Hand Lacerations With Tendon Injury ConcernAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

456 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

Motor Vehicle Collision Evaluation Chest Wall Trauma And Rib Injury Blunt Abdominal Trauma Evaluation Penetrating Trauma Evaluation Pediatric Minor Head Trauma Pediatric Head Trauma Facial Lacerations And Dental Trauma Hand Lacerations With Tendon Injury Concern Puncture Wounds And Retained Foreign Body Concern Electrical Injury Burn Injury Fall Evaluation Assault And Interpersonal Violence Evaluation Eye Trauma And Hyphema Concern

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx69

Presenting context

›Injury context

›Time since injury

›Location at time of injury

›Dominant hand

›Occupation and sport requirements

Mechanism and wound characteristics

›Mechanism details

›Sharp object

›Glass

›Knife

›Saw

›Crush

›Avulsion

›High pressure injection

›Bite

›Human

›Animal

›Fight bite

›Contamination exposure

›Soil

›Fresh water

›Salt water

Functional deficit history

›Function changes

›Inability to actively flex a finger

›Inability to actively extend a finger

›Weakness with flexion

›Weakness with extension

›Mechanical catching

›Loss of grip strength

Neurovascular symptoms

›Neurovascular symptoms

›Numbness

›Tingling

›Cold digit

›Color change

›Persistent bleeding

Onset

›Onset

›Sudden at injury

›Worsening after injury

Provocation/Palliation

›Provocation and palliation

›Worse with finger motion

›Worse with wrist motion

›Worse with passive stretch

›Better with elevation

Quality

›Quality

›Sharp

›Throbbing

›Burning

›Electric

Region/Radiation

›Region and radiation

›Finger

›Palm

›Dorsum hand

›Wrist

›Radiation proximally

Severity

›Severity

›Pain score 0 to 10

›Functional limitation

Timing

›Timing

›Constant

›Intermittent with motion

›Night pain

Prior care and timing

›Prior care

›Field irrigation

›Prior closure attempt

›Prior antibiotics

›Time from injury to closure consideration

Immunization and infectious risks

›Immunization and infectious risks

›Tetanus vaccination date

›Rabies risk if animal bite

›Blood exposure risk assessment

02Alarm Features/alarm37

Hemorrhage and shock

›Hemorrhage risk

›Pulsatile bleeding

›Expanding hematoma

›Soaking dressings despite pressure

›Systolic blood pressure under 90 mmHg

›Heart rate over 120 beats per minute

Limb ischemia

›Ischemia features

›Pale digit

›Mottled digit

›Cool digit

›Capillary refill over 2 seconds

›Absent Doppler signal

Compartment syndrome and crush risk

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Progressive paresthesia

Open fracture and joint violation

›Deep structure violation

›Bone exposed

›Joint capsule concern

›Limited motion due to pain and instability

Infection and rapidly progressive soft tissue disease

›Severe infection risk

›Fever

›Rapidly spreading erythema

›Crepitus

›Skin necrosis

Flexor tenosynovitis red flags

›Flexor tendon sheath infection concern

›Fusiform swelling

›Finger held in flexion

›Tenderness along flexor sheath

›Pain with passive extension

Immediate escalation triggers

›Escalation triggers

›Any ischemia feature with open wound

›Suspected arterial laceration

›Suspected complete tendon laceration

›Suspected joint violation

›Fight bite over MCP joint

03Medications/meds21

Current and recent medications

