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)
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
Finger 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.
or lacerated extensor or flexor tendons or digital nerve injury
Refer to on-call plastic surgery team.
Remember the relative importance of digits (thumb/little finger),
patient's occupation and hobbies, dominant hand.
Spreading or deep hand infections
Refer to senior staff or on-call Plastics (particularly tenosynovitis).
Extensive soft tissue trauma,
e.g. severe burns, digital amputations - refer to ED Duty doctor.
Only refer to the orthopaedic team after discussion
with your ED senior.
Trapped fingers and amputated
Trapped finger tips with partial avulsion should rarely be sutured:
Clean gently, reposition and hold in place by Ethistrip or Steristrip,
with the ends anchored by 'clear tape'. In most cases this should
be done by the doctor, but in any case the position must be checked
by the doctor.
Leave the nail in position (Tinct. Benzolin on skin to help adhesion).
Do not put strips all around the finger
Put on a non-adherent dressing
Over this put a bandage
Check the immunisations are up-to-date
Only give antibiotics if the wound cannot be thoroughly cleaned
Leave for at least 3 days
Warn the patient (parent) that the finger will look awful at the
Either bring the finger injury back to the ED clinic in a further
3 to 4 days (remove top dressing only) or refer back to the GP.
Do not discharge the patient until you are satisfied that function
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:
They should be cleaned thoroughly
The finger is covered with several layers of Tulle Gras and Jelonet
and a mitten bandage is applied.
Leave alone for 2 to 3 days. Then bring back to ED clinic for re-dressing.
Warn the mother that it will look awful but should do very well.
Give advice sheet with photographs.
Do not give any antibiotics but check tetanus immunisation.
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 incisions
Linear lacerations should be cleaned and closed with 5.0 or
If left mal-aligned permanent sensory and functional loss
Remember that even with elevation in a broad arm sling, fingertip
injuries often swell so do not over tighten your sutures.
Local GP should be requested for ROS in 5 -7 days.
Marcaine [BestBets] ring block. Test digital nerves before injecting!
Simple, uncomplicated hand lacerations do not require prophylactic antibiotics[BestBets]
Acute paronychia develops over a few hours when a nail fold becomes
painful, red and swollen.
Throbbing pain indicated presence of pus
F : M = 3:1
Ask about background Diabetes, Immunosuppression,
Raynaud's or fungal infections
Acute case treat with incision / elevation nail fold (image right) rather than antibiotics[BestBets]
Recurrent paronychia or if nail bed involvement best
treated by removing whole nail
Paronychia DDx includes
Splinters, foreign body
Deeper pulp space infection
Risk of osteomyelitis of distal phalanx
Treat with I&D - longitudinal incision parallel
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:
Major hand injuries, including compound fractures / joint injuries,
digital nerve division, tendon injuries Referral form
Discuss emergency management with the Orthopaedic Registrar on-call
who will also advise time and location of referral.
You MUST discuss the case with the your Duty Doc before discussing
with the plastics team.