What is the management for a patient with hand pain for 3 weeks after punching?

Management of Hand Pain 3 Weeks After Punching

This patient requires immediate radiographic evaluation to rule out a "boxer's fracture" (metacarpal neck fracture, typically 5th metacarpal) or occult fracture, followed by assessment for infection, tendon injury, or ligamentous damage—all of which are common complications of closed-fist injuries that can lead to permanent disability if missed. 1

Immediate Diagnostic Workup

Radiographic Assessment

• Obtain plain radiographs of the hand in at least 2 views (PA and lateral) immediately to evaluate for fracture, fracture displacement, and articular involvement 1
• Radiography is the appropriate initial imaging study for chronic hand pain and may be the only examination needed to establish a diagnosis 1
• After 3 weeks, any fracture should be visible on plain films; if clinical suspicion remains high despite negative radiographs, consider MRI or CT 1

Clinical Examination Priorities

• Assess for "fight bite": Examine carefully for any small laceration over the metacarpophalangeal (MCP) joints, which indicates tooth penetration and high risk of septic arthritis or osteomyelitis 1
• Evaluate tendon integrity: Test active and passive range of motion of all digits, particularly flexor and extensor tendons, as delayed tendon rupture can occur 2
• Check for rotational deformity: Have patient make a fist—all fingers should point toward the scaphoid; any scissoring or malrotation suggests fracture malunion 2
• Assess neurovascular status: Document two-point discrimination and capillary refill in all digits 2

Management Based on Findings

If Fracture Identified

Non-displaced or minimally displaced fractures:

• Immobilize with ulnar gutter splint for 3-4 weeks 2
• Refer to orthopedics within 48-72 hours for definitive management 2

Displaced fractures, open fractures, or fracture-dislocations:

• Immediate orthopedic consultation required 2
• These injuries require surgical intervention to prevent permanent functional impairment 2

If Infection Suspected (Fight Bite)

Any evidence of penetrating injury over MCP joint requires aggressive management:

• Obtain urgent hand surgery consultation for possible operative debridement 1
• Start empirical IV antibiotics covering Eikenella corrodens, Staphylococcus aureus, and anaerobes: ampicillin-sulbactam 3g IV every 6 hours 1
• Do NOT use first-generation cephalosporins, penicillinase-resistant penicillins, macrolides, or clindamycin alone—these have poor activity against Pasteurella and Eikenella species 1
• If outpatient oral therapy is appropriate (no deep space infection): amoxicillin-clavulanate 875/125 mg twice daily 1

If No Fracture or Infection: Soft Tissue Injury Management

This represents post-traumatic hand pain, likely from ligamentous injury, capsular damage, or occult cartilage injury:

Non-Pharmacological Interventions (First-Line)

• Provide education on activity modification, ergonomic principles, and pacing to prevent re-injury 1, 3
• Prescribe a custom-made hand orthosis to be worn during activities for at least 3 months—evidence shows beneficial effects on pain with prolonged use 1, 3
• Initiate hand exercises aimed at improving joint mobility, muscle strength, and stability, as multiple trials demonstrate beneficial effects on pain, function, and grip strength 1, 3
• Apply local heat (warm soaks, paraffin wax) before exercise sessions to facilitate range of motion 1

Pharmacological Management

• Topical NSAIDs (diclofenac gel) are first-line pharmacological treatment due to favorable safety profile and efficacy comparable to oral NSAIDs with significantly fewer gastrointestinal side effects 1, 3
• Oral NSAIDs (ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily) for limited duration if topical therapy insufficient 1, 4
• Acetaminophen up to 4g/day can be added for multimodal analgesia, though efficacy is limited compared to NSAIDs 4

Red Flags Requiring Urgent Referral

Immediate hand surgery consultation if:

• Any open wound over MCP joint (fight bite) 1, 2
• Inability to actively extend any digit (extensor tendon rupture) 2
• Rotational deformity or scissoring of digits 2
• Neurovascular compromise 2
• Displaced or open fracture 2
• Signs of deep space infection (severe swelling, inability to flex fingers, fever) 1

Common Pitfalls to Avoid

• Do not dismiss small lacerations over MCP joints as "minor"—these represent tooth penetration until proven otherwise and require aggressive management 1
• Do not prescribe oral NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk factors, particularly in elderly patients 3, 4
• Do not rely on acetaminophen alone for post-traumatic hand pain, as its efficacy is limited 3, 4
• Do not continue conservative management indefinitely without reassessment—if symptoms remain severe after 3 months of appropriate treatment, escalate to specialist consultation 3
• Do not assume normal radiographs exclude significant injury—ligamentous injuries, cartilage damage, and early osteomyelitis may not be visible on plain films 1

Follow-Up

• Reassess in 1-2 weeks if conservative management initiated 3
• If no improvement after 4 weeks of appropriate treatment, consider MRI to evaluate for occult fracture, ligamentous injury, or cartilage damage 1
• Refer to hand surgery if symptoms persist beyond 3 months despite optimal conservative therapy 3