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Wounds and Lacerations

Management of hand lacerations and complex wounds, including high-pressure injection injuries and xylazine-associated necrosis.

Overview

Complex traumatic hand injuries require individualized treatment strategies to optimize outcomes [1]. Acetabular fractures are best managed at trauma centers by multidisciplinary teams experienced with complex patients and injuries [2]. For bite injuries, structural repair in human and other mammalian wounds is indicated based on severity and contamination, with delayed closure often required [3]. All domestic bird bite wounds must be evaluated and explored in the emergency department, with surgical irrigation and debridement considered for penetrating injuries [24].

Ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone do not vary in outcome with treatment modality, though further study is needed to determine the most effective approach [4]. In open extensor tendon injuries, knowledge of modern repair techniques and rehabilitation protocols may improve patient outcomes [22]. Visual estimates of partial flexor tendon lacerations are less accurate near the threshold for repair [6].

Negative pressure wound therapy (NPWT) shows promise in reducing complications in high-risk wounds, including complex diabetic foot wounds when used with simple skin stretching systems, provided appropriate patient selection and intraoperative judgment are applied [15, 56]. However, the evidence base for NPWT in orthopaedic trauma is limited by underpowered trials and heterogeneous outcomes [15]. Vacuum-assisted wound closure requires further research to define optimal indications compared with traditional methods [7].

Extravasation injuries lack robust evidence, with most publications being case reports or non-evidence-based protocols [9]. For mangled lower extremity injuries, no data support definitive indications for limb salvage versus amputation, and long-term studies indicate significant disability regardless of the chosen treatment [25].

Anatomy & Pathophysiology

General Principles and Assessment

Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury [14]. Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [32]. The ultimate goal in treating hand fractures is to achieve good hand function, treating the patient rather than the x-ray [33]. Treatment goals for hand fractures include restoration of length, alignment, and articular congruity, along with stabilization and soft tissue repair [49].

Pediatric Trauma

Fractures of the forearm, wrist, and hand are the most frequent skeletal trauma in the pediatric age group [53]. In pediatric forearm, wrist, and hand trauma, while many fractures can be successfully treated nonsurgically with excellent functional results, early identification of injury type and potential instability is key to good outcomes [53]. The reverse neurocutaneous flap based on the dorsal branch of the ulnar artery facilitates functional hand development through adequate progressive growth and sensory recovery in children [54].

Specific Injury Patterns and Mechanisms

Patterns of peri-articular finger injuries differ greatly between the three finger joints, explained by the mechanism of falling and local biomechanical forces [31]. Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base [35]. In exploded hand syndrome cases, thumb ray dysfunction in sensibility and mobility remained the main functional disability despite generally good outcomes [38]. Modern blade-stopping technology did not prevent all traumatic hand injuries in fast approach speed scenarios but reduced the incidence and severity of injuries [48].

Extensor and Flexor Tendon Pathology

Knowledge of modern repair techniques and rehabilitation protocols may improve patient outcomes in open extensor tendon injuries [22]. Flexor tenolysis findings support it as a motion-enhancing intervention, emphasizing that statistical improvement should be interpreted alongside biomechanical efficiency and long-term functional restoration [43]. Staged tendon reconstruction and investigations in the tendon healing mechanism exemplify the impact and needs of both technical innovation and basic science advancement in hand surgery [39].

Distal Radioulnar Joint and Forearm Stability

Ulnar head replacement is a clinically proven means of re-establishing mechanical contact between the distal radius and ulna to restore stability of the entire forearm [44].

Burns and Reconstructive Considerations

Optimal outcomes in acute surgical management of hand burns require meticulous surgical technique combined with preoperative and postoperative hand therapy to preserve function and prevent contracture [40]. The functional importance of the hand is often underestimated, with an increasing recognition for this rapidly expanding and particularly challenging area of reconstructive surgery [36]. Hand surgery chapters provide a comprehensive overview of hand anatomy, diagnosis, and treatment principles, emphasizing the balance between restoring function and maintaining aesthetic appearance [45].

Evidence Base Limitations

Much of the reviewed knowledge on hand fractures is based on level III and IV evidence [30].

Classification

Complex Traumatic Hand Injury: Each injury is unique, requiring individualized treatment to achieve the best possible outcome [1]. Management of acetabular fractures is best performed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2].

Human and Mammalian Bite Injuries: Structural repair is performed as indicated by the severity and contamination of the injury [3]. These wounds may require delayed closure [3].

Seymour Fractures: These injuries must be recognized early and treated appropriately [5].

