How to manage and wrap a dorsal hand injury until a hand surgeon can be seen?

Management of Dorsal Hand Injuries Prior to Hand Surgeon Evaluation

For dorsal hand injuries awaiting hand surgeon evaluation, immobilize the hand in a safe position with the wrist in 20-30 degrees of extension, the metacarpophalangeal (MCP) joints in 70-90 degrees of flexion, and the interphalangeal (IP) joints in full extension (the "position of function" or "intrinsic-plus position"), using a volar splint that extends from the fingertips to the mid-forearm.

Initial Wound Assessment and Protection

Critical Anatomical Considerations

• Dorsal hand wounds have a significantly higher association with underlying structural injuries compared to palmar wounds (58.5% vs 36.4%) 1
• More than 50% of dorsal wounds in zones 1,3,5,6, and 7 present with at least one underlying lesion 1
• Zone 3 dorsal wounds (overlying the proximal interphalangeal joints) have a 68% rate of major structural injuries including tendon damage and joint violations 1

Immediate Wound Care

• Cover any open wounds with a sterile, moist saline dressing to prevent tissue desiccation and contamination 2
• Apply a waterproof topical dressing as the first layer if there are minor lacerations 3
• Avoid direct pressure over obvious deformities or exposed structures 1

Splinting Technique and Position

Hand Position Rationale

The intrinsic-plus position prevents:

• Collateral ligament contracture at the MCP joints
• Volar plate contracture at the IP joints
• Extensor tendon adhesions on the dorsal surface

Splint Application Steps

1. Use a prefabricated volar splint or create a custom splint that immobilizes:

   • Wrist: 20-30 degrees extension
   • MCP joints: 70-90 degrees flexion
   • PIP and DIP joints: Full extension (0 degrees)

2. Apply padding generously over bony prominences and between digits if multiple fingers are involved 2

3. Secure with elastic bandage wrap using gentle, even pressure:

   • Start distally at the fingertips
   • Wrap proximally toward the forearm
   • Ensure the wrap is snug but not constrictive
   • Check capillary refill and sensation after application

4. Leave fingertips exposed to monitor neurovascular status 2

Pain and Edema Management

Acute Phase Management

• Apply cryotherapy through a wet towel for 10-minute periods for short-term pain relief 4
• Elevate the hand above heart level continuously for the first 48-72 hours
• Avoid complete immobilization beyond the acute phase to prevent muscular atrophy and joint stiffness 4

Medication Considerations

• Provide appropriate analgesia based on pain severity
• Never inject corticosteroids into suspected tendon or ligament injuries, as this may inhibit healing and predispose to spontaneous rupture 4

Critical Warning Signs Requiring Immediate Evaluation

Neurovascular Compromise

• Absent or diminished capillary refill (>2 seconds)
• Numbness or tingling in specific nerve distributions
• Pallor or cyanosis of digits
• Increasing pain despite immobilization and elevation

Infection Risk

• Perform hand hygiene before and after every patient contact 2
• Monitor for signs of infection: increasing redness, warmth, purulent drainage, fever
• Wounds with visible contamination or significant tissue damage require urgent surgical evaluation 1

Special Considerations

Complex Injuries

• Dorsal wounds overlying joints (zone 3) have the highest rate of major structural injuries and warrant urgent hand surgeon evaluation 1
• Through-and-through injuries involving both dorsal and volar surfaces require complex reconstruction planning 5
• Injuries with bone exposure or suspected fractures need radiographic evaluation before definitive splinting 6

Timing of Specialist Evaluation

• All dorsal hand wounds should be evaluated by a hand surgeon regardless of initial appearance, given the high association with underlying structural damage 1
• Arrange hand surgeon consultation within 24-48 hours for closed injuries
• Open wounds, suspected tendon injuries, or neurovascular compromise require same-day or emergency evaluation 1

Patient Instructions

Activity Restrictions

• Keep the splint clean and dry
• Avoid using the injured hand for any activities
• Maintain strict elevation when not ambulating
• Activity modification to reduce movements that provoke pain while maintaining some wrist motion once cleared by hand surgeon 4

Follow-up Protocol

• Regular assessment of pain levels, range of motion, and functional improvement should guide progression of treatment 4
• Document and report any changes in sensation, color, or temperature of the hand
• Return immediately for signs of neurovascular compromise or infection