Page 95 - JSOM Winter 2017

An Ongoing Series

Hand Injuries

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Joshua Banting ; Tony Meriano, MD 2

CONCEPTS AND OBJECTIVES
The series objective is to review various clinical conditions/ are key features to document with all hand injuries. Many of
presentations, including the latest evidence on management, these questions revolve around understanding the potential
and to dispel common myths. In the process, core knowledge functional outcomes of the injury and the risk of infection.
and management principles are enhanced. A clinical case will Infections in the closed spaces of the hand can be particularly
be presented. Cases will be drawn from real life but phrased devastating.
in a context that is applicable to the Special Operations Forces
(SOF) or Tactical Emergency Medical Support (TEMS) en- Assessment of Hand Injuries
vironment. Details will be presented in such a way that the
reader can follow along and identify how they would manage Mechanism
the case clinically depending on their experience and environ- The exact mechanism that caused the trauma is important to
ment situation. Commentary will be provided by currently document because it allows the clinician to understand what
serving military medical technicians. The medics and author underlying structures may have been injured. In addition, it is
will draw on their SOF experience to communicate relevant important to understand what position the hand was in dur-
clinical concepts pertinent to different operational environ- ing the injury. This is critical because tendons may be in a
ments including SOF and TEMS. Commentary and input from different position during the examination, and visualization
active Special Operations medical technicians will be part of of an injury may not be possible. In addition, understanding
the feature. the mechanism helps the clinician assess the risk of infection
from the injury.
The Cases
Time of Injury
You are deployed overseas on a multinational joint training Knowing the time of the injury is important because it can be
exercise. You are providing medical coverage for a group of a factor in determining the treatment. For instance, depending
approximately 250 military personnel. While conducting sick on assessment of the risk of infection, a clinician may delay
parade, a couple of patients come see you with injuries to their closure of a laceration that is more than 18 hours old. 1
hands.
Hand Dominance
The first patient is 24-year-old supply technician who was It is important to document which is the dominant hand of the
opening some crates with his knife and accidentally cut his left patient, because this will help the clinician assess the impact of
hand. The cut looks deep and is across the palmar surface of the injury on the patient’s functional ability.
the fingers and has cut the middle and ring fingers. The second
patient has a laceration to his right hand involving the dorsal Work and Hobby History
surface over the index and middle fingers at the metacarpo- Understanding how the patient makes their living is important
phalangeal joint. because this will allow the clinician to understand the poten-
tial impact of the injury on the patient’s career. For instance,
Before you delve into the cases you spend a couple of minutes injury to a precision shooter’s dominant trigger finger may be
reviewing the approach to hand injuries with your junior med- far more important than an injury to their little finger.
ical technician. The hand is an incredibly complex structure.
An intricate network of nerves, tendons, and muscles work Prior Injuries to the Hand
together to allow us to perform complicated and fine move- Documenting prior injuries, including neurological or func-
ments. Many of the key structures lie very superficially and tional injuries, is important because this allows the clinician
are subject to injury. When taking the patient’s history, there to understand the baseline function of the patient’s extremity.

Comments and suggestions can be sent to sofclinicalcorner@gmail.com
1 LT Banting CD, BSc, CCPA, is a physician assistant with CANSOFCOM. Major Meriano is a practicing emergency physician who has served
2
in various capacities with the Canadian Forces and Reserves since 2003.
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