Flexor Tendon Lacerations: Visual estimates of partial lacerations have lower accuracy when lacerations are close to the threshold for repair [6].

Vacuum-Assisted Wound Closure: Further experience, clinical research, and basic research are required to define optimal indications and benefits compared with traditional methods [7].

War Wounds: The principles of managing war wounds remain the same as in previous conflicts, although treatment methods have evolved [11].

Closed Fractures: Recognizing signs of soft-tissue injury is the foundation for successful management, as incisions through compromised tissue can lead to wound breakdown and deep infection [13].

Negative Pressure Wound Therapy (NPWT): NPWT should be used for limited durations in carefully selected patients with specific types of chronic wounds as a second-line treatment [23]. It may be used as a first-line treatment in some cases of acute wounds [23].

Ring Avulsion Injury: Microsurgical reconstruction should always be undertaken for ring avulsion injury with rupture of both digital arteries despite a completely intact skin envelope to ensure excellent survival and good functional outcome [27]. These injuries are commonly classified with the Urbaniak class system [37].

Open Fractures: The classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables [34].

Platelet-Rich Plasma: Classification systems and identification of differences among platelet-rich plasma products are needed to understand the implications of variability [51].

Clinical Presentation

Complex traumatic hand injuries are unique and require individualized treatment to achieve the best possible outcome [1]. Acetabular fractures are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2]. Hand crush injuries are devastating and present challenges in diagnosis and treatment [8]. Samurai sword assaults can cause severe hand injuries with devastating loss of function for the victims [46].

Mechanism and History: Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury [14]. Evaluation of acute cervical soft-tissue injury and late deformity requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [18]. Many nail bed injuries are preventable, and targeted prevention strategies should be considered [42]. Girls and women may be more likely than boys and men to sustain more severe mountain biking-related injuries requiring hospitalization [50].

Bite and Special Injuries: Structural repair in human and other mammalian bite injuries of the hand is performed as indicated by the severity and contamination of the injury [3]. Wounds from human and other mammalian bite injuries of the hand may require delayed closure [3]. Earlier recognition of injury severity and referral for dog bite injuries to the hand might avoid morbidity and resource use associated with prolonged treatment [17]. Patients with acute fight bites presenting within 24 hours generally have excellent outcomes regardless of treatment [19]. Patients with acute fight bites presenting with infection or delayed presentation require operative debridement [19]. Further study is needed to determine the most effective treatment for ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone among patients with opioid dependency [4].

Tendon, Nerve, and Skeletal Assessment: Accuracy of visual estimates of partial flexor tendon lacerations is lower for lacerations close to the threshold for repair [6]. It is imperative to recognize Seymour fractures early and treat them appropriately [5]. Service members with more severe initial combat-sustained peripheral nerve injuries had worse final outcomes [20]. Fair or poor functional outcomes persist after flexor tendon repair, particularly in complex trauma and zone 5 injuries [10].

Soft Tissue and Infection Risk: Recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures, as incisions through compromised tissue can lead to wound breakdown and deep infection [13]. There is a marked paucity of evidence to support specific management of extravasation injuries, with the overwhelming majority of publications comprising case reports/series and non-evidence-based protocols [9]. Infections after acute repairs of upper-extremity lacerations were rare [47]. The text on skin cover in the injured hand provides an overview of sports medicine, serving as a reference for physicians managing sports-related injuries and an introduction to the physiology and epidemiology of these injuries [21].

Investigations

Plain radiography: Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury [14]. Radiological assessment is needed for penetrating hand injuries, particularly when the history is vague [67]. In cases of septic arthritis of the proximal interphalangeal joint after rattlesnake bite, aggressive surgical management and increased suspicion for retained foreign bodies are important, as rattlesnake fangs may be initially undetected on standard radiographs [61]. Clinical assessment and plain radiography were very accurate in a series evaluating a novel method for wound exposure using a sutureless, self-retaining system [64]. Evaluation of acute cervical soft-tissue injury and late deformity requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [18].

MRI: Diffusion weighted imaging can effectively identify subcutaneous grease following high-pressure injection injuries, aiding in diagnosis and management [70].

