Treatment of Glass Embedded in the Hand
Glass injuries to the hand require immediate surgical exploration under anesthesia, as clinical examination significantly underestimates the extent of neurovascular and tendon damage in the majority of cases. 1
Immediate Assessment and Imaging
Obtain plain radiographs in all cases of suspected glass injury to the hand, regardless of clinical findings, as glass fragments are radiopaque and easily detected on X-ray. 2 The relatively low cost and high efficacy of radiographs, combined with the serious complications of retained foreign bodies (infection, delayed healing, persistent pain, late migration injury), make imaging essential even when examination appears benign. 2
Critical History Elements
- Document the mechanism of injury specifically - whether from car window, broken glass/dish/bottle, hand through glass, or other source, as this predicts injury pattern and likelihood of retained fragments. 2
- Failure to obtain detailed accident history constitutes medical malpractice and leads to missed foreign bodies requiring secondary surgery. 3
Surgical Exploration Indications
All glass injuries to the hand warrant formal surgical exploration under anesthesia, not bedside wound closure. 1 The preoperative examination, even when specifically evaluating for deficiencies, significantly underestimates actual damage in the operating room. 1
Expected Injury Patterns by Location
Above the elbow, structures injured in order of frequency include:
- Median nerve (75%)
- Brachial artery (58%)
- Ulnar nerve (50%)
- Musculocutaneous nerve (33%)
- Radial nerve (25%) 4
Below the elbow, most frequently injured structures are:
- Ulnar nerve (71%)
- Ulnar artery (57%)
- Flexor carpi ulnaris (57%)
- Flexor digitorum superficialis and profundus tendons (43%)
- Median nerve (43%) 4
Overall most common injuries found intraoperatively:
- Flexor digitorum superficialis (33% of all tendon injuries)
- Radial artery (39% of all arterial injuries)
- Superficial branch of radial nerve (22% of all nerve injuries) 1
Surgical Management
Early exploration is critical to successful management, with vascular repairs and/or microneurorrhaphy necessary in all cases of significant glass injury. 4
- Remove all glass fragments under direct visualization during formal exploration 2
- Repair all identified neurovascular structures using microsurgical techniques when indicated 4
- Repair all divided tendons identified during exploration 5
Expected Outcomes
- Vascular reconstructions in children and adolescents show no clinical problems at 4-9 year follow-up 4
- Nerve repairs demonstrate remarkably good results in pediatric populations with long-term follow-up 4
- 52% of patients require hospital admission >1 day 5
- Mean follow-up visits: 3.6, with majority requiring hand therapy and occupational therapy 5
Common Pitfalls to Avoid
Never perform bedside wound closure by nursing staff without physician exploration - this constitutes inadequate treatment and medical malpractice. 3
Never rely on clinical examination alone - an innocent-appearing skin wound frequently disguises extensive neurovascular damage beneath. 4 The preoperative examination significantly underestimates damage to tendons, arteries, and nerves even when specifically evaluating for deficiencies. 1
Never skip radiographic imaging - despite the efficacy of plain radiographs in detecting glass, these are sometimes not obtained, leading to complications from retained foreign bodies. 2
Never assume superficial exploration is adequate - glass injuries can be deceivingly debilitating, and careful orthopedic evaluation with surgical management should be considered even with a normal preoperative examination. 1