A bystander calls 9-1-1 for an elderly male who complains of a painful, swollen hand and wrist following a fall. When you arrive on scene, the patient appears uncomfortable and mildly intoxicated, and you notice alcohol on his breath. The patient’s hand is wrapped in a dripping, blood-soaked handkerchief. When you ask him what happened, the patient states that he tripped when leaving a bar and used his hand to break the fall. His initial vitals and exam are remarkable only for a pulse rate of 110 and an obvious injury to the wrist and hand. To make things more complicated, the patient refuses to go to the hospital.
Because of the hand’s complex bone and muscle structure, injuries are common and can easily become extreme. Image Edward T. Dickinson
First Things First
Although it’s tempting to focus on the obvious injury, don’t forget your priorities. A potentially unstable cervical spine should take precedence over an extremity injury, and alcohol–a good anesthetic–may mask neck pain or tenderness. You should first determine: Did the patient trip and fall, or did he have a syncopal event? Does he have a history of diabetes or a cardiac dysrhythmia? Did the patient also sustain head trauma and suffer any loss of consciousness? The answers to these questions might directly affect your management on the scene and be critical to communicate to medical providers in the emergency department.
You find out the patient is diabetic and has a pacemaker. Although his glucose reads low and the rhythm strip shows a heart rate of 48 with no pacer spikes, and he wants to sign a refusal, it’s your obligation to communicate the risks and consequences of refusing further treatment or hospital transport whether or not he appears intoxicated. He has to understand that his pacemaker may need to be evaluated for proper operation, that he may need to be monitored while his glucose level is being corrected and that a CT scan of the brain will likely be required in the ED.
Since it’s unclear whether the patient struck his head and lost consciousness, he may have significant brain atrophy due to his age and alcoholism, thereby putting him at increased risk for a subdural hematoma. The bottom line is that you have to have performed enough of a thorough assessment, including the patient’s injured hand, to appropriately apprise him of the risks and consequences necessary for obtaining an informed refusal of consent.
Illustration from Gray’s Anatomy 20th Ed.
Stabilizing the Injury
You’re drawn to the obvious, but don’t forget safety precautions. Never blindly stick your fingers into clothing, a dressing or a wound that can’t be adequately visualized because you may encounter broken glass, bone fragments or needles. As you carefully unwrap this patient’s bloody, debris-filled dressing (which includes glass fragments of a broken beer bottle), you notice the back of the wrist appears swollen, tender and ecchymotic, and there’s a superficial laceration over the fleshy thenar eminence at the base of the thumb.
Most bleeding will stop with direct pressure, but it may be necessary to use a proximal tourniquet to achieve adequate control. This is especially true for patients who may be intoxicated, because alcohol acts as an anticoagulant. To do this, elevate the affected limb to allow venous drainage and reduce hemorrhage volume, and then apply a tourniquet or a blood pressure cuff at approximately 100 mmHg above the patient’s systolic pressure. The cuff can be inflated for several minutes without undue discomfort for as long as one or two hours without causing significant ischemia to the distal extremity. Be sure to remove any rings to avoid increased swelling that could cause significant disruption of blood supply to the fingers.
This type of wrist fracture is known as the “dinner fork deformity,” named after the eating utensil of a similar shape. Photo Jon Politis
Patient History & Symptoms
Once initial patient stabilization has been addressed, a more vectored history should be obtained. The patient should be asked about any pain, swelling, numbness or tingling, and weakness or sensory loss.
Information about possible crush injuries, blood loss and wound contamination can be determined by gathering further details about the mechanism of injury. The position of the hand at the time of injury–flexion or extension–may help determine the type and location of fractures, fragments or possible tendon injury. It’s also helpful to inquire about the patient’s occupation, whether the injury involves the patient’s dominant hand and if they had any prior neurologic or functional deficits. Underlying medical problems that might affect management should also be determined, including bleeding disorders, metabolic bone disease, osteoporosis, hyperparathyroidism, rheumatoid or degenerative arthritis and use of anticoagulants. The patient’s tetanus immunization status is also important to know in the case of any open wounds.
If fingers have been amputated prior to EMS arrival, the amputated parts should be found and cleansed, wrapped in gauze and placed in a water-tight container. Photo Edward T. Dickinson
Extremity Complexity
As in the maxim “big things come in small packages,” the hand and wrist have an especially complex architecture. Serious injuries to the hand and wrist are often hidden beneath seemingly innocuous-appearing superficial wounds. Although it’s beyond the scope of the average EMT or paramedic to perform a detailed neurovascular exam, a basic working knowledge of the anatomy of the hand is essential to avoid missed injuries and therefore potentially devastating complications, especially if the patient wants to refuse treatment or transport.
