What is the recommended management for a benign hand contusion?

Management of Benign Hand Contusions

For a benign hand bruise without fracture or open wound, the primary management consists of ice application (10-20 minutes with a towel barrier), elevation of the hand above heart level, and oral acetaminophen up to 4 grams daily as first-line analgesia. 1, 2

Initial Assessment and Red Flags

Before confirming a contusion is truly "benign," you must exclude serious pathology:

• Obtain three-view radiographs (PA, lateral, and oblique) if there is any bony tenderness, deformity, or mechanism suggesting possible fracture — two views alone miss occult fractures 1, 2
• Examine for compartment syndrome signs: pain disproportionate to injury, pain with passive stretch, tense swelling, or neurovascular compromise 3
• Assess the entire upper extremity kinetic chain including elbow and shoulder, as FOOSH-type mechanisms can produce injuries throughout the arm 1
• Rule out tendon injury by testing active range of motion of all digits and checking for extensor lag or inability to flex 4, 5

A crush mechanism warrants particular vigilance, as these injuries can initially appear deceptively minor but progress to compartment syndrome, vascular damage, or tissue necrosis over hours 3.

Non-Pharmacologic Management

Immediate measures:

• Apply ice-water mixture for 10-20 minutes using a thin towel barrier to reduce acute swelling 1
• Elevate the hand above heart level using a sling for outpatients or tubular stockinet with IV pole for inpatients — this accelerates healing 2
• Avoid heat application in the acute phase (first 48-72 hours), though heat may be beneficial later for stiffness 2

Activity modification:

• Education on joint protection and avoiding adverse mechanical factors should be provided 2
• Gentle range-of-motion exercises should begin once acute pain subsides to prevent stiffness 2

Pharmacologic Management

First-line analgesia:

• Acetaminophen (paracetamol) up to 4 grams daily is the oral analgesic of first choice due to its efficacy and safety profile for both short-term and long-term use 2

Second-line options if acetaminophen insufficient:

• Topical NSAIDs are preferred over oral NSAIDs for safety reasons, particularly in older adults 2, 1
• Oral NSAIDs should be used at the lowest effective dose for the shortest duration if topical agents fail 2, 1
• In patients with gastrointestinal risk, add gastroprotection or use selective COX-2 inhibitors; in those with cardiovascular risk, avoid COX-2 inhibitors 2

Follow-Up and Reassessment

• Reassess within 24 hours either by phone or office visit to ensure no progression of symptoms 2
• If pain worsens, swelling increases dramatically, or neurovascular symptoms develop, consider hospitalization and urgent surgical consultation 2
• If symptoms persist beyond 2-4 weeks without improvement, re-evaluate and consider alternative diagnoses such as occult fracture, ligament injury, or compartment syndrome sequelae 6

Critical Pitfalls to Avoid

• Never assume a "simple bruise" without adequate examination — hand injuries account for 20-30% of emergency visits and frequently involve multiple tissue structures 4, 5
• Do not discharge elderly patients with hand trauma from falls without comprehensive fall-risk assessment including orthostatic blood pressures and "get-up-and-go" testing 1
• Avoid closing any wound before obtaining radiographs, as hidden fractures or foreign bodies alter management 1
• Do not apply heat in the first 48-72 hours, as this can worsen inflammation and swelling 2