›Medication profile

›Anticoagulants

›Antiplatelets

›NSAIDs

›Chronic opioids

›Steroids

›Biologics

›Diabetes medications

Bleeding risk modifiers

›Bleeding risk modifiers

›Warfarin

›DOAC

›Aspirin

›Clopidogrel

Antibiotic considerations

›Antibiotic related risks

›Allergy history

›Prior MRSA colonization

›Recent antibiotics within 90 days

Analgesia and sedation interactions

›Interaction risks

›Benzodiazepines

›Alcohol use with sedatives

›QT prolonging medications if planning antiemetics

04Diet/diet10

Intake and hydration

›Intake status

›Last oral intake time

›NPO status if procedural sedation possible

Alcohol and substances

›Substance exposures

›Alcohol today

›Cannabis today

›Stimulant exposure

Wound relevant exposures

›Exposure modifiers

›Poor nutrition concern

›Recent vomiting limiting intake

05Review of Systems/ros16

Constitutional and infection

›Constitutional symptoms

›Fever

›Chills

›Malaise

Hand and upper extremity

›Upper extremity symptoms

›Increasing swelling

›Increasing pain

›Redness tracking proximally

›Drainage

Neurologic

›Neurologic symptoms

›Numbness

›Weakness

›Radiating pain

Cardiopulmonary for procedural risk

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

06Collateral History and Family History/chafh10

Collateral sources

›Collateral

›Witness account

›EMS report

›Photo of object and scene

Family history

›Family risks

›Bleeding disorder history

›Connective tissue disorder history

Household and exposure context

›Exposure context

›Sick contacts if febrile

›Animal vaccination status if bite

07Risk Factors/rf17

Patient factors affecting healing

›Healing risk factors

›Diabetes mellitus (E11.9)

›Peripheral arterial disease (I73.9)

›Smoking

›Chronic kidney disease (N18.9)

›Immunosuppression

Infection risk by wound type

›Wound infection risks

›Bite wound

›Fight bite

›Gross contamination

›Delayed presentation over 12 hours

Occupational and functional risk

›Functional risk

›Manual labor

›Need for fine motor precision

Bleeding and thrombosis risks

›Hemostasis modifiers

›Anticoagulation use

›Platelet dysfunction concern

08Differential Diagnosis/ddx39

Life threatening and limb threatening

›Life threatening or limb threatening

›Arterial laceration

›Pulsatile bleeding

›Ischemia features

›Compartment syndrome (T79.A)

›Pain with passive stretch

›Tense compartments

›Necrotizing soft tissue infection (M72.6)

›Rapid progression

›Pain out of proportion

›Flexor tenosynovitis (M65.9)

›Kanavel features present

›Fever or systemic symptoms

Common

›Common

›Simple laceration

›No deep structure involvement

›Normal tendon function

›Partial tendon laceration

›Pain with active motion

›Weakness with isolated testing

›Digital nerve laceration

›Two point discrimination abnormal

›Sensory loss in nerve distribution

›Retained foreign body (Z18.9)

›Glass mechanism

›Persistent focal pain

Less common and mimics

›Less common

›Open fracture (S62.9)

›Bony tenderness

›Deformity

›Joint capsule violation

›Laceration over joint

›Pain with joint range

›Central slip injury

›PIP extension weakness

›Elson test abnormal

›Volar plate injury

›PIP pain after hyperextension

›Instability on exam

09Past Medical History/pmh11

Conditions impacting management

›Relevant conditions

›Diabetes mellitus (E11.9)

›Peripheral arterial disease (I73.9)

