Hand Injuries

Hand Injuries 
NB Hand injuries are important. Closed hand fractures requiring surgery are referred to Ortho On-call. Open fractures with potential tendon and nerve injuries are referred to the Plastic surgeons. If you think a fracture may need surgery - ask advice.
Metacarpal injuries 
Fracture dislocation base of 1st M.C.(Bennett's #, Rolando #)  
Refer to Ortho On-call.   
Fracture base 1st M.C. not involving joint  
POP slab including thumb. Refer Virtual Fracture Clinic (VFC). 

Fracture neck 5th M.C. (Boxer's #) (& less commonly of other M.C.'s)
Check for rotational deformity. Position usually acceptable.
Tubigrip/ Futura splint and buddy strapping. Encourage finger exercises. 
If no rotational deformity D/C or ED review clinic 1-2 weeks.If rotational deformity refer to VFC. If angulation >45o refer Ortho On-call. 

Other undisplaced MC fractures  
Usually well splinted by neighbouring bones so: tubigrip/ Futura splint
Encourage finger exercises. 
Refer VFC. 
Severely displaced M.C. fractures  
Multiple M.C. fractures
Refer Ortho On-call.  

Metacarpophalangeal joint (MCPJ) injuries 
Dislocation 1st MCPJ  
Reduce, Check ulnar collateral ligament.         
Thumb splint.      
Refer VFC.
If irreducible - refer Ortho On-call.  
Ruptured ulnar collateral ligament  
Refer Ortho On-call.
Sprain 1st MCPJ    
Exclude instability      
Advise mobilise      
Thumb spica if necessary for symptoms      
Review clinic 2 weeks if follow up needed 

Dislocation other MCPJ  
Rare - ask advice

Fractures of the phalanges (PP) 

Undisplaced fractures  (Check for rotational deformity)        
Neighbour strapping.      
Refer VFC.    

Displaced fracture  
Refer Ortho On-call.
Epiphyseal fracture base PP  
Reduce (local infiltration of LA)      
Re-X-ray. Buddy strapping     
Refer VFC. 

Injuries of the PIP joints
Dislocation PIPJ
Ring block, reduce, check stability, Re-X-ray. Buddy strapping.      
Refer VFC.
Sprain of PIPJ  
Buddy strapping. Encourage mobilisation     
Review Clinic 1-2 weeks if needed.

Volar plate injuries
Large fragment with significant intra-articular component refer Ortho On-calll.
Small avulsion, buddy strapping and refer Hand OT.


Finger tip injuries 

Dislocated DIPJ    
Reduce, test stability, re-X-ray      
If stable - no splintage required. Refer VFC. 
Epiphyseal fracture base D.P.  
Undisplaced    Mallet splint and refer VFC.
Displaced       Reduce (digital nerve block)
Replace nail under nail fold.
DO NOT remove the nail unless absolutely necessary      
If open wound give antibiotics      
Mallet splint. Review clinic 5 days.

Other fractures of the D.P.  
If subungual haematoma - trephine, and Flucloxacillin (as have made compound) 

Mallet finger    
If no fracture or small avulsion Mallet splint and refer Hand OT     
If intra-articular fracture >25% refer Ortho On-call.  

Tendon & Nerve Injuries in the Hand 
-- Closed tendon injuries --

Extensor tendon central slip rupture (Boutonnière deformity)  
Refer Hand Surgery service 
Closed rupture flexor tendons  
Refer Hand Surgery service (usually FDP)    
Closed EPL rupture    
Refer Hand Surgery service 
-- Open tendon injuries --

Extensor tendons PARTIAL division    
If > 50% refer Hand Surgery service.      
If < 50% ask advice  
COMPLETE division  
Refer Hand Surgery service 
Flexor Tendon injuries  
Refer Hand Surgery service  
Open nerve injuries    
Refer Plastic surgeons