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Medical Author:

Chad Tarr, MD

Medical Editor:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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Soft tissue injuries and amputations

• Stabilize the injured person first, and then if possible, preserve amputated body part.
• Evaluate to determine extent of injury
• Pain relief
• X-ray to confirm or rule out fracture and further define the scope of the injury
• Referral to hand surgeon for repair

These injuries can be devastating to the hand and the patient. Reattaching (replantation) is difficult, and even if successful may, cause long-term complications with pain and infection. Situations when a surgeon may attempt replantation are amputation involving a child, thumb amputation, or amputation of multiple fingers or the entire hand.

Crush or tear injuries and prolonged delay before evaluation may make successful replantation impossible. Each injury requires an immediate evaluation because each person's circumstances warrant all possibilities to be considered. The type, location, extent, person's wishes, and time of injury all contribute to the treatment plan. Some injuries will require immediate surgery for replantation. Others will require little medical intervention beyond cleansing, bandaging, and allowing the injury to heal. In some locations, the doctors and facilities needed for replantation do not exist.

Infections

• X-ray if indicated (especially if gas gangrene is expected)
• Referral to a hand specialist if needed for extensive cleaning of the wound
• Antibiotics for bacterial infection of the tissue; antifungals for fungal infections

Fingertip and nail infections may be treated in the clinic or emergency department with incision and drainage (if indicated), antibiotics, and close follow-up. A major consideration for an infection in the hand is the presence of a fluid collection or an abscess. If the infection is isolated to the skin, known as cellulitis, treatment involves antibiotics and close follow-up. However, an abscess requires drainage (sometimes known as "lancing"). If the abscess is large or near nerves, arteries, ligaments, or tendons surgery may be necessary for treatment. Hand infections have the potential for rapid progression leading to severe loss of function.

Serious burn injuries to the hand may require an evaluation by a hand or burn surgeon. Hospital admission may be required for treatment. Multiple operations including skin grafting may be needed in order to ensure the best outcome.

First-degree burn

• Cool burned area with water, not ice
• Pain relief
• Reevaluation of depth or degree of burn
• Bandage the injured area with antibacterial ointment
• Follow-up in 48-72 hours

Second-degree burn

• Cool burned area with water, not ice
• Pain relief
• Reevaluation of depth or degree of burn
• Sterile rupture of blisters is recommended by some, but not all health care professionals
• Bandage injured area with antibacterial ointment
• Close follow-up in 48-72 hours

Third-degree burn and deep second-degree burns

• Cool with saline or water, not ice
• Pain relief
• Reevaluation of depth or degree of burn
• Use Sterile dressings with antibacterial ointment on injured area
• Referral to a doctor skilled in burn treatment for evaluation and debridement within 24-48 hours of injury (debridement is the process of removing dirt, foreign bodies, and dead tissue from a wound; this procedure could involve washing, scrubbing, and cutting away of dead tissue). Some patients, especially those with burns that completely surround the fingers, hand, or wrist, may be admitted to a hospital burn unit because of the potential to develop compartment syndrome.

Chemical burns

• Treatment tailored to type of chemical, most require lots of irrigation with water
• Certain exposures require immediate debridement. In some burns, water is not used because it further damages the skin, other exposures require systemic treatments so a specialist in burns is good to consult; in addition, the poison control center (1-800-222-1222) can help decide what special emergency treatments may help with certain patients.
• Local wound care

Electrical burns

• Local wound care
• Evaluation for electrical injury to other organ systems
• If severe: IV fluids, cardiac monitoring

Cold injuries

• Rapid rewarming of tissue with warm water (104-08 F or 40-42.2 C) for 15-30 minutes
• Sterile incision of blisters is usually recommended
• Ointment plus sterile dressings over injured area
• Pain relief
• Consideration for antibiotics
• Local wound care with follow-up in 48-72 hours

High pressure injuries

• X-rays
• Tetanus booster
• Broad-spectrum antibiotics
• Splint
• Steroids may be considered
• Consult a hand specialist immediately as debridement my be required

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