›Prior tendon injury or repair

›Prior hand infection

Prior surgeries and procedures

›Prior procedures

›Prior hand surgery

›Prior vascular repair

Baseline function

›Baseline status

›Baseline range of motion limits

›Baseline neuropathy symptoms

10Physical Exam/exam48

Vitals and general

›General

›Fever pattern

›Hemodynamic stability

›Distress level

Wound inspection

›Wound characteristics

›Location by digit and surface

›Length and configuration

›Depth estimate

›Contamination

›Tissue loss

›Nail bed involvement

Hemostasis and vascular exam

›Vascular status

›Capillary refill each digit

›Temperature comparison

›Radial pulse

›Ulnar pulse

›Doppler signal distal to wound

›Allen test result

Neurologic exam

›Sensation and motor

›Two point discrimination

›Light touch by digital nerve territories

›Thumb opposition

›Finger abduction and adduction

Tendon exam flexor

›Flexor tendon function

›FDP isolated testing

›DIP flexion with PIP held extended

›Compare to contralateral side

›FDS isolated testing

›PIP flexion with other digits held extended

›Compare to contralateral side

Tendon exam extensor

›Extensor tendon function

›MCP extension against resistance

›PIP extension

›DIP extension

›Elson test for central slip

Joint and bone assessment

›Bone and joint

›Point tenderness over phalanges and metacarpals

›Rotational alignment with finger flexion

›Passive range of motion limits

Infection focused exam

›Infection signs

›Erythema extent

›Warmth

›Purulence

›Lymphangitic streaking

Pitfalls and subtle findings

›Pitfalls

›Tendon laceration with preserved motion

›Partial tendon laceration with pain only

›Nerve injury masked by local anesthesia

11Lab Studies/labs13

Core labs when indicated

›Labs for complications

›CBC if systemic infection concern

›CRP if deep infection concern

›BMP if IV antibiotics planned

Bleeding and anticoagulation context

›Coagulation context

›INR if warfarin use

›Platelets if bleeding concern

Point of care and special populations

›Point of care

›Glucose if diabetes or altered status

›Pregnancy test when relevant before imaging or meds

Limitations

›Limitations

›Normal labs do not exclude tendon injury

›Normal labs do not exclude early deep space infection

12Imaging/img22

Scoring Systems

›Clinical criteria tools

›Kanavel features for flexor tenosynovitis

›High pressure injection injury triage as limb threatening

MRI

›MRI use cases

›Occult tendon discontinuity when exam limited

›Deep space infection extent when unclear

›Contraindications

›Non MRI compatible device

›Metallic foreign body in eye risk

›CT use cases

›Occult fracture when radiographs equivocal

›Radiopaque foreign body localization if complex

›Contrast cautions

›Prior severe contrast reaction

›Severe chronic kidney disease

Ultrasound

›Ultrasound and POCUS

›Tendon continuity assessment

›Dynamic exam with active motion

›Foreign body detection

›Pitfalls

›Small superficial foreign bodies can be missed

›Operator dependent accuracy

13Special Tests/spec12

Bedside tendon and ligament tests

›Tendon and ligament tests

›FDP isolation test

›FDS isolation test

›Elson test for central slip injury

›Mallet finger assessment

Neurovascular bedside tests

›Neurovascular tests

›Two point discrimination threshold documentation

›Allen test

›Doppler evaluation of digital arteries

Deep structure violation tests

›Deep structure tests

›Saline load test for suspected joint penetration local protocol dependent

›Exploration under adequate anesthesia and tourniquet control

14ECG/ecg7

Indications in this presentation

›ECG indications

›Age over 40 with sedation planned

›Known cardiac disease with sedation planned

Abnormalities impacting sedation choice

›Sedation relevant patterns

›Significant bradycardia

›Tachyarrhythmia

›Ischemic changes

15Assessment/ax17

Problem representation

›Injury summary

›Hand laceration with tendon injury concern (S61.4)

