Patient assessment

Hand surgery involves a multi-specialty approach to the assessment, treatment, and aftercare of hand trauma. Therefore, the specialized teams should be involved early on according to the specific injury requirements.

A diagnosis is made based on the history, the mechanism of the trauma, clinical examination, and by x-rays in two planes.

Check for:

• Swelling
• Open wound
• Loss of sensation in the fingers (indicating nerve injuries)
• Perfusion (reperfusion of more than 2 seconds may indicate vascular injuries)

Check for anatomical architecture (position and relation) of the whole hand:

• Longitudinal arc
• Metacarpal arc
• Oblique arcs (with thumb in opposition)

The tips of the flexed fingers should point to the scaphoid. Check for deviating or overlapping fingers. This will indicate malrotation.

Check for shortening of a finger. Interrupted finger cascade may indicate shortening.

Check for deformity of a phalanx. In a fracture situation, the distal fragment may be pulled dorsally.

Check the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint stability. Compare this with the contralateral finger.

Lack of lateral stability indicates injury of the collateral ligaments or their bony attachments.

AP view of the whole hand and lateral view of the finger are needed for diagnosis. In base fractures, an oblique view may be helpful.

All views need to be inspected to get information about the fracture pattern, eg, the orientation of an oblique fracture plane.

Obliquity of the fracture is possible either in the plane visible in the AP view or the plane visible in the lateral view. Always confirm the fracture configuration with views in both planes.

Ultrasound evaluation may help define suspected ligament and tendon injuries.

CT imaging is required for impacted intraarticular fractures to evaluate the fragmentation and plan for reconstruction.

Isolated ligamentous injuries may be seen in an MRI.