Acute hand injuries are routinely managed by family medicine and primary care physicians. An appropriate initial assessment and treatment, early referral to a hand surgeon when indicated, and timeous referral to a hand therapist are imperative. A patient case report is presented reporting on the initial and subsequent assessment, treatment and outcomes at 3, 6, 7 and 9 months for a patient who sustained an acute finger injury. Finger range of motion (ROM), sensation, pain, time of wound closure, hand function measured with the standardised disability of the shoulder, arm and hand (DASH) questionnaire were the outcomes used. Pain, crepitus, decreased sensation, decreased ROM right index finger proximal interphalangeal joint (PIPJ) and dense scarring was measured at 9 months. Missed injuries or lack of recognition of injury severity leads to delayed referral to specialist hand surgeons and therapists, which lengthens recovery time and leads to sub-optimal outcomes. This article aims to provide the primary care practitioner with the initial management of a patient who sustained a traumatic hand injury whilst using a power tool.
Research on the leading cause of hand injuries sustained during the COVID-19 pandemic in the United Kingdom showed an increase in injuries related to using machinery.
The management of acute hand injuries should be guided by the initial assessment and the wound. Open wounds must be irrigated and debrided.
Following traumatic hand injuries, the correct initial management is imperative to prevent substantial morbidity related to poor hand function, decreased quality of life and low work productivity. Timeous referral to a hand surgeon, a hand therapist, occupational therapists (OT) or physiotherapist, is of great importance to ensure optimal outcomes. The article aims to provide the primary care practitioner with the initial management of a traumatic hand injury patient sustained whilst using a power tool.
A 56-year-old right-hand dominant male sustained an index finger injury on 6 June 2020 whilst at home in South Africa during the national lockdown period. He works as a site manager, is a handyman and is an avid fisherman. The injury occurred at home whilst cutting a piece of wood with a small angle grinder fitted with a steel wood cutting blade. He lost control of the grinder and the blade cut into the radial side of his right index finger (
Index finger injury.
The initial management included washing and suturing the wound by a primary care physician. After 13 days, the sutures were removed and the patient’s finger was passively flexed by the primary care physician with gaping of the wound observed by the patient. A wound care nurse was consulted every three days. Still, the patient became increasingly concerned about the wound and persistent pain. He consulted a hand surgeon on 2 July 2020, with the assessment presented in
Preoperative hand surgeon’s assessments.
Outcomes | 02 July 2020 | 27 August 2020 |
---|---|---|
Wound observation | Open, dry, non-infected wound from the PIPJ, midline, volar to the radial side of the DIPJ | Nearly healed |
Oedema | General presence | General presence |
Tendons | Flexor digitorum profundus (FDP) intact. |
Poor FDP glide |
Range of motion | Active and passive severely limited | Severely decreased. |
Sensation | Ulnar digital nerve (UDN) normal. |
Radial digital nerve was 3/10 with 2-point discrimination (2-PD) 15 mm and monofilaments > 4 g. |
Pain | Present with hypersensitivity | Present with hypersensitivity |
X-ray | Taken 2 weeks post-injury: |
- |
PIPJ, proximal interphalangeal joint; DIPJ, distal interphalangeal joint.
At 4 weeks after the date of injury, there was already a high likelihood of requiring a nerve graft, and therefore the decision was made to allow the wound to heal before doing the exploration and nerve graft. The wound care was performed by a local wound care nurse. After three months, wound closure was achieved. In the meantime, he was referred to an OT to regain ROM before surgery. No prior hand therapy referral was made. The patient’s primary complaints were hypersensitivity over the scar and the lack of finger ROM in the index and middle fingers.
As an adjunct to the initial assessment, an X-ray should have been taken at the first presentation, which would have identified the fracture earlier, instead of only being performed after two weeks.
The diagnosis made by the primary care physician was an uncomplicated laceration requiring wound care. The differential diagnosis for such an injury with an open wound should include assessment for possible digital nerve injury, flexor tendon injury and phalangeal fractures.
Surgery was performed because of persistent symptoms of numbness on the lateral side of the index finger from the distal interphalangeal joint (DIP), hypersensitivity over the scar and loss of digital ROM. During surgery on 27 August 2021, the flexor digitorum profundus (FDP) tendon was found to be stuck in dense scarring and a thorough tenolysis was performed. He had a complete radial digital nerve (RDN) injury with a nerve gap repaired with a posterior interosseus nerve (PIN) autograft (
Posterior interosseous nerve graft of the radial digital nerve index finger.
Throughout five sessions, OT treatment after the surgery included scar massage, desensitisation and oedema management through pressure sleeves. Active and passive joint mobilisation techniques were utilised, including a night extension splint and shotgun sleeve. A home exercise programme was prescribed, which he followed diligently.
