This briefing document synthesizes the competencies required for Hand Examination and Assessment for Emergency Practitioners and Doctors within the NHS.
Hand Examination and Assessment Competencies: A Clinical Briefing
HAND
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ANATOMY | |
Describe the anatomy within the scope as an NP including: Bones, ligaments, tendons, and soft tissues of the hand Neurovascular anatomy | |
HISTORY | |
Describe and perform a full history Understanding the importance of hand dominance, occupation and hobbies. | |
Discuss importance of mechanism of injury and describe the injuries associated with different mechanisms | |
EXAMINATION | |
Demonstrates a full hand assessment. Inspection, palpation, movement, assessment of neurovascular status with special consideration for assessment of tendon injury. (Recognise Importance of establishing position of hand when injury occurred and necessity to explore wound with hand in different positions. | |
Understands the indications is able to demonstrate special tests to assess ligamentous/tendon injury. | |
INVESTIGATIONS | |
Demonstrate understanding of indications and contraindications for X-ray.(for example FB from fight bites) | |
Interpret Hand/finger Xray and describe common injury patterns. (Understanding own limitations and when to request advice/review.) | |
MANAGEMENT | |
Describe and demonstrate understanding of wound management relating to hand injuries. With special consideration for need for antibiotic treatment and assessment of tetanus risk. (with specific consideration in fight bites) | |
Demonstrate understanding of common injuries and how they are manage including: • Fractures (open/closed/crush) • Dislocations • Flexor and extensor tendon injury • Ulnar collateral ligament injury | |
• Subungual haematoma • Nailbed laceration • Nailbed injury with deformity | |
Demonstrates understanding of common and important presentations and how they are managed including: • Flexor tenosynovitis • Dupitron’s Contracture • Trigger finger • Paronychia • Felon • Gout • Ganglion cyst • Herpetic whitlow | |
Understands the importance of appropriate advice and follow up, demonstrating safe discharge. |
1. Executive Summary
Hand injuries account for approximately 20% of all Emergency Department (ED) attendances in the UK. The complexity of hand anatomy means that seemingly minor surface wounds can mask debilitating injuries to tendons, nerves, or joints.
Critical Takeaways:
Position of Injury: Wounds must be explored through the full range of motion (ROM) to detect retracted tendon injuries.
Fight Bites: Any laceration over the metacarpal head (knuckle) is a human bite until proven otherwise. These require aggressive washout and antibiotics due to high risk of septic arthritis.
Rotational Deformity: Scissoring of fingers on flexion is the hallmark of malrotated metacarpal/phalangeal fractures and requires reduction/fixation.
Kanavel’s Signs: Recognition of these four signs is vital for diagnosing flexor tenosynovitis, a surgical emergency.
2. Clinically Relevant Anatomy
Osteology
Carpals: 8 bones arranged in two rows. Mnemonic: Some Lovers Try Positions That They Can't Handle (Scaphoid, Lunate, Triquetrum, Pisiform (proximal); Trapezium, Trapezoid, Capitate, Hamate (distal)).
Metacarpals (MC): 1st (Thumb) to 5th (Little). The 4th and 5th MCs are mobile (allowing grip), while the 2nd and 3rd are rigid stability pillars.
Phalanges: Proximal, Middle, Distal (Thumb lacks a middle phalanx).
Soft Tissue & Tendons
Flexors:
FDP (Flexor Digitorum Profundus): Inserts at distal phalanx. Flexes DIPJ.
FDS (Flexor Digitorum Superficialis): Splits (Chiasma of Camper) to insert at middle phalanx. Flexes PIPJ.
Pulleys: Annular (A1-A5) and Cruciate (C1-C3) ligaments hold tendons to bone. A2 and A4 are critical for preventing "bowstringing."
Extensors: Complex dorsal apparatus including central slip (extends PIPJ) and lateral bands (conjoin to extend DIPJ).
Ligaments:
Collateral Ligaments: Taut in flexion (MCPJ) and extension (IPJ).
Volar Plate: Thick ligament preventing hyperextension of PIPJ.
Neurovascular Anatomy
| Nerve | Motor Function (Simplified) | Sensory Area (Autonomous Zone) |
| Median | "Precision" (Thenar muscles, Lumbericals 1-2). "OK" Sign. | Volar tip of index finger. |
| Ulnar | "Power" (Interossei, Adductor pollicis, Hypothenar). Finger spread. | Volar tip of little finger. |
| Radial | "Extension" (Wrist/Finger extensors). Thumbs up. | First dorsal web space. |
Vascular: Superficial and deep palmar arches supplied by Ulnar (dominant supply) and Radial arteries. Digital arteries run along the lateral and medial aspects of digits.