Other Considerations: Each complex traumatic hand injury is unique and requires individualized treatment to achieve the best possible outcome [1]. Complex acetabular fractures are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2]. Structural repair in human and other mammalian bite injuries of the hand is performed as indicated by the severity and contamination of the injury [3]. Wounds from human and other mammalian bite injuries of the hand may require delayed closure [3]. Further study is needed to determine the most effective treatment for ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone among patients with opioid dependency, as outcomes did not vary with treatment modality in the studied series [4]. It is imperative to recognize Seymour fractures early and treat them appropriately [5]. Accuracy of visual estimates of partial flexor tendon lacerations is lower for lacerations close to the threshold for repair [6]. Initial evaluation of hand crush injuries emphasizes the devastating nature of these injuries and the challenges in diagnosis and treatment [8]. There is a marked paucity of evidence to support specific management of extravasation injuries, with the overwhelming majority of publications comprising case reports/series and non-evidence-based protocols [9]. Late open reduction may be successful for dorsal dislocation of the metacarpophalangeal joint of the index finger even when performed three and one-half months after injury [12]. Recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures, as incisions through compromised tissue can lead to wound breakdown and deep infection [13]. Combined dislocation of the trapezoid and finger carpometacarpal joints (steering wheel injury) results in nearly identical wrist injuries with good short-term functional outcomes when injuries are quickly recognized and appropriately addressed at initial surgery [65]. Closed rupture of the volar plate of the distal interphalangeal joint may be confused with an avulsion of the profundus tendon [69].

Treatment

Management of complex traumatic hand injuries must be individualized to achieve the best possible outcome [1]. Acetabular fractures are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2]. The principles of managing war wounds remain the same as in previous conflicts, although the methods of treatment have evolved [11]. Improved survival rates on the battlefield have resulted in new and ongoing challenges in the care of U.S. military personnel, necessitating the application of new technology and treatment alternatives [52].

Bite Injuries

Structural repair in human and other mammalian bite injuries of the hand is performed as indicated by the severity and contamination of the injury [3]. Wounds from human and other mammalian bite injuries of the hand may require delayed closure [3]. All domestic bird bite wounds should be properly evaluated and explored in the emergency department [24]. Surgical irrigation and debridement should be considered for penetrating domestic bird bite wounds [24].

Tendon and Fracture Management

Seymour fractures require early recognition and appropriate treatment [5]. Visual estimates of partial flexor tendon lacerations have lower accuracy when lacerations are close to the threshold for repair [6]. Fair or poor functional outcomes persist after flexor tendon repair, particularly in complex trauma and zone 5 injuries [10]. Late open reduction may be successful for dorsal dislocation of the metacarpophalangeal joint of the index finger even when performed three and one-half months after injury [12]. Excellent outcomes can be obtained with conservative treatment for mallet finger as a complication of liquid nitrogen cryosurgery for verruca vulgaris in appropriate settings [68].

Advanced Wound Closure and Adjuncts

Dermabond (2-octylcyanoacrylate) is an efficient and effective repair technique for the management of acute nail bed lacerations compared with suture repair [58]. A consensus document proposes 22 evidence-based recommendations to promote best practices in surgical wound closure and soft tissue management, aiming to reduce variability in clinical practice and improve patient outcomes [57].

Vacuum-assisted wound closure requires further experience, clinical research, and basic research to define optimal indications and benefits compared with traditional methods of wound management [7]. Vacuum-assisted closure (VAC) is a useful adjunct to traditional interventions for difficult hand wounds, though well-designed large prospective randomised controlled trials are needed to assess its effectiveness [55]. Negative pressure wound therapy (NPWT) shows promise in reducing complications associated with high-risk wounds, but the evidence base is limited by low numbers of underpowered trials and heterogeneous outcome measures [15]. NPWT should be used for limited durations in carefully selected patients with specific types of chronic wounds as a second-line treatment [23]. NPWT should be used for limited durations in carefully selected patients with specific types of acute wounds as the first-line treatment in some cases [23].

Ischemic and Extravasation Injuries

Ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone among patients with opioid dependency require further study to determine the most effective treatment, as outcomes did not vary with treatment modality in the studied series [4]. There is a marked paucity of evidence to support specific management of extravasation injuries, with the overwhelming majority of publications comprising case reports/series and non-evidence-based protocols [9]. Surgical debridement in the management of injury presents issues and challenges characterized by early findings from experienced surgeons rather than fully controlled comparative studies [16].

Complications

Wound complications: Complex traumatic hand injuries require individualized treatment to optimize outcomes [1]. Management of structural repair in human and other mammalian bite injuries is indicated by the severity and contamination of the injury, and such wounds may require delayed closure [3]. Negative pressure wound therapy shows promise in reducing complications associated with high-risk wounds, though the evidence base is limited by low numbers of underpowered trials and heterogeneous outcome measures [15]. Vacuum-assisted wound closure requires further experience, clinical research, and basic research to define optimal indications and benefits compared with traditional methods [7]. Major wound healing problems did not occur with the use of unidirectional barbed suture after primary total knee arthroplasty [62].