›Location and suspected tendon zone

Severity and risk stratification

›Severity stratification

›Complete tendon laceration suspected

›Partial tendon laceration suspected

›Neurovascular injury suspected

›Contaminated wound or bite wound

Complications to exclude

›Must exclude

›Joint violation

›Open fracture

›Retained foreign body

›Flexor tenosynovitis if infectious features

Key supporting features

›Supporting features

›Mechanism consistent with deep injury

›Exam showing isolated tendon weakness

›Sensory deficit consistent with digital nerve injury

16Plan/plan57

First 5 minutes

›Immediate stabilization

›Direct pressure for bleeding

›Tourniquet use if uncontrolled bleeding and brief duration

›IV access if ongoing bleeding or need for sedation

›Analgesia early

Wound anesthesia and exploration

›Exploration strategy

›Digital nerve block with local anesthetic

›Avoid epinephrine in poorly perfused digit

›Irrigation volume based on contamination

›Visualization through full range of motion

Tendon injury management

›Tendon injury pathway

›Suspected complete tendon laceration

›Hand surgery consult in ED

›Splint immobilization position based on tendon group

›Suspected partial tendon laceration

›Avoid bedside tendon repair if uncertain depth

›Urgent hand surgery follow up within 24 to 72 hours

Neurovascular injury management

›Neurovascular pathway

›Digital nerve laceration suspected

›Early hand surgery referral

›Sensory mapping documentation pre anesthesia when possible

›Arterial injury suspected

›Immediate hand surgery consult

›Warmth and elevation while awaiting definitive care

Imaging and testing sequence

›Diagnostic sequencing

›Radiographs if foreign body concern

›Ultrasound if tendon continuity unclear

Antibiotics and tetanus

›Antibiotic strategy

›Clean simple laceration without deep injury

›No antibiotics routine

›Consider if high risk host

›Bite wound or gross contamination

›Amoxicillin clavulanate PO 875 mg twice daily

›Duration 3 to 5 days prophylaxis local protocol dependent

›Penicillin allergy option local protocol dependent

›Doxycycline PO 100 mg twice daily

›Add metronidazole PO 500 mg twice daily if anaerobe coverage needed

›Tetanus prophylaxis

›Unknown or incomplete vaccination and dirty wound

›Tdap

›Tetanus immune globulin per local protocol

›Up to date vaccination

›Booster timing based on wound type

Closure and immobilization

›Closure considerations

›Delayed primary closure if heavily contaminated

›Avoid tight closure if swelling expected

›Splinting

›Suspected flexor tendon injury

›Dorsal blocking splint

›Wrist flexion and MCP flexion position per hand surgery protocol

›Suspected extensor tendon injury

›Extension splinting across involved joint

›Maintain joint alignment

Reassessment loop

›Reassessment

›Neurovascular recheck after anesthesia and after splint

›Pain reassessment within 30 to 60 minutes

›Bleeding reassessment after closure and dressing

17Disposition/dispo21

Admit and OR pathway

›Admission or urgent OR

›Arterial injury requiring repair

›Open fracture

›Joint violation requiring washout

›Flexor tenosynovitis concern

›High pressure injection injury

Observation pathway

›Observation

›Uncertain tendon injury with high functional risk

›Pain control requiring parenteral meds

Discharge criteria

›Discharge criteria

›Hemostasis achieved

›Normal perfusion

›No concern for complete tendon laceration requiring immediate repair

›Reliable follow up within 24 to 72 hours

›Splint and dressing tolerated

Follow up timing

›Follow up

›Hand surgery within 24 to 72 hours for tendon or nerve concern

›Wound check in 2 days if high risk wound

›Suture removal timing by location

›Hand and fingers often 10 to 14 days local protocol dependent

›Palm often 14 days local protocol dependent

18Discharge Instructions/di23

Copy discharge instructions

›Summary

›You have a cut on your hand that may involve deeper structures like tendons that move the finger

›Your hand has been cleaned and dressed and may be splinted to protect healing

›Wound care

›Keep the dressing clean and dry for 24 hours

›After 24 hours gentle soap and water around the wound

›No soaking in a bath pool or hot tub until healed

›Splint care

›Keep the splint on at all times unless told otherwise

›Do not test finger strength against resistance

›Medications

›Take pain medicine as directed

›If antibiotics were prescribed take all doses as directed

›Follow up

›Hand specialist follow up within ___ days

›Wound check within ___ days if instructed

›Return to ED now for

›Finger becomes cold pale or blue

›New numbness or worsening numbness

›Increasing pain not controlled with medication

›Increasing swelling redness warmth or pus

›Fever

›Bleeding that does not stop with 10 minutes of firm pressure

19References/r6

Guidelines and core sources

›Key references

›CDC Tetanus prophylaxis guidance 2024

›IDSA Skin and soft tissue infections guideline 2014

›American Society for Surgery of the Hand acute hand injury resources 2023

›British Society for Surgery of the Hand standards for hand trauma care 2020

›AAOS management of open fractures and antibiotic prophylaxis resources 2022

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Hand Lacerations With Tendon Injury ConcernAPPROACH

