What are the primary care guidelines for managing a hand injury in an adult patient with no significant past medical history?

Primary Care Management of Hand Injuries

For acute traumatic hand injuries in primary care, immediately obtain three-view radiographs (PA, lateral, and 45° oblique) to rule out fractures, then assess for tendon lacerations, neurovascular compromise, and infection risk—with urgent hand surgeon referral required for open fractures, tendon injuries, significant tissue loss, or neurovascular damage. 1, 2

Initial Assessment and Imaging

Mandatory First Steps

• Obtain standard three-view wrist/hand radiographs immediately for any acute blunt or penetrating trauma to establish baseline and exclude fractures 1, 3, 4
• The three views must include: posteroanterior (PA), lateral, and 45° semipronated oblique 3
• Do not skip radiographs even when injury appears purely soft tissue—underlying fractures must be excluded first 4

When Initial X-rays Are Negative

• If symptoms persist despite negative radiographs, order MRI without IV contrast as the definitive study—it detects both occult fractures (changed diagnosis in 55% and management in 66% of cases) and soft tissue injuries critical for surgical planning 1
• MRI demonstrates 92% sensitivity and 100% specificity for flexor tendon injuries, with 100% sensitivity/specificity for detecting tendon re-tears 1
• Alternative: repeat radiographs in 10-14 days or CT without IV contrast if MRI unavailable, though CT cannot evaluate ligamentous injuries 1, 3
• Never order contrast-enhanced studies—no evidence supports IV contrast use in acute hand trauma 4

Acute Management Protocol

Immediate Treatment (First 48-72 Hours)

• Apply ice for 15-20 minutes every 2-3 hours to reduce swelling and pain 3
• Compress with elastic bandage and elevate hand above heart level 3
• Immobilize with splint in neutral position (specific positioning depends on injury type) 3
• Administer appropriate analgesics for pain control 3
• Ensure tetanus prophylaxis is current 2

Critical Red Flags Requiring Urgent Hand Surgeon Referral

• Open fractures or fracture-dislocations 2
• Tendon lacerations (flexor or extensor) 2, 5
• Significant tissue loss or fingertip amputations 2
• Neurovascular compromise 2
• Bite injuries (high infection risk) 2
• Nail bed injuries requiring repair 2
• Any injury where you suspect severity may be underestimated 6

Subacute Management (After 48-72 Hours)

Transition Phase

• Gradually transition from complete rest to controlled movement to prevent stiffness—prolonged immobilization leads to contractures 3
• Continue intermittent ice application as needed 3
• Begin gentle range of motion exercises when pain allows 3
• Refer to hand therapist early (within first week if possible)—delayed referral lengthens recovery and leads to suboptimal outcomes 6

Follow-up Imaging Considerations

• If persistent symptoms despite conservative management, consider MRI or ultrasound to evaluate occult fractures or soft tissue injuries 3
• For suspected ligament injuries with joint malalignment but no fracture on X-ray, MRI without IV contrast or ultrasound are appropriate next steps 1

Common Injury-Specific Considerations

Soft Tissue Injuries

• MRI excels at evaluating critical structures that determine long-term function: shows tendon retraction level, tendon stump quality, and pulley injuries (100% accuracy for A2 pulleys, 91% for A4 pulleys) 1
• Detects collateral ligament injuries with 67% sensitivity and 91% specificity 1
• Volar plate injuries diagnosed by MRI are critical—untreated lesions result in contractures or joint laxity 1

Fracture Management

• Reduce and immobilize fractures appropriately 2
• Obtain post-reduction radiographs to confirm alignment 2
• CT is primarily useful for complex wrist fractures requiring preoperative planning or carpometacarpal joint fracture-dislocations, not routine metacarpal/digital fractures 1

Infection Prevention

• Obtain soft tissue coverage for open wounds 2
• Bite injuries require aggressive management—high risk for infectious tenosynovitis 2
• Monitor for signs of tenosynovitis: fusiform swelling, flexed posture, pain with passive extension, tenderness along flexor tendon sheath 2

Return to Activities

• Gradual return to daily activities as symptoms improve 3
• Delay return to sports or heavy manual labor until no pain with resistance is achieved 3
• Returning too soon leads to prolonged symptoms or reinjury 3

Critical Pitfalls to Avoid

• Missing injuries or failing to recognize severity—this is the most common error leading to delayed specialist referral and suboptimal outcomes 6
• Failure to obtain appropriate initial imaging 3
• Skipping radiographs when soft tissue injury seems obvious 4
• Prolonged immobilization without early mobilization planning 3
• Delayed or absent hand therapist referral 6
• Inadequate assessment for tendon, nerve, or vascular injury in seemingly simple lacerations 2, 5

Hand injuries account for 10-30% of emergency department visits and 28% of musculoskeletal injuries, predominantly affecting young male laborers through occupational and home accidents 7, 5. Proper initial assessment and timely specialist referral are essential to prevent substantial long-term disability in this otherwise healthy population 2.