Infection: Modern wound management paradigms for extremity war injury lead to reasonable early outcomes with notably lower rates of early infection and flap failure than previously reported in civilian series [28]. The principles of managing war wounds remain the same as in previous conflicts, although treatment methods have evolved [11]. Surgical debridement in injury management presents issues and challenges, with early findings from experienced surgeons rather than fully controlled comparative studies [16].

Functional impairment / Stiffness: Hand crush injuries are devastating and present challenges in diagnosis and treatment [8]. Fair or poor functional outcomes persist after flexor tendon repair, particularly in complex trauma and zone 5 injuries [10]. Service members with more severe initial peripheral nerve injuries sustained in combat had worse final outcomes [20].

Other Considerations: Acetabular fractures are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2]. Seymour fractures must be recognized early and treated appropriately [5]. Late open reduction for dorsal dislocation of the metacarpophalangeal joint of the index finger may be successful even when performed three and one-half months after injury [12]. Outcomes for ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone did not vary with treatment modality in the studied series [4]. Long-term outcomes for pelvic fractures are dependent on the pelvic ring injury and associated injuries, and are complicated by posterior pelvic pain [26]. Firework injuries to the hand inflict substantial morbidity, with patients undergoing a median of three surgical operations and having a long duration of initial hospital stay [29]. The incidence of upper-extremity power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015 [60]. More experience with the use of saws does not necessarily protect one from table saw injuries of the hands and fingers [66].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return. Management of complex traumatic hand injuries must be individualized to achieve the best possible outcome [1]. Complex injuries are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2].

Full activity (months): Evidence does not provide specific month ranges for full activity or strength return. Hand crush injuries present challenges in diagnosis and treatment, requiring review of initial evaluation and short- and long-term management strategies [8]. Fair or poor functional outcomes persist after flexor tendon repair, particularly in complex trauma and zone 5 injuries [10].

Complete recovery / outcome plateau (months): Evidence does not provide specific month ranges for outcome plateau. Late open reduction may be successful for dorsal dislocation of the metacarpophalangeal joint of the index finger even when performed three and one-half months after injury [12]. Regardless of treatment choice, long-term studies show that patients with limb-threatening injuries sustain significant disability [25]. Long-term outcomes for pelvic fractures are dependent on the pelvic ring injury as well as associated injuries [26]. Long-term outcomes for pelvic fractures are complicated by posterior pelvic pain and are largely multifactorial [26]. Further studies with long-term follow-up are needed to determine whether the grafted area maintains structural and functional integrity over time after autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [59].

Rehabilitation protocol: Evidence does not specify PT phasing, immobilisation duration, or weight-bearing protocols. Subsequent attentive care after acute management of hand burns leads to optimal hand functionality and cosmetic long-term outcomes [63].

Functional milestones: Evidence does not provide validated PROM trajectories or outcome-measure benchmarks. Microsurgical reconstruction should always be undertaken for ring avulsion injury with rupture of both digital arteries, regardless of the class of injury, to ensure excellent survival and good functional outcome [27].

Other Considerations: Structural repair in bite injuries is performed as indicated by the severity and contamination of the injury [3]. Wounds in bite injuries may require delayed closure [3]. Further study is needed to determine the most effective treatment of ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone, as outcomes did not vary with treatment modality in the studied series [4]. Further experience and clinical and basic research are required to define optimal indications and benefits of vacuum-assisted wound closure compared with traditional methods [7]. The principles of managing war wounds remain the same as in previous conflicts, although treatment methods have evolved [11]. Surgical debridement in injury management presents issues and challenges, with early findings from experienced surgeons rather than fully controlled comparative studies [16]. Earlier recognition of injury severity and referral for dog bite injuries might avoid morbidity and resource use associated with prolonged treatment [17]. Patients presenting within 24 hours of an acute fight bite generally have excellent outcomes regardless of treatment [19]. Patients with acute fight bites presenting with infection or delayed presentation require operative debridement [19]. No data support definitive indications for limb salvage versus amputation in mangled lower extremity injuries [25]. Application of modern wound management paradigms in extremity war injury leads to reasonable early outcomes with notably lower rates of early infection and flap failure than previously reported in civilian series [28]. Firework injuries to the hand inflict substantial morbidity, with patients undergoing a median of three surgical operations and having a long duration of initial hospital stay [29]. Management of agricultural injuries to the hand and upper extremity requires expedient administration of antibiotic and tetanus prophylaxis [71]. Management of agricultural injuries to the hand and upper extremity requires aggressive irrigation [71]. Management of agricultural injuries to the hand and upper extremity requires serial débridement [71]. Management of agricultural injuries to the hand and upper extremity requires consideration of delayed wound closure or reconstruction [71].