TRAUMA AND WOUNDS · 19 SECTIONS

⚲

456 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx69

Presenting context

›Injury context

›Time since injury

›Location at time of injury

›Dominant hand

›Occupation and sport requirements

Mechanism and wound characteristics

›Mechanism details

›Sharp object

›Glass

›Knife

›Saw

›Crush

›Avulsion

›High pressure injection

›Bite

›Human

›Animal

›Fight bite

›Contamination exposure

›Soil

›Fresh water

›Salt water

Functional deficit history

›Function changes

›Inability to actively flex a finger

›Inability to actively extend a finger

›Weakness with flexion

›Weakness with extension

›Mechanical catching

›Loss of grip strength

Neurovascular symptoms

›Neurovascular symptoms

›Numbness

›Tingling

›Cold digit

›Color change

›Persistent bleeding

Onset

›Onset

›Sudden at injury

›Worsening after injury

Provocation/Palliation

›Provocation and palliation

›Worse with finger motion

›Worse with wrist motion

›Worse with passive stretch

›Better with elevation

Quality

›Quality

›Sharp

›Throbbing

›Burning

›Electric

Region/Radiation

›Region and radiation

›Finger

›Palm

›Dorsum hand

›Wrist

›Radiation proximally

Severity

›Severity

›Pain score 0 to 10

›Functional limitation

Timing

›Timing

›Constant

›Intermittent with motion

›Night pain

Prior care and timing

›Prior care

›Field irrigation

›Prior closure attempt

›Prior antibiotics

›Time from injury to closure consideration

Immunization and infectious risks

›Immunization and infectious risks

›Tetanus vaccination date

›Rabies risk if animal bite

›Blood exposure risk assessment

02Alarm Features/alarm37

Hemorrhage and shock

›Hemorrhage risk

›Pulsatile bleeding

›Expanding hematoma

›Soaking dressings despite pressure

›Systolic blood pressure under 90 mmHg

›Heart rate over 120 beats per minute

Limb ischemia

›Ischemia features

›Pale digit

›Mottled digit

›Cool digit

›Capillary refill over 2 seconds

›Absent Doppler signal

Compartment syndrome and crush risk

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Progressive paresthesia

Open fracture and joint violation

›Deep structure violation

›Bone exposed

›Joint capsule concern

›Limited motion due to pain and instability

Infection and rapidly progressive soft tissue disease

›Severe infection risk

›Fever

›Rapidly spreading erythema

›Crepitus

›Skin necrosis

Flexor tenosynovitis red flags

›Flexor tendon sheath infection concern

›Fusiform swelling

›Finger held in flexion

›Tenderness along flexor sheath

›Pain with passive extension

Immediate escalation triggers

›Escalation triggers

›Any ischemia feature with open wound

›Suspected arterial laceration

›Suspected complete tendon laceration

›Suspected joint violation

›Fight bite over MCP joint

03Medications/meds21

Current and recent medications

›Medication profile

›Anticoagulants

›Antiplatelets

›NSAIDs

›Chronic opioids

›Steroids

›Biologics

›Diabetes medications

Bleeding risk modifiers

›Bleeding risk modifiers

›Warfarin

›DOAC

›Aspirin

›Clopidogrel

Antibiotic considerations

›Antibiotic related risks