The patient experienced pain and hypersensitivity on the palmar aspect of the index finger. At three months post-injury, he had pain of 8/10 on the visual analogue scale (VAS) over the scar. After five OT sessions, his pain and hypersensitivity improved, with increased hand function. At the 1-year follow-up, the patient complained of 3/10 (VAS) pain over the index distal interphalangeal joint (DIPJ) with movement of the index finger, but no pain at rest.
Initial OT assessment revealed active ROM for the right index finger DIP 0° – 5° and PIP 30° – 60 (wrist active ROM of 45° extension and 60° flexion). After five sessions, he achieved active ROM of PIP 0° – 70° and DIP 0° – 35° (active ROM of the wrist extension: 50° and flexion: 70°).
The patient’s occupation involved working with tools. As a result of the hypersensitivity and decrease in ROM, he struggled to perform his duties at work. He also struggled with self-care such as fastening buttons. Hand function was assessed with the disability of the shoulder, arm and hand (DASH) questionnaire, where a possible score is out of 100. A score of 100 indicates extreme disability, and 0 shows a fully functional patient with no disability related to the arm, shoulder or hand injury. At three months post-injury, a DASH score of 72.5 and at six months post-injury, a DASH score of 53.33 were calculated.
At follow up on 30 March 2021, approximately seven months after surgery and nine months after his injury, he was satisfied with his recovery but developed new pain in his index finger DIPJ. Clinically he had crepitus, which is likely post-traumatic osteoarthritis because of the injury. His ROM of his right index finger proximal interphalangeal joint (PIPJ) was 30° – 94° with a fixed flexion deformity of 30° and his DIPJ 10° – 30°. There were still areas of dense scarring. He had a 2 PD of 10 mm and monofilaments of 2.0 g of his RDN, compared with 4 mm and 0.5 g for his ulnar digital nerve (UDN). His ROM was functional and he had recovered protective sensation.
The case report patient did not have immediate access to a specialised hand surgeon with delayed recognition and incorrect management leading to long-term consequences for a patient’s quality of life, function and work.
Primary care physicians routinely manage patients who sustained traumatic hand injuries but a thorough assessment and subsequent referral to a hand surgeon is imperative in complex hand injuries.
We can only speculate about the factors contributing to the delay in referral. The COVID-19 pandemic has definitely caused a delay in presentation to emergency departments and a long distance to travel has also been observed as a cause for delay in presentation.
Power tools cause deep and complex injuries to multiple structures.
Determining whether a tendon injury occurred is imperative through assessing the flexor digitorum superficialis (FDS) by blocking all fingers except the injured finger into extension and then asking the patient to flex the PIPJ of the affected finger. Assess the FDP by blocking the PIPJ and asking the patient to flex the DIP. No movement present indicates a potential injury. Observation is vital in assessing a possible tendon injury as the hand loses the natural cascade position. To evaluate a potential extensor tendon injury, ask the patient to extend the involved finger while blocking the proximal joints. It is important to note that it can be very difficult to adequately assess tendon function in the presence of an underlying fracture.
When presented with a patient who sustained an acute traumatic hand injury, do a thorough hand assessment (especially neurovascular) and two views X-rays.
With complicated hand fractures, neurological or vascular fall out, tendon involvement or complicating wound and soft tissue injuries, refer the patient to a hand surgeon without delay. If in doubt, contact your local hand surgeon to discuss the case.
The role of the primary care physician is to provide adequate pain control, irrigate the wound and in so doing remove any gross contamination. Control active bleeding with direct compression and loosely approximate the skin as far as possible. Depending on the experience and available facilities, the primary carer should use local anaesthetic for further examination and wound irrigation at the time of skin approximation, thus influencing the need for specialist referral.
Early referral of the patient to a qualified OT or physiotherapy with a special interest (or advanced training) in hand injuries will assist with oedema management and ROM.
Nerve injuries of the fingers are repairable.
The authors would like to acknowledge Ms. Chanel McCabe and Ms. Monique Malan for their continued support during his recovery and rehabilitation and for providing additional information regarding the patient’s progress.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
M.M.K. conceptualised and proposed the case study write up. M.M.K. and P.W.J. assessed the patient and applied for ethical clearance. M.M.K. drafted the first article. M.M.K. and P.W.J. read, reviewed and contributed to the final article.
This case study was approved by the Health Sciences Research Ethics Committee of the University of the Witwatersrand with the number M2011130. Written informed consent was obtained from the patient.
The authors received no financial support for the research, authorship and publication of this article.
The authors confirm that the data supporting the findings of this study are available within the article.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.