The wrist and hand have 27 bones all together–19 of which are in the hand alone–and 48 individual muscles and tendons responsible for movement of the hand and fingers. The joints are stabilized by ligaments and cartilaginous plates so that, even in the absence of a bony fracture seen on X-ray, a missed injury to these structures may lead to significant disability or permanent dysfunction.
Examining the Injured Extremity
Perform a simple inspection of the hand. Note the general appearance and condition, and gently palpate the injured extremity. This can provide critical information prior to detailed neurovascular assessment. Any obvious, or even subtle, swelling, deformity, discoloration, tenderness or crepitus may provide clues to the location and nature of injury, whether identifying a fracture or simply a contusion to the underlying soft tissue structures.
Count the fingers. A partial or complete amputation may require immediate attention and subsequent digital replantation. If such an injury is present, the amputated part should be found, gently cleansed with normal saline or lactated Ringers solution, wrapped in moistened gauze and placed in a plastic bag or water-tight container. The container should then be floated in an ice-water solution with no direct contact of the digit with the ice.
Identify lacerations. Pay particular attention to anything/any particular injury that may suggest underlying tendon or nerve injury, or indicate joint capsule disruption. A loss of normal skin color or temperature might signify a lack of perfusion due to vascular injury, and decreased moisture/sweat may reflect a loss of sympathetic innervation due to nerve damage.
A delay in capillary refill may point to compromise of the blood supply of the digits. If present, the five p’s of vascular insufficiency–pain, pallor, pulselessness, parethesias and paralysis–may be helpful in indicating injury too, but these are neither reliable nor specific findings.
Observe hand and wrist resting position. Does the hand assume its normal resting stance, where the wrist is held in slight extension? This allows the digits to assume their normal cascade, with each digit from index to little finger progressively flexed against the palm. Any alteration in this normal stance or cascade configuration may indicate an otherwise occult tendon injury or a fracture with rotational deformity.
Inspect the entire arm. Even though the apparent injury may be confined to a particular location, it’s also important to examine the entire extremity. This is particularly true with the joints so you don’t miss any associated injuries.
Thumbs are important digits, so it’s important that you retrieve and bring them to the hospital to be reattached. Photo Edward T. Dickinson
Assessing Sensory Function
A detailed sensory exam of the injured hand may be difficult for you to perform, but a simple two-point discrimination test is a good way to assess sensory function. This can be accomplished by simply bending open a paperclip so that there’s approximately 5 mm between the two ends. Touch both points to the fingertip in the longitudinal axis. Without looking, the patient should be able to tell that he is being touched by two points. If the patient perceives only one point, spread the points further apart and repeat until the patient perceives two distinct points.
The likelihood of injury to the sensory nerves increases as the two points are spread further apart.1 For the fingertip, most people should be able to feel two points between 2—4 mm, and anything above 5 mm is probably abnormal.
If there’s any question, providers should repeat the test with an uninjured extremity to provide a comparison. In addition, a quick and pure test for each of the nerves to the hand is as follows: The median nerve innervates the palmar or volar tip of the index finger (second digit), the ulnar nerve supplies the volar tip of the little finger or pinky (fifth digit), and the radial nerve can be tested in the first web space between the thumb and index finger.
Assessing Motor Function
To perform a detailed assessment of the motor function of the hand, it’s useful to have a working knowledge the various motions of the hands and fingers, which are mediated by the tendons. Inability or pain encountered when performing the motions suggests that additional assessment of the injury is necessary.
Flexion of the fingers happens when we bend them to hold on to something or make a fist, and extension is what we do when we straighten them to reach out and grab an object. The fingers may also be abducted or adducted by stretching them away or contracting them toward the midline in the plane of the palm. With the palm facing down, the wrist can be flexed down or extended back, and it can also deviate from side to side.
The thumb is much more complicated: It abducts by moving in a plane ninety degrees away from the palm, and adducts by moving in the same plane back toward the palm. The thumb may also be flexed across the palm in the same plane, or extended away from the palm, again in the same plane. The thumb can also be opposed by touching its tip to the tip of the little finger or pinky.