›Allergy history

›Prior MRSA colonization

›Recent antibiotics within 90 days

Analgesia and sedation interactions

›Interaction risks

›Benzodiazepines

›Alcohol use with sedatives

›QT prolonging medications if planning antiemetics

04Diet/diet10

Intake and hydration

›Intake status

›Last oral intake time

›NPO status if procedural sedation possible

Alcohol and substances

›Substance exposures

›Alcohol today

›Cannabis today

›Stimulant exposure

Wound relevant exposures

›Exposure modifiers

›Poor nutrition concern

›Recent vomiting limiting intake

05Review of Systems/ros16

Constitutional and infection

›Constitutional symptoms

›Fever

›Chills

›Malaise

Hand and upper extremity

›Upper extremity symptoms

›Increasing swelling

›Increasing pain

›Redness tracking proximally

›Drainage

Neurologic

›Neurologic symptoms

›Numbness

›Weakness

›Radiating pain

Cardiopulmonary for procedural risk

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

06Collateral History and Family History/chafh10

Collateral sources

›Collateral

›Witness account

›EMS report

›Photo of object and scene

Family history

›Family risks

›Bleeding disorder history

›Connective tissue disorder history

Household and exposure context

›Exposure context

›Sick contacts if febrile

›Animal vaccination status if bite

07Risk Factors/rf17

Patient factors affecting healing

›Healing risk factors

›Diabetes mellitus (E11.9)

›Peripheral arterial disease (I73.9)

›Smoking

›Chronic kidney disease (N18.9)

›Immunosuppression

Infection risk by wound type

›Wound infection risks

›Bite wound

›Fight bite

›Gross contamination

›Delayed presentation over 12 hours

Occupational and functional risk

›Functional risk

›Manual labor

›Need for fine motor precision

Bleeding and thrombosis risks

›Hemostasis modifiers

›Anticoagulation use

›Platelet dysfunction concern

08Differential Diagnosis/ddx39

Life threatening and limb threatening

›Life threatening or limb threatening

›Arterial laceration

›Pulsatile bleeding

›Ischemia features

›Compartment syndrome (T79.A)

›Pain with passive stretch

›Tense compartments

›Necrotizing soft tissue infection (M72.6)

›Rapid progression

›Pain out of proportion

›Flexor tenosynovitis (M65.9)

›Kanavel features present

›Fever or systemic symptoms

Common

›Common

›Simple laceration

›No deep structure involvement

›Normal tendon function

›Partial tendon laceration

›Pain with active motion

›Weakness with isolated testing

›Digital nerve laceration

›Two point discrimination abnormal

›Sensory loss in nerve distribution

›Retained foreign body (Z18.9)

›Glass mechanism

›Persistent focal pain

Less common and mimics

›Less common

›Open fracture (S62.9)

›Bony tenderness

›Deformity

›Joint capsule violation

›Laceration over joint

›Pain with joint range

›Central slip injury

›PIP extension weakness

›Elson test abnormal

›Volar plate injury

›PIP pain after hyperextension

›Instability on exam

09Past Medical History/pmh11

Conditions impacting management

›Relevant conditions

›Diabetes mellitus (E11.9)

›Peripheral arterial disease (I73.9)

