What should be included in the physical assessment of a 16-year-old patient with swelling and bruising on the right dorsal hand, from the last two knuckles down, and severe pain, after hitting a cement wall?

Physical Assessment of Right Dorsal Hand Injury in 16-Year-Old After Cement Wall Impact

Your physical assessment must systematically evaluate for metacarpal fractures (particularly boxer's fracture of the 5th metacarpal), tendon injuries, neurovascular compromise, and compartment syndrome, as hand wounds are often more serious than wounds to fleshy parts of the body and pain disproportionate to injury near bone or joint suggests periosteal penetration. 1

Immediate Inspection and Documentation

• Document swelling pattern and location precisely - note whether swelling is localized to the metacarpophalangeal (MCP) joints of the 4th and 5th digits or extends across the entire dorsal hand 1
• Assess bruising characteristics - record color, pattern, and exact distribution from the last two knuckles distally, as patterned bruising would be concerning 2, 3
• Photograph the injury if there are any inconsistencies in the history, as bruise appearance changes rapidly 2
• Look for open wounds, lacerations, or puncture wounds that would require irrigation and increase infection risk 1
• Check for rotational deformity - have the patient make a loose fist and observe whether all fingers point toward the scaphoid; any scissoring or overlap indicates rotational malalignment from fracture 1

Range of Motion Assessment

• Active range of motion of all digits - ask the patient to make a full fist, then fully extend all fingers; inability to do either suggests tendon injury or severe fracture 1
• Passive range of motion - gently move each MCP, proximal interphalangeal (PIP), and distal interphalangeal (DIP) joint through full range; pain disproportionate to examination suggests periosteal penetration or intra-articular involvement 1
• Wrist range of motion - assess flexion, extension, radial and ulnar deviation to rule out associated wrist injury 1

Neurovascular Examination

• Two-point discrimination on the radial and ulnar aspects of each digit to assess digital nerve integrity 4
• Capillary refill in all fingertips - should be less than 2 seconds 4
• Radial and ulnar pulse palpation at the wrist 4
• Sensory mapping - test light touch and pinprick sensation in the distribution of the radial, median, and ulnar nerves 4, 5

Tendon Integrity Testing

• Extensor tendon function - have the patient extend each MCP joint individually against resistance while you stabilize the proximal phalanx; inability indicates extensor tendon rupture 1
• Flexor digitorum profundus (FDP) - stabilize the middle phalanx and have patient flex the DIP joint 1
• Flexor digitorum superficialis (FDS) - hold all other fingers in extension and have patient flex the PIP joint of the affected digit 1
• Extensor pollicis longus - have patient extend thumb against resistance if thumb involvement suspected 1

Palpation for Fracture

• Systematic palpation of each metacarpal shaft from base to head, noting point tenderness that localizes the fracture site 1
• Palpate the MCP joints of the 4th and 5th digits specifically, as these are the "last two knuckles" and most commonly fractured in punching injuries 1
• Assess for crepitus during palpation or with gentle passive motion, indicating fracture 1
• Check for step-off deformity along the metacarpal shafts, suggesting displaced fracture 1

Compartment Syndrome Screening

• Assess for pain with passive stretch - passively extend the fingers; pain out of proportion suggests compartment syndrome, a surgical emergency 1
• Palpate compartment tension - the hand has multiple compartments; firm, tense swelling suggests elevated compartment pressure 1
• Monitor for progressive pain - pain that worsens despite immobilization and analgesia is concerning 1

Additional Considerations

• Measure and document pain intensity using a 0-10 numeric rating scale at rest and with movement 6
• Assess functional impact - ask what activities the patient cannot perform due to pain or mechanical limitation 6
• Evaluate for joint effusion at the MCP joints, though this is uncommon with isolated fracture and suggests intra-articular pathology 1
• Check for signs of infection if there is any break in skin - erythema, warmth, purulent drainage 1

Critical Pitfalls to Avoid

• Do not dismiss severe pain as simple contusion - pain rated 8/10 with significant swelling after high-impact trauma warrants radiographic evaluation for fracture 1
• Never assume intact tendon function without specific testing - extensor tendon injuries can be missed if you only observe resting hand position 1
• Assess all joints distal and proximal to injury - associated injuries to the wrist or phalanges are common 1
• Elevation is critical - instruct immediate elevation above heart level to reduce swelling, as this accelerates healing 1