What is the best course of treatment for a patient with a cut on the palmar aspect of their hand?

Management of Palmar Hand Lacerations

For a palmar hand cut, immediately irrigate thoroughly with sterile saline or tap water, obtain radiographs to rule out fracture or foreign body, assess for tendon/nerve/vessel injury, administer tetanus prophylaxis if indicated, prescribe amoxicillin-clavulanate for prophylaxis, and avoid primary closure if there is any concern for contamination or deep structure involvement. 1, 2, 3

Initial Assessment and Imaging

• Obtain 3-view radiographs of the hand (posteroanterior, lateral, and oblique) as the initial imaging study to detect fractures, foreign bodies, or bone involvement, even in penetrating trauma 1
• Radiographs are essential in palmar wounds to identify fracture fragments that may require open reduction and internal fixation, particularly with suspected tendon injuries 1
• Examine for tendon injury by testing active range of motion of all digits—inability to flex suggests flexor tendon laceration requiring surgical repair 1
• Assess neurovascular status by checking two-point discrimination and capillary refill in all digits 3

Wound Cleansing Protocol

• Irrigate the wound with high-pressure sterile saline or potable tap water to remove bacteria, foreign bodies, and blood clots—there is no evidence that antiseptic irrigation is superior to sterile saline or tap water 2, 4, 3
• Use copious irrigation volume (at least 200-500 mL depending on wound size) to mechanically remove contaminants and reduce bacterial load 2, 5
• Debride devitalized tissue and surrounding callus with a scalpel if present, but avoid excessive debridement that enlarges the wound 2, 5
• Never close contaminated or deep palmar wounds primarily—infected or heavily contaminated wounds should never be sutured as this traps bacteria in deeper tissues 2, 4

Antibiotic Prophylaxis

• Prescribe amoxicillin-clavulanate 625 mg orally three times daily for 5-7 days to prevent polymicrobial infection, as palmar wounds are at high risk for contamination 2
• For penicillin-allergic patients, use doxycycline 100 mg orally twice daily for 7 days 2
• Do not use first-generation cephalosporins or clindamycin monotherapy as they lack adequate coverage for common pathogens in hand wounds 2
• Prophylactic antibiotics are particularly important for palmar wounds due to the risk of deep space infections and tenosynovitis 2, 3

Tetanus Prophylaxis

• Verify tetanus immunization status immediately and administer 0.5 mL tetanus toxoid intramuscularly if the last dose was >10 years ago or status is unknown 2, 4
• Do not delay tetanus prophylaxis—this must be addressed at the initial visit 2

Wound Closure Decisions

• Primary closure can be performed for clean, sharp lacerations with minimal contamination that can be closed within 24 hours of injury, provided no deep structure injury exists 5, 3
• For contaminated wounds, impact injuries, or wounds with suspected deep structure involvement, leave open for delayed primary closure after 3-5 days 5, 6
• Suturing can be completed up to 24 hours after trauma for appropriate wounds 3

Wound Dressing and Care

• Cover the wound with antibiotic ointment (such as bacitracin) and a clean occlusive dressing to maintain a moist environment and prevent contamination 4, 7, 8
• Apply a small amount of antibiotic ointment (equal to fingertip surface area) 1-3 times daily and cover with sterile bandage 7
• Patients can get the wound wet within 24-48 hours without increasing infection risk 9, 3
• Elevate the hand during the first few days to reduce inflammation and promote healing 4

Follow-Up and Monitoring

• Schedule follow-up within 24 hours to assess for signs of infection including increasing pain, redness, swelling, warmth, purulent drainage, or fever 2, 4
• Monitor specifically for deep space infections, flexor tenosynovitis (Kanavel's signs), and compartment syndrome in palmar wounds 2
• Consider hospitalization if infection progresses despite antibiotics, systemic signs develop, or deep tissue involvement is suspected 2

Critical Pitfalls to Avoid

• Never suture palmar puncture wounds or heavily contaminated lacerations—this dramatically increases infection risk by trapping bacteria 2, 4
• Do not miss flexor tendon injuries—test active flexion of all digits before wound closure 1
• Do not overlook foreign bodies or fracture fragments on initial radiographs—these require removal 1
• Avoid inadequate irrigation—this is the single most important factor in preventing infection 2, 5, 3