Key Evidence

  • [L5] Each injury is unique, and treatment must be individualized to achieve the best possible outcome. (10.1016/j.hcl.2014.12.005)
  • [L5] Structural repair is performed as indicated by the severity and contamination of the injury, and wounds may require delayed closure. (10.5435/jaaos-23-01-47)
  • [L4] Whereas outcomes did not vary with treatment modality in this series, further study is needed to determine the most effective treatment of these injuries. (10.1177/1558944716672198)
  • [L4] It is imperative to recognize these injuries early and treat them appropriately. (10.1016/j.jhsa.2013.08.104)
  • [L5] Accuracy was lower for lacerations close to the threshold for repair. (10.1016/j.jhsa.2015.09.009)
  • [L5] Further experience is required, as well as clinical and basic research, to define optimal indications and benefits compared with traditional methods of wound management. (10.5435/00124635-200209000-00002)
  • [L5] This paper provides a review of the initial evaluation of hand crush injuries as well as short- and long-term management strategies, emphasizing the devastating nature of these injuries and the challenges in diagnosis and treatment. (10.1016/j.jhsa.2017.03.028)
  • [L4] There is a marked paucity of evidence to support specific management of extravasation injuries, with the overwhelming majority of publications comprising case reports/series and non-evidence-based protocols. (10.1177/1753193413511921)
  • [L5] Although outcomes have improved, fair or poor functional outcomes persist, particularly in complex trauma and zone 5 injuries. (10.1177/17531934231182868)
  • [L5] The principles of managing war wounds remain the same as in previous conflicts; however, the methods of treatment have evolved. (10.5435/00124635-200600001-00016)
  • [L4] The case shows that late open reduction may be successful even when performed three and one-half months after injury, contrary to previous reports suggesting poor prognosis. (10.2106/00004623-197254060-00028)
  • [L5] Recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures, as incisions through compromised tissue can lead to wound breakdown and deep infection. (10.5435/00124635-200311000-00007)
  • [L3] Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury. (10.1177/17531934231211566)
  • [L5] NPWT shows great promise in reducing complications associated with high-risk wounds, but the evidence base is limited by low numbers of underpowered trials and heterogeneous outcome measures. (10.1302/0301-620x.98b8.bjj-2016-0373)
  • [L5] The collection of papers explores the issues and challenges characterizing the role of surgical debridement in the management of injury, presenting early findings from experienced surgeons rather than fully controlled comparative studies. (10.1016/j.injury.2007.10.033)
  • [L4] Earlier recognition of injury severity and referral might avoid morbidity and resource use associated with prolonged treatment. (10.1054/jhsb.1999.0320)
  • [Case_report] Evaluation requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury. (10.2106/00004623-197961020-00031)
  • [L4] Patients presenting within 24 hours generally have excellent outcomes regardless of treatment, whereas those presenting with infection or delayed presentation require operative debridement. (10.1016/j.jhsa.2013.03.002)
  • [L4] Service members with more severe initial injuries had worse final outcomes. (10.1016/j.jhsa.2020.08.004)
  • [L5] This text provides the most current and comprehensive overview of sports medicine, serving as a valuable reference source for physicians managing sports-related injuries and an introduction to the physiology and epidemiology of these injuries. (10.2106/00004623-199312000-00029)
  • [L4] Knowledge of modern repair techniques and rehabilitation protocols may improve patient outcomes. (10.1016/j.jhsa.2014.06.136)
  • [L4] NPWT should be used for limited durations in carefully selected patients with specific types of chronic wounds (as a second-line treatment) or acute wounds (as the first-line treatment in some cases). (10.1016/j.otsr.2016.04.018)
  • [L5] All wounds should be properly evaluated and explored in the emergency department, and surgical irrigation and debridement should be considered for penetrating wounds. (10.1016/j.jhsa.2012.02.044)
  • [L4] Microsurgical reconstruction should always be undertaken regardless of the class of injury to ensure excellent survival and good functional outcome. (10.1177/1753193408089052)
  • [L4] Application of modern wound management paradigms leads to reasonable early outcomes with notably lower rates of early infection and flap failure than previously reported in civilian series. (10.5435/00124635-200600001-00014)
  • [L4] The morbidity inflicted by firework injuries to individual patients is substantial, with patients undergoing a median of three surgical operations and having a long duration of initial hospital stay. (10.1177/1558944719829905)
  • [L5] This issue of Hand Clinics summarizes facets of hand fractures including anatomy, basic science, biomechanics, and treatment techniques, noting that much of the reviewed knowledge is based on level III and IV evidence. (10.1016/j.hcl.2013.09.003)
  • [L4] The patterns of peri-articular finger injuries differ greatly between the three finger joints, explained by the mechanism of falling and local biomechanical forces. (10.1177/17531934251381203)
  • [L5] The ultimate goal is to achieve good hand function: treat the patient, not the x-ray. (10.1016/j.hcl.2013.08.005)
  • [L5] The classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables. (10.5435/00124635-200305000-00008)
  • [L4] Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base. (10.1177/1753193415620186)
