Thumb MC #bennetts

Fractures of the base of the thumb metacarpal not involving the joint need to be differentiated from fracture dislocations or subluxation (Bennett's #)

  • Treat Bennett's fracture-dislocation with : Bennett's POP and refer to the on call orthopaedics. Good initial reduction is important. Thereafter, there is no significant evidence between surgical and conservative management approach. [BestBets]

  • Fracture base thumb MC not involving joint : Thumb spica or Bennett's POP and fracture clinic (Referral form). Sling

Ruptured Ulnar Collateral Ligament (UCL) thumb MCPJ  (Gamekeeper's thumb) 

See link above or Here


Index - Ring metacarpal fractures

Usually undisplaced. Treat with bandage and a sling and refer to the Fracture Clinic. If displaced, ask for advice.


Punch Injuries

Infected punch injury
  • Beware apparently innocuous injuries.
  • If the skin in breached, assume the joint space and or extensor tendon have been breeched until proven otherwise.
  • X-ray all (FB)
  • Detail neurovascular and tendon (including middle slip) status.
  • Treat abrasions with antibiotics and treat as needlestick injury.
  • All deep wounds need referral to ortho for formal exploration and washout.

Little metacarpal fractures

  • Usually displaced. 
  • Treat with neighbour strapping and early mobilisation in preference to Edinburgh slab [BestBets] and sling 
  • Refer to the Fracture Clinic at CUH Referral form
  • Severely displaced fractures may benefit from K wire.
  • If in doubt ask ED Duty Doc.

Proximal metacarpal injuries

Most are stable injuries if sustained with a clenched fist (no rotation at the time of injury) butDislocated CMC Joint

Beware of a proximal (carpometacarpal) dislocation.

Dislocation of PIP and DIP joints  

Volar plate injuries


Phalangeal fracturesProx phanyngeal fixation

  • Transverse fractures of the prox phalanges are unstable (often need fixing)
  • Discuss with your ED Duty Doc
  • Spiral fractures are also unstable and particularly prone to rotation. 
  • ANY rotation deformity must be corrected and splinted in a position of anatomical function before discharge from the department. 
  • All spiral fractures are followed up in the next fracture clinic. 
  • Refer to your ED Duty doctor and / or on-call ortho SpR if reduction not achieved

Spiral rotating fracture

  • Displaced finger fractures involving the joint should be referred to the orthopaedic team on call.
  • Open fractures other than those of the tuft require immediate referral. 
  • Those of the tuft require wound toilet and anti-staphylococcal antibiotics

Mallet finger

mallet finger 1
  • More Info Here
  • X-ray to look for avulsion fracture (better chance of healing). 
  • With a large fragment check that the DIP joint is not subluxed.
  • Check that PIPJ is not gong into hyperextension (occurs in small % of those with mallet) - will need to be treated if present.
  • General management includes : Apply a mallet (stack) splint full-time for 6 weeks, then at night for 2 weeks. GP or plastics clinic follow up. Follow 2 week rule - if extension lag at any time then return to splint full time for another fortnight.
  • If splint is removed the finger must be kept straight even when washing.
  • Explain the prognosis - (1/2 left with deformity even if in splint) but that the function of the hand / finger will not be effected.  Warn the patient that it may not heal.  Patients with exceptional hand requirements may be referred to the fracture clinic or plastic clinic.
  • It is important that the mallet splint allows for full flexion at the PIP joint and patients are encouraged to mobilize at the PIPJ level.
  • If the joint is subluxed please refer to the on-call orthopaedic team Referral form

Boutonnière finger

Middle slip deformity 1middle slip test 1middle slip 1Finger extensor tendon normally has two lateral slips (inserting into distal phalanx) and a middle slip inserting into the base of the intermediate phalanx. If this middle slip ruptures the patient may have point tenderness as the site of the rupture and a "button hole" or Boutonniere deformity ensues. Patients will be unable to extend the PIPJ flexed over the edge of a table (and will have hyperextension of the DIPJ). Apply splint to hold the PIPJ straight and refer to the next CUH fracture clinic Referral Form.


Ruptured or lacerated extensor or flexor tendons or digital nerve injury


Spreading or deep hand infections



Trapped fingers and amputated finger-tipsNail Anatomy

Trapped finger tips with partial avulsion should rarely be sutured:


Guillotine amputations of finger tips

Terminal amputations of the finger tips in young children do extremely well with conservative treatment only. Even if the bones protrude slightly it should be left alone:

There should be regrowth of the tip and nail and complete restoration of function with an excellent cosmetic result eventually (look at series of photographs in the ED). As long as the amputation is distal to the distal interphalangeal crease the result should be very good.


Pulp / fingertip incisionspulp suture 1

Analgesia


Hand lacerations


Subungal haematoma

Subungal haematoma inage


Paronychia / Felon#

Acute paronychia develops over a few hours when a nail fold becomes painful, red and swollen.

Throbbing pain indicated presence of pus

Location of paronychia pus

Paronychia DDx includes


Herpetic whitlow / felon

Felon


Hand injury referrals:

Severe hand injuries have very long-term implications for patients. Efficient management and referral are of paramount importance. In this ED service the following referral protocol should be followed:

Referral CUH fracture clinic:

You MUST discuss the case with the your Duty Doc before discussing with the plastics team.


Preservation of amputated parts