Hand laceration

Question 1

A 22 year old man has fallen through a glass window when intoxicated. He has a 4cm transverse laceration just proximal to the flexor crease of his right hand. It is bleeding profusely but can be controlled with local pressure. He is obviously intoxicated but cooperative. How will you manage this situation?

Answer 1

Impression
Deep hand laceration in setting of intoxication.

Key considerations
- neuromuscular injuries and compromise of distal hand
- flexor tendon damage, intrinsic hand muscle injuries
- alcohol intoxication: increases ongoing bleeding risk
- potential for other injuries (head, neck, etc) to have been sustained given intoxicated state

Goals
- A to E assessment given MOI to assess for other injuries, ?degree of blood loss and secondary hypovolaemia etc
- referral to orthodontist/plastics for reconstructive surgery as required depending on findings of assessment, otherwise repair in ED for haemostasis

Question 2

Hand laceration - Assessment

Answer 2

Assessment
- ensure HD stability given blood loss
- consider degree of intoxication, safety, setting of care
- secondary review for additional injuries sustained given acute intoxication

Question 3

Hand laceration - History

Answer 3

History
- MIST AMPLE

Question 4

Hand laceration - Examination

Answer 4

Examination
- General appearance + vitals
- hand examination: neurovascular assessment, finger flexion/extension, wound inspection

Question 5

Hand laceration - Investigations

Answer 5

Investigations
Key/diagnostic
- X-ray

Other
- pre-op bloods: G+H, coags, FBC, UEC

Question 6

Hand laceration - Management

Answer 6

Management
Acute
- local anaesthetic to facilitate appropriate cleaning and thorough assessment of wound for any injuries noted; flexor tendons, arterial lacs, any nervous tissue damage
o Consider risk of lignocaine + adrenaline in end-organs
o consider regional anaesthetic blocks
- If significant neuromuscular/tendon/bony injuries noted, then refer to ortho/plastics for emergency theatre for exploration and definitive mx - place in back-slab and dress wounds in interim
- If no neurovascular/tendon/bony involvement and just soft tissue injury, then close primarily with sutures to stem bleeding and close wound, discharge, then for F/U with GP for suture removal at 7-8 days.

Supportive
- tetanus prophylaxis

Ongoing
- Review in GP