  • [L5] The functional importance of the hand is often underestimated but there has been an increasing recognition for this rapidly expanding and particularly challenging area of reconstructive surgery. (10.1016/j.hcl.2014.07.007)
  • [L4] Ring avulsion injuries are commonly classified with the Urbaniak class system. (10.1177/1558944717692094)
  • [L4] While general outcomes were good, thumb ray dysfunction in sensibility and mobility remained the main functional disability. (10.1177/1753193412468577)
  • [L5] Staged tendon reconstruction and investigations in the tendon healing mechanism are perfectly exemplary of the impact and needs of both technical innovation and basic science advancement in the field of hand surgery. (10.1016/j.hcl.2013.04.001)
  • [L5] Optimal outcomes require meticulous surgical technique combined with preoperative and postoperative hand therapy to preserve function and prevent contracture. (10.1016/j.jhsa.2014.07.032)
  • [L4] Both methods can obtain a good range of motion at the proximal interphalangeal joint. (10.1177/17531934211059300)
  • [L4] Many of these injuries are preventable, and targeted prevention strategies should be considered. (10.1177/1753193419826465)
  • [L5] The findings support flexor tenolysis as a motion-enhancing intervention, yet emphasize that statistical improvement should be interpreted alongside biomechanical efficiency and long-term functional restoration. (10.1016/j.jhsg.2026.101000)
  • [L4] Ulnar head replacement is a clinically proven means of re-establishing mechanical contact between the distal radius and ulna to restore stability of the entire forearm. (10.1177/1753193414534380)
  • [L4] This case series demonstrates the extent and severity of hand injuries that can be caused by sword assaults with devastating loss of function for the victims. (10.1177/1753193410381576)
  • [L2] Infections after acute repairs of upper-extremity lacerations were rare. (10.1016/j.jhsa.2025.01.030)
  • [L5] Modern blade-stopping technology did not prevent all traumatic hand injuries in fast approach speed scenarios, but it reduced the incidence and severity of injuries. (10.1016/j.jhsa.2022.01.028)
  • [L4] Girls and women may be more likely than boys and men to sustain more severe injuries requiring hospitalization. (10.1177/0363546510383478)
  • [L4] Classification systems and identification of differences among products are needed to understand the implications of variability. (10.5435/jaaos-21-12-739)
  • [L5] Improved survival rates on the battlefield have resulted in new and ongoing challenges in the care of U.S. military personnel, necessitating the application of new technology and treatment alternatives to provide the best care to those wounded in war. (10.1016/j.jhsa.2007.07.007)
  • [L4] The flap facilitates functional hand development through adequate progressive growth and sensory recovery. (10.1016/j.jhsa.2022.09.001)
  • [Case_report] Clinical experience substantiates the use of VAC as a useful adjunct to traditional interventions for difficult hand wounds, though well-designed large prospective randomised controlled trials are needed to assess its effectiveness. (10.1177/175899830200700102)
  • [L4] More attention should be paid to appropriate patient selection and intraoperative judgment to ensure wound closure and avoid undue complications. (10.1186/s13018-021-02405-6)
  • [L5] The document proposes 22 evidence-based recommendations to promote best practices in surgical wound closure and soft tissue management, aiming to reduce variability in clinical practice and improve patient outcomes. (10.1530/eor-24-0002)
  • [L1] In the management of acute nail bed lacerations, Dermabond is an efficient and effective repair technique. (10.1016/j.jhsa.2007.10.008)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L3] The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015. (10.1016/j.jhsa.2017.01.025)
  • [L5] This case highlights the importance of aggressive surgical management and increased suspicion for retained foreign bodies, such as rattlesnake fangs, which may be initially undetected on standard radiographs. (10.1016/j.jhsa.2021.04.004)
  • [L4] Major wound healing problems did not occur with the use of unidirectional barbed suture. (10.1186/s13018-016-0340-y)
  • [L5] Subsequent attentive care will lead to optimal hand functionality and cosmetic long-term outcomes. (10.1016/j.hcl.2016.12.001)
  • [L4] Clinical assessment and plain radiography were very accurate in our series. (10.1177/1753193411409125)
  • [Case_report] Both cases demonstrate similar mechanisms resulting in nearly identical wrist injuries with good short-term functional outcomes when injuries are quickly recognized and appropriately addressed at initial surgery. (10.1016/j.jhsa.2010.06.005)
  • [L4] Contrary to the hypothesis, more experience with the use of saws does not necessarily protect one from saw injuries. (10.1016/j.jhsg.2023.01.017)
  • [L4] This case emphasizes the need for radiological assessment of penetrating hand injuries, particularly when the history is vague, and highlights the difficulty in using metronidazole in individuals with a history of alcohol abuse. (10.1054/jhsb.1999.0357)
  • [L4] Excellent outcomes can be obtained with conservative treatment in appropriate settings. (10.1177/1753193409105085)
  • [L4] This case presents an injury that may be confused with an avulsion of the profundus tendon. (10.2106/00004623-197961010-00029)
  • [Case_report] Diffusion weighted imaging can effectively identify subcutaneous grease following high-pressure injection injuries, aiding in diagnosis and management. (10.1177/17531934211017401)
  • [L5] Management requires expedient administration of antibiotic and tetanus prophylaxis, aggressive irrigation, serial débridement, and consideration of delayed wound closure or reconstruction. (10.5435/jaaos-22-10-605)

