Ep 179 Hand Injuries – Finger Tip Injuries, Jersey Finger, PIP Dislocations, Metacarpal Fractures, Thumb Injuries, Tendon Lacerations

In Part Two of this two-part series on hand injuries, Dr. Matt Distefano and Dr. Arun Sayal walk us through the recognition and management of common, and some not so common, hand injuries that present to the Emergency Department. Some injuries are easy to diagnose but we often fall short when managing them in the ED, while others are hard to recognize and frequently go undiagnosed. They answer such questions as: which finger tip injuries need to go to the O.R.? What is the best management strategy for nail bed lacerations? What is the tip and slip method for reduction of PIP dislocations that are difficult to reduce? How are proximal metacarpal fractures similar to Lisfranc injuries and easy to miss? How is a Rolando fracture different to a Bennet fracture? Which volar tendon lacerations should we consider repairing in the ED? and much more…

Podcast production, sound design & editing by Anton Helman; voice editing by Braedon Paul

Written Summary and blog post by Ian Beamish and Kate Dillon, edited by Anton Helman February, 2023

Cite this podcast as: Helman, A. Distefano, M. Sayal, A Episode 179 Hand Injuries - Finger Tip Injuries, Jersey Finger, Finger Dislocations, Metacarpal Fractures, Thumb Injuries, Tendon Lacerations. Emergency Medicine Cases. February, 2023. https://emergencymedicinecases.com/hand-injuries-finger-tip-injuries-jersey-finger-pip-dislocations-metacarpal-fractures-thumb-injuries-tendon-lacerations. Accessed May 30, 2024

Résumés EM CasesFinger-tip injuries - avulsions, amputations and tuft fractures

Finger tip avulsions and amputations

Finger tip avulsions/amputations are classified into Zone I, II, or III which each require specific management.

Zone I – No exposed bone. Management principle is 'less if more' and includes basic wound care, non-adherent bulky dressing (avoid dressing that are too tight that may lead to ischemia) and follow-up in 7 days. Heals by secondary intention. Complete return of sensation may take up to 18 months.

Zone II – Bone exposed and often associated with tuft fractures. Basic wound care, debridement of devitalized tissue to 1mm below the level of the soft tissue laceration, non-adherent bulky loose dressing and follow-up in 7 days. May heal by secondary intention - apply absorbable sutures only if obvious viable flap that can be closed without tension. Empiric antibiotics may be indicted in the case of a patient with comorbidities.

Zone III – between the DIP and tuft that includes the insertion of the FDP, insertion of extensor tendon, germinal matrix and nail fold, that may require distal phalanx amputation. Decision to rongeur bone and close in the ED should be guided by clinician familiarity with the procedure and hand surgeon availability, but these almost always require specialist referral.

Volar pad involvement: Finger tip amputations that involve a significant proportion of the volar pad are high risk injuries. Significant injuries of volar pad should be management by a plastic surgeon as future sensation of the finger tip is at risk.

Pitfall: a common pitfall is approximating the skin of a finger tip avulsion injury with sutures when there is a great deal of tension on the skin when closed; this does not allow for adequate healing and may cause ischemic injury; rather, healing by secondary intention is indicated for all finger tip avulsions where approximating the skin would place significant tension on the tissues.

Pearl: Use rongeurs to trim bone 1mm below level of soft tissue ...