A working knowledge of anatomy usually allows much of the examination for an acute injury to be performed without touching the actual site of injury. Posture of the fingers can indicate specific tendon injuries. Even under anesthesia, if the tendons and phalanges are intact, the fingers should assume a position of progressively more flexion of both proximal and distal interphalangeal joints proceeding from the index to the small finger (Fig. 1a). Color of the skin and nail beds compared to the opposite side can indicate arterial or venous insufficiency, and bruising at a site away from an area of impact strongly suggests an underlying skeletal injury even with normal x-rays. Sensory, motor and vascular examination distal to the injury can provide clues as to the status of more proximal wounds. A focused examination of the median (Fig. 1b), ulnar (Fig. 1c), and radial (Fig. 1d) nerves can be performed in a few seconds. Active unresisted motion may be limited, but even so can provide information regarding tendon and nerve status. Allen's test for patency of the radial and ulnar arteries can be performed by applying pressure to the palm without requiring the patient to make a fist. This gentle approach is clearly preferable to attempting to define the injury by instrumenting the wound itself in the accident ward.
Evaluation of an acute injury commences with triage: brief history ("the door closed on my hand"), brief examination (Wounds? Deformity?), and then a more directed and detailed history, radiographs and detailed examination.
Hand Injury Examination