What is the appropriate initial assessment and management for a hand injury with an open wound, swelling, and possible neurovascular compromise?

Initial Assessment and Management of Hand Injury with Open Wound, Swelling, and Possible Neurovascular Compromise

Immediately control active bleeding with direct compression; if bleeding persists despite compression, or if there is loss of radial pulse, apply a tourniquet proximally and do not release it until definitive surgical management is available. 1

Immediate Hemorrhage Control

• Apply direct pressure first for any active bleeding from the hand wound 1
• Tourniquet application is indicated when:
  • Direct compression fails to control bleeding 1
  • Radial pulse is absent (suggesting major arterial injury) 1
  • Multiple simultaneous interventions are required 1
  • Patient is in hemorrhagic shock or cardiac arrest 1
• Never perform iterative tourniquet releases to "spare ischemia"—this worsens both local muscle injury and systemic rhabdomyolysis 1
• If you must reassess under a tourniquet, apply a second tourniquet distal to the first, then loosen the proximal one to avoid recurrent blood loss 1

Neurovascular Assessment

Perform a systematic vascular examination looking for "hard signs" and "soft signs" of arterial injury:

Hard Signs (Require Immediate Surgical Exploration) 1

• Absent radial/ulnar pulses 1
• Pallor of the hand 1
• Pulsatile bleeding 1
• Palpable thrill or audible bruit over the wound 1

Soft Signs (Require CT Angiography) 1

• Wound proximity to a major vascular axis 1
• Non-expanding hematoma near an arterial path 1
• Neurological deficit suggesting nerve compression by hematoma 1
• History of arterial bleeding that has since stopped 1

If hard signs are present, proceed directly to surgical exploration; if only soft signs exist, obtain CT angiography to avoid both unnecessary surgery and missed vascular injuries. 1

Radiographic Evaluation

Obtain a minimum 3-view radiographic series (posteroanterior, lateral, and oblique) before any wound closure or suturing. 1, 2

• The oblique view is critical—two-view examinations miss a significant proportion of fractures 1, 2
• Radiographs identify fractures, dislocations, and radiopaque foreign bodies that fundamentally alter management 2
• Intra-articular fractures with ≥2mm step-off or gap require surgical referral to prevent post-traumatic osteoarthritis 2
• If radiographs are negative but clinical suspicion remains high, splint the hand and repeat radiographs in 10-14 days, or obtain CT without contrast 1, 2

Foreign Body Detection

For suspected penetrating trauma with foreign body:

• CT has 63% sensitivity and 98% specificity for foreign body detection and is superior to MRI for radiopaque materials 1
• Ultrasound allows real-time localization of foreign bodies and assessment of adjacent tendons and vessels 1
• MRI has lower sensitivity (58%) but 100% specificity and is useful for complicated cases or when osteomyelitis is suspected 1

Tendon and Nerve Injury Assessment

Any suspicion of flexor tendon, nerve, or vascular damage mandates immediate referral to a hand surgeon for operative exploration. 3, 4

• Flexor tendon injuries at or distal to the wrist require immediate surgical consultation 3
• Any wound that cannot be reliably explored in the emergency department should be managed in the operating room by a hand surgeon 4
• MRI without IV contrast or ultrasound are equivalent alternatives for evaluating suspected tendon or ligament injuries when radiographs show fracture 1
• MRI with dedicated neurography sequences (diffusion-weighted) improves visualization of traumatic nerve injuries 1

Immediate Referral Criteria

Obtain immediate hand surgery consultation for: 3, 4

• Nerve damage (motor or sensory deficit) 3
• Vascular injury (hard signs as above) 3, 1
• Fracture-dislocation injuries 3
• Open fractures 3
• Substantial skin loss 3
• Flexor tendon injuries at or distal to the wrist 3
• Amputation or devascularization 4

Initial Wound Management

For wounds without immediate surgical indications:

• Apply ice-water mixture for 10-20 minutes with a thin towel barrier to reduce swelling 5
• Avoid heat application and do not attempt to straighten deformed fingers manually before splinting 5
• Splint the hand in the position found until proper evaluation 5
• When in doubt about injury severity, immobilize in a splint with next-day hand surgery referral 3

Critical Pitfall

Missed injuries or failure to recognize injury severity leads to delayed specialist referral, prolonged recovery, and suboptimal outcomes. 6 The systematic tissue-oriented approach—evaluating vasculature first, then skin, bone, joint, nerve, and tendon—ensures no injuries are overlooked. 7