Hand Open Wounds

Open wounds at the hand imply the disruption of the skin with exposure of deeper structures.

Pathology

Open wounds at the hand imply the disruption of the skin with exposure of deeper structures. Depending on the mechanism of injury, these wounds can present as sharp lacerations, a crush component that if severe enough will tear the skin apart, a pulling force (avulsion), shearing and saw injuries that will produce a sharp or a ragged edge on the tissues depending on the thickness of the saw. Any combination of the above type of injuries can happen.

Open wounds can be classified as superficial when they remain above the level of the deep fascia, which is a whitish looking, well defined envelope covering the tendons, muscles, deep nerves and arteries. A superficial wound can involve the skin, subcutaneous tissue (fat) and superficial vessels or nerves. All wounds demand immediate assessment and treatment by a trained hand surgeon to correctly identify the injured structures. A superficial wound can be treated in an emergency room setting and a hand specialist contacted to discuss a clear treatment plan. The patient should then be seen by a hand specialist for further evaluation and recommendation. Tetanus is updated if it has been longer than 10 years since receiving a tetanus shot or if the wound is a dirty wound, then the tetanus is updated if it has been five years since receiving a tetanus shot. This is to avoid the danger of acquiring gas gangrene that can be deadly. The use of oral antibiotics for one week after a repair is used as a prophylaxis to avoid the risk of infection. Special splints are applied after the procedure for comfort or protection. The injured extremity must be elevated to at least heart level to avoid swelling of the limb that can cause moderate pain, cut off the blood supply and delay wound healing.

Some of these cases will require urgent exploration, debridement (surgical cleaning that is deeper and more thorough than a regular wash out in the emergency room), and repair of superficial nerves. This should be done as soon as possible within a week time from injury. Some of these cases may require only close observation for the wounds to appropriately heal if the physical exam indicates that the tendons, nerves and vessels are intact.

A deep wound can involve the above mentioned structures and a number of deep tendons, muscles, nerves and arteries. The degree of contamination, the extent and severity of the injury will demand different urgency of treatment that only a qualified health care professional can appropriately assess. Emergency treatment of a deep wound can receive initial cleaning by a emergency health care professional, and any bleeders can be controlled at that time by gentle pressure or by direct suturing and the laceration can be closed after a thorough preliminary assessment has been done and a hand specialist has been contacted to discuss appropriate definitive treatment recommendations. Many of these injuries can be referred to a hand specialist for further evaluation and recommendations in an URGENT within a one week time. At ROC, however, we also offer emergency treatment of the injury if the patient is ready to proceed with surgery and has the appropriate medical clearance to have the surgery performed.

Some patients may present with severe contamination, incontrollable bleeding, presence of a foreign body (glass), a pulseless extremity (that is at the highest risk for loosing tissue), open joint or other associated injuries like an open fracture that demand EMERGENT surgical care the moment it presents. In these cases the patients need to be stabilized, the hand specialist needs to be contacted immediately to communicate the emergent need of attention and organize appropriate routes and locations for triage of the patient or the patient can present directly to ROC where a hand specialist is always present.

Treatment

Non-operative treatment of wrist ganglions has been reported consisting of aspiration with or without steroid injections and short term splinting. In the best of the cases, only 30 to 50 % of cases are successfully treated. Technically, it is very challenging to aspirate the fluid even with a large needle because of the thickness of the fluid and also the larger the needle, the higher the risk of injury to the tendons, nerves or vessels during the procedure. Aspiration is also difficult because of collapse of the cyst and occlusion of the needle tip before complete aspiration of the fluid is accomplished. The most reliable procedure is surgical excision that can be done through a small incision at the site of the mass. In the fingers, the removal of the cysts and bony spurs cleaning the arthritic joint will result in good cosmesis and function. These procedures provide reliable outcomes with unlikely recurrence and complete resolution of symptoms and return to normal activities in most cases.