3. Clinical Assessment
History
Hand Dominance: Crucial for occupational prognosis and rehabilitation goals.
Occupation/Hobbies: High-demand manual work vs. fine motor skills (e.g., musician).
Mechanism of Injury (MOI):
Crush: Expect bursting wounds, compartment syndrome, distal phalanx fractures.
High-pressure injection: Surgical Emergency. Small entry wound but extensive internal chemical necrosis.
Punch: 5th MC fracture, fight bite.
Fall: Scaphoid, Distal Radius.
Tetanus Status: Verify last booster.
Physical Examination
Look (Inspection)
Posturing: A hand at rest forms a "cascade" where fingers progressively flex from index to little. Disruption suggests tendon laceration.
Deformity: Rotational deformity (fingers crossing/scissoring) is best seen during active flexion.
Wounds: location, contamination, skin loss.
Feel (Palpation)
Tenderness: Pinpoint specific structures (e.g., anatomical snuffbox for Scaphoid).
Temperature: Cold digit suggests vascular compromise.
Move (Range of Motion)
Active vs. Passive: Discrepancy suggests tendon pathology or nerve palsy.
Tendon Integrity Testing:
FDP: Hold PIPJ in extension; ask patient to flex DIPJ.
FDS: Hold all other fingers in full extension (neutralizes FDP); ask patient to flex the isolated finger.
Extensor Pollicis Longus (EPL): Lift thumb off the table (retropulsion).
Neurovascular Status
Vascular: Capillary Refill Time (CRT) <2s. Allen’s Test to assess patency of radial/ulnar arteries.
Neurological:
Two-Point Discrimination (2PD): The gold standard for digital nerve injury. Normal is <6mm (<5mm static). Compare with the uninjured side.
Note: Sensation may remain intact initially after nerve transection due to overlap; 2PD is most sensitive.
Special Tests
Elson’s Test: For Central Slip injury (Boutonnière deformity). Flex PIPJ 90° over table edge and ask to extend against resistance. Weakness/floppy DIPJ = positive.
UCL Stress Test: Stress the thumb MCPJ in 30° flexion and extension. Laxity >30° or lack of firm end-point = rupture (Skier's/Gamekeeper's thumb).
Critical Note on Wound Exploration:
A tendon laceration may not align with the skin wound if the finger was flexed during injury. You must explore the wound while taking the digit through full ROM to visualize the tendon.
4. Investigations
Imaging (X-ray)
Standard Views: PA (Posterior-Anterior), Lateral, and Oblique.
Indications: Deformity, bony tenderness, significant crush, glass foreign body suspicion, fight bites (tooth fragments).
Foreign Bodies (FB):
Glass: Nearly all glass (even clear) is radiopaque if >2mm.
Organic (wood/thorns): Radiolucent. Requires Ultrasound (US) if suspected and not found on exploration.
Interpretation Patterns
Boxer’s Fracture: Fracture of the 5th Metacarpal neck. Check for volar angulation.
Volar Plate Avulsion: Small fleck of bone at the volar base of the middle phalanx.
Scaphoid: Look for fracture line through waist. If negative X-ray but snuffbox tenderness + axial loading pain -> Treat as fracture (MRI/CT follow-up).
5. Management
Wound Management
Irrigation: Copious saline irrigation.
Analgesia: Digital nerve block (Plain Lidocaine or Bupivacaine) allows thorough exploration. Caution: Avoid adrenaline in digital blocks in patients with severe PVD, though modern evidence suggests it is safe in healthy digits.
Antibiotics:
Simple cuts: Not routinely required.
Bites (Human/Animal): Mandatory. Co-amoxiclav is first line (covers Eikenella corrodens in human bites and Pasteurella in animal bites).
Tetanus: Booster or Immunoglobulin based on status and wound dirtiness.