See Also

References

[1] Management of Complications Relating to Complex Traumatic Hand Injuries. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2014.12.005

[2] Chapter 33 Evaluation and Management of Acetabular Fractures. 2021.

[3] Human and Other Mammalian Bite Injuries of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-23-01-47

[4] Ischemic Hand Complications From Intra-Arterial Injection of Sublingual Buprenorphine/Naloxone Among Patients With Opioid Dependency. HAND. 2016. DOI: 10.1177/1558944716672198

[5] Seymour Fractures. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.104

[6] Accuracy of Visual Estimates of Partial Flexor Tendon Lacerations. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.09.009

[7] New Techniques in Wound Management: Vacuum-Assisted Wound Closure. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200209000-00002

[8] Crush Injuries of the Hand. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.03.028

[9] Extravasation injuries: a review. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193413511921

[10] Complications of flexor tendon repair. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934231182868

[11] Moderatorsʼ Summary: Wound Management (Session II). Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200600001-00016

[12] Dorsal Dislocation of the Metacarpophalangeal Joint of the Index Finger Treated by Late Open Reduction. The Journal of Bone & Joint Surgery. 1972. DOI: 10.2106/00004623-197254060-00028

[13] Soft-Tissue Injury Associated With Closed Fractures: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200311000-00007

[14] Recommendations for radiographic assessment of hand wounds. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231211566

[15] Negative pressure wound therapy and orthopaedic trauma. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b8.bjj-2016-0373

[16] Surgical wound management. Injury. 2007. DOI: 10.1016/j.injury.2007.10.033

[17] Injuries to the Hand from Dog Bites. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0320

[18] Acute cervical soft-tissue injury and late deformity. A case report.. The Journal of Bone & Joint Surgery. 1979. DOI: 10.2106/00004623-197961020-00031

[19] Acute Fight Bite. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.03.002

[20] Combat-Sustained Peripheral Nerve Injuries in the United States Military. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.08.004

[21] Skin Cover in the Injured Hand. The Hand and Upper Limb. Vol. 9.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199312000-00029

[22] Open Extensor Tendon Injuries. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.06.136

[23] Negative pressure wound therapy in orthopaedic surgery. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.04.018

[24] Domestic Bird Bites. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.02.044

[25] Chapter 15 The Mangled Lower Extremity. 2021.

[26] Chapter 32 Pelvic Fractures: Definitive Treatment and Outcomes. 2021.

