What is the approach to evaluating and managing hand pain in the emergency department (ED)?

Approach to Hand Pain in the Emergency Department

The evaluation of hand pain in the emergency department should begin with standard radiographs (posteroanterior, lateral, and oblique views) as the first-line imaging study, followed by a targeted physical examination focusing on alignment, joint spaces, and signs of fracture or soft tissue injury. 1

Initial Assessment

History

• Mechanism of injury (trauma, repetitive use, spontaneous onset)
• Timing and duration of symptoms
• Location and radiation of pain
• Aggravating and alleviating factors
• Associated symptoms (numbness, tingling, weakness)
• Previous hand injuries or conditions
• Occupation and hand dominance

Physical Examination

1. Inspection:

   • Swelling, erythema, ecchymosis
   • Deformity or malalignment
   • Skin integrity and wounds
   • Comparison with contralateral hand

2. Palpation:

   • Tenderness over specific structures (bones, joints, tendons)
   • Joint stability assessment
   • Tendon integrity evaluation

3. Range of Motion:

   • Active and passive movement of all joints
   • Comparison with unaffected side

4. Neurovascular Assessment:

   • Two-point discrimination
   • Capillary refill
   • Radial and ulnar pulses
   • Motor function of intrinsic and extrinsic muscles

Diagnostic Imaging

First-Line Imaging

• Standard radiographs (3 views: posteroanterior, lateral, and oblique) 1
  • Allows assessment of:
    • Bone alignment and ulnar variance
    • Joint spaces
    • Impaction syndromes
    • Static instability
    • Fractures (healed, non-united)
    • Soft tissue mineralization and swelling
    • Erosions

Second-Line Imaging (if radiographs are normal or show nonspecific findings)

• Ultrasound - useful for evaluating superficial structures including:

  • Tendons and ligaments
  • Muscles
  • Nerves
  • Dynamic examination capabilities 1

• MRI (without contrast) - for suspected soft tissue injuries not visible on radiographs

• CT scan (without contrast) - for complex fractures or when detailed bony anatomy is needed

Pain Management

Pain management should be addressed promptly in patients with hand injuries, as pain is reported in up to 78% of ED visits 1.

Analgesic Options:

1. NSAIDs - First-line for mild to moderate pain without contraindications
2. Acetaminophen - Alternative for those who cannot take NSAIDs
3. Opioids (morphine, fentanyl, hydromorphone) - For severe pain
4. Regional nerve blocks - Consider for digital or wrist injuries

Management Algorithm

1. Mild injuries (no deformity, normal neurovascular status, minimal pain):

   • Radiographs if mechanism suggests fracture
   • Symptomatic treatment
   • Follow-up instructions

2. Moderate injuries (stable fractures, partial tendon injuries, significant pain):

   • Radiographs
   • Immobilization with splint
   • Pain control
   • Outpatient follow-up within 3-5 days

3. Severe injuries (open fractures, neurovascular compromise, unstable fractures, complete tendon ruptures):

   • Immediate orthopedic/hand surgery consultation
   • Appropriate imaging
   • Pain management
   • Tetanus prophylaxis if indicated
   • Antibiotics for open injuries

Indications for Immediate Specialist Consultation

• Neurovascular compromise
• Open fractures
• Unstable fractures or dislocations
• Complete tendon lacerations
• Significant skin loss
• Flexor tendon injuries at or distal to the wrist 2

Common Pitfalls to Avoid

1. Failing to compare with the uninjured hand
2. Missing subtle fractures (especially scaphoid)
3. Inadequate pain management
4. Improper splinting technique
5. Overlooking neurovascular injuries
6. Inadequate documentation of sensory and motor function
7. Missing foreign bodies in wounds

By following this structured approach to hand pain evaluation in the ED, clinicians can effectively diagnose and manage these common injuries while ensuring appropriate disposition and follow-up care.