
Robins RHC: Injuries and Infections of the Hand, 1st ed, Williams and Wilkins, 1961. |
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