EMERGENCY EVALUATION & TREATMENT
Hand trauma is one of the more common reasons for emergency department evaluations of individuals and specifically of children. Studies suggest that hand and upper extremity injuries comprise over 31% of all traumatic injuries in children younger than 12 years. There is bimodal distribution of injuries with the highest incidence between 1 and 2 years of age, and the second highest incidence at 12 years. In addition to the potential functional loss associated with hand injuries, a review of the psychiatry of injuries indicates that a child’s “self esteem and skill are associated with hand sensation, appearance, and functions.” Because of the potential mechanical and developmental consequences, appropriate initial evaluation and management of hand injuries is crucial.
The hand is a complex body part to examine because of the number of mechanical and neurovascular components in a small area. Examination of the hand is detailed to isolate the integrity of individual structures. Positioning of the patient’s body and hand must be optimized to allow for a thorough examination. Ideally the patient should be supine on a stretcher with the hand outstretched as comfortably as possible on a clean, illuminated area such as a bedside table. Examination of a pediatric patient can be challenging; therefore placement of the child in parent’s lap with the hand extended on a table may be the best positioning available.
Although injuries to the hand are often accompanied by significant morbidity, they are fortunately not a source of great mortality in isolation. However, bleeding can be brisk from the well-vascularized hand and particularly in the setting of laceration of the distal forearm involving the radial and ulnar arteries. Hemostasis is typically the most emergent intervention necessary for the hand. Elevation and direct pressure are primary strategies and are usually successful. If necessary, an arterial tourniquet such as a manual blood pressure cuff inflated on the forearm above the systolic blood pressure can be helpful. Clamps should be avoided if possible because it can be extremely difficult to distinguish nerves from blood vessels in a bloody wound. Intravenous (IV) access should be established for patients with heavy bleeding, need for IV antibiotics, sedation, or potentially surgery.
Analgesia can be attained by several methods and can improve patient comfort and cooperation to optimize ease of examination and treatment. Splinting, oral analgesia, and nerve blocks are discussed in detail later.
Amputated tissues must be preserved immediately. Strategies for effective storage are discussed below
Details gathered from a full description of the incident can be integral. As with any childhood illness, engaging the family and witnesses can be very helpful in obtaining the necessary elements of the incident.