What is the appropriate initial evaluation and management for a right-hand injury?

Initial Evaluation and Management of Right-Hand Injury

Obtain a standard 3-view radiographic examination immediately as the first-line imaging for any acute hand injury, including posteroanterior (PA), lateral, and oblique views. 1, 2

Immediate Imaging Protocol

• Standard radiography is always indicated as initial imaging for suspected acute hand trauma and provides sufficient diagnostic information to guide treatment in most cases 1
• A minimum 3-view examination is mandatory—relying on only 2 views is inadequate and leads to missed fractures 1, 3
• For hand injuries specifically, obtain PA view of entire hand, lateral, and oblique projections 1
• For wrist involvement, use a 4-view series (PA, lateral, 45° semipronated oblique, and scaphoid view) to increase diagnostic yield 4
• An internally rotated oblique projection in addition to standard externally rotated oblique increases detection of phalangeal fractures 3

Critical Physical Examination Findings

Assess for these specific findings that require immediate specialist consultation:

• Nerve or vascular damage (immediate hand surgery consultation required) 5
• Open fractures or fracture-dislocations (immediate referral) 5
• Flexor tendon injuries at or distal to the wrist (immediate consultation) 5
• Substantial skin loss (immediate referral) 5
• Radial-sided tenderness and scaphoid snuffbox pain (suggests scaphoid fracture) 4
• Palmar displacement of distal phalanx or interfragmentary gap >3 mm (surgical indication) 3
• Finger range of motion must be assessed immediately—finger stiffness is the most functionally disabling complication and extremely difficult to treat later 4

Management Based on Initial Radiographic Findings

Indications for Operative Intervention:

• Intra-articular fractures involving >1/3 of articular surface 3, 4
• Residual articular surface step-off >2 mm 1, 2
• Coronally oriented fracture line or die-punch depression 1, 2
• Palmar displacement or interfragmentary gap >3 mm 3, 4
• Multiple metacarpal shaft fractures or deformity in second/third metacarpals 6

Non-operative Management:

• Immobilize in splint and instruct active finger motion exercises immediately to prevent finger stiffness, regardless of treatment method chosen 4
• Extra-articular fractures without significant displacement can be managed with cast immobilization 2
• Consider vitamin C supplementation for prevention of complex regional pain syndrome 4

Advanced Imaging When Radiographs Are Equivocal

If initial radiographs are negative but clinical suspicion remains high, you have two options:

1. Place patient in splint and repeat radiographs in 10-14 days 3
2. Proceed directly to MRI without IV contrast to detect occult fractures and evaluate soft tissue injuries 2, 3

When to Order CT Without IV Contrast:

• Suspected intra-articular extension not clearly visible on radiographs 2, 4
• Carpometacarpal joint fracture-dislocations 4
• Preoperative planning for complex articular injuries (3D reconstructions helpful) 2
• Never order CT with IV contrast—no evidence supports its use in acute hand trauma 4

When to Order MRI Without IV Contrast:

• Radiographs negative but high clinical suspicion for fracture 2, 3
• Evaluation of tendon injuries (high sensitivity/specificity for tendon tears) 3
• Assessment of scapholunate ligament tears that may affect surgical treatment 2

CT Arthrography Considerations:

• Most accurate for detecting scapholunate and lunotriquetral ligament tears (nearly 100% sensitivity, specificity, accuracy) 4
• Consider if concern for associated ligamentous injuries 2

Common Pitfalls to Avoid

• Do not rely on 2-view radiographs alone—they miss significant pathology 4
• Do not delay finger motion exercises—finger stiffness is most functionally disabling and nearly impossible to treat later 4
• Do not obtain immediate MRI for surgical decision-making—it has little added value for determining which patients require surgery 4
• Avoid ultrasound for fracture detection—low sensitivity and specificity 4
• Bone scan is not indicated in acute hand trauma 4
• Failure to obtain adequate views leads to missed diagnosis of significant injuries including intra-articular fractures 2, 3
• Missed injuries or delayed recognition of severity leads to delayed specialist referral, prolonged recovery, and suboptimal outcomes 7

When Severity Is Doubtful

Immobilize in splint with next-day hand specialist referral when injury severity is uncertain 5. Hand injuries account for 10-30% of emergency department visits, with fractures being most common, followed by tendon injuries 8. Though rarely life-threatening, inappropriate treatment leads to significant morbidity and long-term functional loss 9.