Even if the patient demonstrates apparent normal function, partial tendon injuries are often easily missed, leading to subsequent functional disability. Normal motor function can be displayed even when up to 90% of a tendon is disrupted; supplying resistance against a tendon helps to more fully assess motor function.
Putting it All Together
In this case, you discover that the patient fell on an outstretched palm, with his wrist in extension, in an attempt to break his fall. He has a painfully swollen, tender and crepitant wrist and an obvious “dinner fork” deformity. (See above.) The patient’s sensory function appears intact, and aside from pain-limited range of motion, the patient’s neurovascular status appears to be intact.
The battery of tests you performed results in the patient agreeing to transport. You splint the injury in a position of comfort (see “Splinting Considerations,” below) prior to transporting him to the ED, where an X-ray confirms a distal forearm fracture of the ulna and of the radius, the most common site of fracture in the upper extremity.2 The dorsally angulated distal bone fragment, typically referred to as a Colles fracture, is also confirmed.
Differential Diagnosis
Although this patient suffered the most common fracture of an upper extremity, other injuries with the same mechanism may present with more subtle findings. Imagine the same scenario, patient and mechanism of injury, except this time he presents with a painful, swollen wrist, but without any gross deformity or severely limited range of motion.
Perhaps a seemingly minor injury, the patient could have fractured the scaphoid, the largest carpal or wrist bone that articulates with the distal radius in the forearm. Although this is the most commonly fractured carpal bone, it’s important to maintain a high index of suspicion and perform a careful examination for this injury, especially as it may be missed on initial X-ray evaluation in the ED.3 Neglecting this injury could result in improper immobilization and treatment leading to severe dysfunction of the thumb or of the entire hand.
This injury may be detected by palpating for tenderness over the scaphoid, located dorsally in the anatomic “snuffbox” between the two tendons at the base of the thumb.
Parting Thoughts
Management of acute injuries to the wrist and hand begins only after the patient and injured extremity are stabilized, followed by an organized and systematic evaluation drawing from a working knowledge of relevant anatomy and function. This provides the basis for maintaining a high index of suspicion for injury to bones, tendons, ligaments, blood vessels and nerves, and will serve to inform appropriate on-scene management and transport to definitive care. jems
References
1. Finnell JT, Knopp R, Johnson P, et al. A calibrated paper clip is a reliable measure of two-point discrimination. Acad Emerg Med. 2004;11(6):710—4.
2. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908.
3. Eiff MP, Hatch RL, Calbach WL: Carpal fractures. In (2nd) Fracture Management for Primary Care. Saunders: Philadelphia, 2003.
Resources
American Society for Surgery of the Hand: The hand: Examination and diagnosis, (Ed 2), Churchill Livingstone: Edinburgh, N.Y., 1983.
Carter PR: Common hand injuries and infections (Ed.1), WB Saunders: Philadelphia,1983.
Harris JG, Harris WH, Novelline RA: The radiology of emergency medicine (Ed.3), Williams & Wilkins: Baltimore 1993.
Hoppenfeld S: Physical examination of the spine and extremities, (Ed. 1). Appleton-Century-Crofts: New York, N.Y., 1976.
Rosen P, Barkih MB: Emergency medicine: Concepts and clinical practice, (Ed. 3), Mosby — Year Book: St. Louis,1992.
Simon RJ, Koenigsknect SJ: Emergency orthopedics: The extremities, (Ed. 2), Appleton & Lange: East Norwalk, Conn., 1987.
Slaby F, Jacobs ER: Radiographic anatomy (Ed.1), John Wiley & Sons: New York, N.Y., 1990.
Don’t Forget
In addition to our fall patient’s hand and wrist injuries, he also has what appears to be a superficial laceration over the fleshy thenar eminence, which is located at the base of the thumb on the volar or palmar side of his hand.
Although this injury may appear trivial, it provides another example of how knowledge of the surface anatomy of the hand can help to keep you and your patient out of trouble. Underlying the thenar eminence are three muscles that enable the thumb to flex across the palm, abduct away from the palm, and oppose or touch the little finger. These motor functions are supplied by the superficial and therefore dangerously located recurrent branch of the median nerve, the general location of which can be identified by flexing your middle finger to where it touches the palm.
Often also referred to as the “million dollar nerve,” a missed injury due to even a superficial laceration over this area can result in permanent disability–and considerable medical liability as well. In this case, having a patient sign a refusal without adequate knowledge of the risks and consequences of doing so could lead to potentially devastating complications.