[27] Ring Avulsion Injury with Rupture of Both Digital Arteries Despite a Completely Intact Skin Envelope. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408089052

[28] Standard Wound Coverage Techniques for Extremity War Injury. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200600001-00014

[29] Firework Injuries of the Hand: An Analysis of Treatment and Health Care Utilization. HAND. 2019. DOI: 10.1177/1558944719829905

[30] Preface. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.09.003

[31] Is there a difference in the types of injuries occurring around each finger joint after a fall?. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251381203

[32] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[33] Selection of Appropriate Treatment Options for Hand Fractures. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.08.005

[34] Open Fractures: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200305000-00008

[35] Motorcyclist’s thumb: carpometacarpal injuries of the thumb sustained in motorcycle crashes. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415620186

[36] Hand Flaps. Hand Clinics. 2014. DOI: 10.1016/j.hcl.2014.07.007

[37] Ring Avulsion Injuries: A Systematic Review. HAND. 2017. DOI: 10.1177/1558944717692094

[38] The exploded hand syndrome: a report of five industrial injury cases. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412468577

[39] Intrinsic Tendon Healing and Staged Tendon Reconstruction: Reflection of Legends. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.04.001

[40] Acute Surgical Management of Hand Burns. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.032

[41] Volar plating versus external fixation for unstable dorsal fracture-dislocations of the proximal interphalangeal joint. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211059300

[42] Experience of nail bed injuries at a tertiary hand trauma unit: a 12-month review and cost analysis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419826465

[43] Comment on “Clinical Outcomes of Flexor Tenolysis Following Zone 2–3 Flexor Tendon Repair: A Retrospective Review”. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.101000

[44] Digital artery intravascular myopericytoma – a rare cause of a painful finger. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414534380

[45] 9. Hand Surgery. 2013.

[46] Severe hand injuries resulting from Samurai sword assaults: a Dublin case series. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410381576

[47] Prophylactic Antibiotics for Uncomplicated Upper-Extremity Lacerations: A Retrospective Cohort Study of Private Insurance Claims. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.01.030

[48] RETRACTED: Can a Blade-StoppingMechanism on Circular Table Saws Reduce the Severity of Hand Injuries in Contact Scenarios? A Cadaveric Study. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.028

[49] Chapter 95 Hand Trauma. 2019.

[50] Mountain Biking–Related Injuries Treated in Emergency Departments in the United States, 1994-2007. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510383478

[51] Platelet-rich Plasma in Orthopaedic Applications: Evidence-based Recommendations for Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/jaaos-21-12-739

[52] Injuries Sustained to the Upper Extremity Due to Modern Warfare and the Evolution of Care. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.07.007

[53] Chapter 54 Pediatric Forearm, Wrist, and Hand Trauma. 2020.

[54] Reverse Neurocutaneous Flap Based on the Dorsal Branch of the Ulnar Artery for Palm Coverage in Children: Long-Term Results. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.09.001

[55] Vacuum-assisted closure of a hand wound: A case report. The British Journal of Hand Therapy. 2002. DOI: 10.1177/175899830200700102

[56] Application of a simple skin stretching system and negative pressure wound therapy in repair of complex diabetic foot wounds. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02405-6

[57] Consensus document on the management of wound closure in orthopaedic surgery. EFORT Open Reviews. 2025. DOI: 10.1530/eor-24-0002

[58] A Prospective, Randomized, Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.10.008

[59] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[60] The Impact of Safety Regulations on the Incidence of Upper-Extremity Power Saw Injuries in the United States. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.01.025

[61] Septic Arthritis of the Proximal Interphalangeal Joint After Rattlesnake Bite. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.04.004

[62] What are the important surgical factors affecting the wound healing after primary total knee arthroplasty?. Journal of Orthopaedic Surgery and Research. 2016. DOI: 10.1186/s13018-016-0340-y

[63] Acute Management of Hand Burns. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2016.12.001

[64] Novel method for wound exposure using a sutureless, self-retaining system. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411409125

[65] Combined Dislocation of the Trapezoid and Finger Carpometacarpal Joints—The Steering Wheel Injury: Case Report. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.005

[66] Epidemiology of and Risk Factors for Table Saw Injuries of the Hands and Fingers. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2023.01.017

[67] “Uneasy Lies the Hand in which Rests the Crown” an Unusual Foreign Body Following a Punch Injury. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0357

[68] Mallet finger as a complication of liquid nitrogen cryosurgery for verruca vulgaris. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409105085

[69] Closed rupture of the volar plate of the distal interphalangeal joint.. The Journal of Bone & Joint Surgery. 1979. DOI: 10.2106/00004623-197961010-00029

[70] Diffusion weighted imaging to identify subcutaneous grease after a high-pressure injection injury: a case report. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211017401

[71] Agricultural Injuries to the Hand and Upper Extremity. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-10-605

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