Common Traumatic Injuries
| Injury | Key Management Principles |
| Metacarpal Fracture | Boxer's: Accept up to 40-50° angulation (neck). Neighbor strapping. Shaft: Rotational deformity is unacceptable -> ORIF. |
| Dislocations (PIP/DIP) | Ring block -> Reduction (traction). Check stability and NV status post-reduction. Buddy strap. Early mobilization usually required to prevent stiffness. |
| Tendon Injury | Flexor: Plastics referral. Skin closure only; do not attempt tendon repair in ED. Extensor: Open injuries refer. Closed Mallet (zone 1) = Stack splint 6-8 weeks strictly. |
| UCL Injury | Skier's Thumb. If unstable (Stener lesion risk), refer to ortho/plastics. Spica splint. |
| Subungual Haematoma | If >50% of nail bed or painful: Trephination (hot wire/needle) to relieve pressure. |
| Nailbed Laceration | Remove nail plate, suture nail bed with 6-0 absorbable (Vicryl Rapide), replace nail plate as a splint (or use foil). |
Common Presentations (Pathology)
Flexor Tenosynovitis: Infection of the tendon sheath.
Kanavel’s Signs: 1. Fusiform swelling (sausage digit), 2. Finger held in flexion, 3. Pain on passive extension (most sensitive), 4. Tenderness along tendon sheath.
Mgmt: IV Antibiotics, admission, urgent washout.
Felon: Abscess of the finger pulp. Requires incision and drainage (lateral or volar approach). Watch for osteomyelitis.
Paronychia: Nail fold infection. Oral Abx if minor; I&D if fluctuant.
Herpetic Whitlow: HSV infection. Vesicles, clear fluid. Do NOT Incise & Drain (risks viremia/bacterial superinfection). Cover and Acyclovir.
High Pressure Injection: Pain may be mild initially. Immediate Plastics Referral for debridement.
Dupuytren's Contracture: Palmar fascial thickening. Elective referral if positive "Table Top Test" (cannot place hand flat).
6. Complications
| Complication | Timeframe | Prevention/Management |
| Stiffness | Delayed | The most common complication. Early mobilization for stable injuries. Splint in "Position of Safety" (MCP 90°, IP 0°). |
| Infection | Immediate/Delayed | Aggressive washout. Early Abx for bites. Elevation. |
| Complex Regional Pain Syndrome (CRPS) | Delayed | Vitamin C 500mg daily for 50 days post-distal radius # reduces risk. Pain management, physio. |
| Tendon Rupture | Delayed | Watch for attrition rupture after distal radius # (EPL) or missed diagnosis. |
7. EPIC EHR Documentation Structure
Chief Complaint: Hand Injury / Hand Pain
SmartBlock: Hand Examination
History:
Hand Dominance: [Right / Left / Ambidextrous]
Occupation: [***]
Mechanism: [Crush / Slice / Punch / Fall / Bite / High Pressure]
Tetanus Up to Date: [Yes / No]
Examination:
Inspection: [No deformity / Rotational deformity / Swelling / Erythema / Wounds]
Wound Characteristics: [Clean / Contaminated / Flap]
Palpation: [Non-tender / Snuffbox tender / 5th MC tender / Volar plate tender]
Neurovascular:
Radial Pulse: [2+] Ulnar Pulse: [2+]
Capillary Refill: [<2s / >2s]
Sensation (2PD): [Intact (<6mm) / Diminished / Absent] in [Median / Ulnar / Radial] distribution.
Motor/Tendons:
FDP (DIP flexion): [Intact / Absent]
FDS (PIP flexion): [Intact / Absent]
Extensors (EPL/EDC): [Intact / Absent]
OK Sign: [Normal] | Finger Spread: [Normal] | Thumbs Up: [Normal]
Special Tests:
UCL Stress: [Stable / Laxity >30 deg]
Elson's Test: [Negative / Positive]
Medical Decision Making (MDM):
X-rays interpreted: [Negative / Fracture of *** / FB present]
Wound explored under [Digital Block]. Full ROM exploration performed.
Tendon integrity confirmed visually and mechanically.
Diagnosis: [***]
Plan: [Conservative / Washout & Closure / Splint / Plastics Referral]
Discharge Advice: Elevation, Signs of infection, Safety netting for stiffness.
8. References
Giladi AM, Shauver MJ, Ho A, et al. Variation in the management of closed hand fractures. J Hand Surg Am. 2014;39(12):2403-2412.
British Society for Surgery of the Hand (BSSH). Hand Injuries: Triage and Management Guidelines. London: BSSH; 2018.
Tintinalli JE, et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill Education; 2020. Chapter 268: Hand Injuries.
National Institute for Health and Care Excellence (NICE). Bites: human and animal. Clinical knowledge summary. London: NICE; 2020.
Kennedy CD, Lauder AS, Pribaz JR, Kennedy SA. Differentiation between pyogenic flexor tenosynovitis and other finger infections. Hand (N Y). 2017;12(6):585-590.
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