What is the initial management for a patient presenting with acute hand swelling and absent range of motion (ROM) at the wrist and fingers?

Acute Hand Swelling with Absent ROM: Emergency Management

This presentation demands immediate evaluation for compartment syndrome or vascular compromise, which are surgical emergencies requiring urgent orthopedic consultation and potential emergent fasciotomy or vascular exploration to prevent permanent disability or limb loss.

Immediate Clinical Assessment

Critical Red Flags Requiring Emergency Intervention

• Assess hand perfusion immediately: Check capillary refill, skin color (pale vs pink), temperature, and radial/ulnar pulses at the wrist 1
• Evaluate for compartment syndrome: The combination of acute swelling with complete loss of ROM suggests either compartment syndrome or severe vascular compromise 1
• Document neurovascular status: Test sensation in all nerve distributions and motor function if any movement is possible 1

Vascular Compromise Protocol

If the hand is pale and cold with absent pulses:

• Emergent reduction of any underlying fracture or dislocation is indicated, even before imaging if vascular compromise is severe 1
• After reduction, if perfusion does not improve (persistent pale, cold hand with absent pulses), immediate open exploration of the antecubital fossa and potentially the forearm/hand is indicated to prevent limb loss 1
• The catastrophic risks of persistent inadequate perfusion include loss of limb, ischemic muscle contracture, nerve injury, and permanent functional deficit 1

If pulses are absent but the hand remains perfused (pink, warm):

• Clinical judgment is required, though the evidence for optimal management in this scenario is inconclusive 1
• Close monitoring with serial neurovascular examinations is essential 1

Initial Imaging Strategy

Standard Radiographic Evaluation

• Obtain plain radiographs immediately: Standard 3-view series (posteroanterior, lateral, and 45° semipronated oblique) is the appropriate initial imaging 1
• Consider 4-view series: Adding a scaphoid view increases diagnostic yield for both distal radius and carpal injuries 2
• Evaluate soft tissues carefully: Soft-tissue swelling patterns on radiographs help localize occult fractures—dorsal hand fat-plane swelling suggests metacarpal fractures, while dorsal wrist fat-plane swelling indicates carpal fractures or dislocations 3

When Initial Radiographs Are Negative or Equivocal

• MRI without IV contrast or CT without IV contrast are equivalent appropriate next steps if fracture is still suspected clinically 1
• MRI is superior for soft tissue evaluation: Unlike CT, MRI can identify concomitant ligament injuries, tendon ruptures, and early compartment syndrome changes 1
• If immediate advanced imaging is unavailable and clinical suspicion for fracture remains, place in short arm cast and repeat radiographs in 10-14 days 1, 2

Differential Diagnosis Considerations

High-Priority Emergent Conditions

• Compartment syndrome: Requires emergent fasciotomy 1
• Vascular injury with ischemia: Requires emergent vascular exploration 1
• Complex fracture-dislocation: May require emergent reduction 1
• Severe soft tissue injury with tendon disruption: Complete loss of ROM suggests multiple tendon injuries requiring urgent surgical consultation 1, 4

Other Serious Conditions

• Septic arthritis or deep space infection: Can present with acute swelling and loss of motion, though typically with systemic signs 1
• Severe crush injury: May have delayed presentation of compartment syndrome 5, 6

Management Algorithm

1. Immediate neurovascular assessment with documentation of pulses, perfusion, sensation, and any residual motor function 1

2. If vascular compromise present: Emergent orthopedic consultation for potential immediate reduction or surgical exploration 1

3. Obtain plain radiographs (3-4 views) while arranging consultation 1, 2

4. If radiographs show fracture/dislocation: Proceed with appropriate reduction and fixation based on injury pattern 1

5. If radiographs negative but clinical concern remains high: Proceed to MRI without IV contrast to evaluate for occult fracture, ligament injury, or compartment syndrome 1, 2

6. Initiate edema control measures only after ruling out compartment syndrome: Elevation, ice, and immobilization 5, 6

Critical Pitfalls to Avoid

• Do not delay vascular assessment or intervention: Waiting for imaging when a pale, pulseless hand is present risks permanent disability 1
• Do not assume absence of fracture on initial radiographs: Soft-tissue swelling patterns should guide suspicion for occult injury requiring advanced imaging 3
• Do not apply circumferential casts or tight splints in the acute setting with significant swelling, as this can precipitate or worsen compartment syndrome 5
• Do not rely on 2-view radiographs alone: This is inadequate for detecting wrist and hand fractures 2
• Do not skip orthopedic consultation: Complete loss of ROM with acute swelling is never a benign finding and requires specialist evaluation 1, 6