›Prior tendon injury or repair

›Prior hand infection

Prior surgeries and procedures

›Prior procedures

›Prior hand surgery

›Prior vascular repair

Baseline function

›Baseline status

›Baseline range of motion limits

›Baseline neuropathy symptoms

10Physical Exam/exam48

Vitals and general

›General

›Fever pattern

›Hemodynamic stability

›Distress level

Wound inspection

›Wound characteristics

›Location by digit and surface

›Length and configuration

›Depth estimate

›Contamination

›Tissue loss

›Nail bed involvement

Hemostasis and vascular exam

›Vascular status

›Capillary refill each digit

›Temperature comparison

›Radial pulse

›Ulnar pulse

›Doppler signal distal to wound

›Allen test result

Neurologic exam

›Sensation and motor

›Two point discrimination

›Light touch by digital nerve territories

›Thumb opposition

›Finger abduction and adduction

Tendon exam flexor

›Flexor tendon function

›FDP isolated testing

›DIP flexion with PIP held extended

›Compare to contralateral side

›FDS isolated testing

›PIP flexion with other digits held extended

›Compare to contralateral side

Tendon exam extensor

›Extensor tendon function

›MCP extension against resistance

›PIP extension

›DIP extension

›Elson test for central slip

Joint and bone assessment

›Bone and joint

›Point tenderness over phalanges and metacarpals

›Rotational alignment with finger flexion

›Passive range of motion limits

Infection focused exam

›Infection signs

›Erythema extent

›Warmth

›Purulence

›Lymphangitic streaking

Pitfalls and subtle findings

›Pitfalls

›Tendon laceration with preserved motion

›Partial tendon laceration with pain only

›Nerve injury masked by local anesthesia

11Lab Studies/labs13

Core labs when indicated

›Labs for complications

›CBC if systemic infection concern

›CRP if deep infection concern

›BMP if IV antibiotics planned

Bleeding and anticoagulation context

›Coagulation context

›INR if warfarin use

›Platelets if bleeding concern

Point of care and special populations

›Point of care

›Glucose if diabetes or altered status

›Pregnancy test when relevant before imaging or meds

Limitations

›Limitations

›Normal labs do not exclude tendon injury

›Normal labs do not exclude early deep space infection

12Imaging/img22

Scoring Systems

›Clinical criteria tools

›Kanavel features for flexor tenosynovitis

›High pressure injection injury triage as limb threatening

MRI

›MRI use cases

›Occult tendon discontinuity when exam limited

›Deep space infection extent when unclear

›Contraindications

›Non MRI compatible device

›Metallic foreign body in eye risk

›CT use cases

›Occult fracture when radiographs equivocal

›Radiopaque foreign body localization if complex

›Contrast cautions

›Prior severe contrast reaction

›Severe chronic kidney disease

Ultrasound

›Ultrasound and POCUS

›Tendon continuity assessment

›Dynamic exam with active motion

›Foreign body detection

›Pitfalls

›Small superficial foreign bodies can be missed

›Operator dependent accuracy

13Special Tests/spec12

Bedside tendon and ligament tests

›Tendon and ligament tests

›FDP isolation test

›FDS isolation test

›Elson test for central slip injury

›Mallet finger assessment

Neurovascular bedside tests

›Neurovascular tests

›Two point discrimination threshold documentation

›Allen test

›Doppler evaluation of digital arteries

Deep structure violation tests

›Deep structure tests

›Saline load test for suspected joint penetration local protocol dependent

›Exploration under adequate anesthesia and tourniquet control

14ECG/ecg7

Indications in this presentation

›ECG indications

›Age over 40 with sedation planned

›Known cardiac disease with sedation planned

Abnormalities impacting sedation choice

›Sedation relevant patterns

›Significant bradycardia

›Tachyarrhythmia

›Ischemic changes

15Assessment/ax17

Problem representation

›Injury summary

›Hand laceration with tendon injury concern (S61.4)

›Location and suspected tendon zone

Severity and risk stratification

›Severity stratification

›Complete tendon laceration suspected

›Partial tendon laceration suspected

›Neurovascular injury suspected

›Contaminated wound or bite wound

Complications to exclude

›Must exclude

›Joint violation

›Open fracture

›Retained foreign body

›Flexor tenosynovitis if infectious features

Key supporting features

›Supporting features

›Mechanism consistent with deep injury

›Exam showing isolated tendon weakness

›Sensory deficit consistent with digital nerve injury

16Plan/plan57

First 5 minutes

›Immediate stabilization

›Direct pressure for bleeding

›Tourniquet use if uncontrolled bleeding and brief duration

›IV access if ongoing bleeding or need for sedation

›Analgesia early

Wound anesthesia and exploration

›Exploration strategy

›Digital nerve block with local anesthetic

›Avoid epinephrine in poorly perfused digit

›Irrigation volume based on contamination

›Visualization through full range of motion

Tendon injury management

›Tendon injury pathway

›Suspected complete tendon laceration

›Hand surgery consult in ED

›Splint immobilization position based on tendon group

›Suspected partial tendon laceration

›Avoid bedside tendon repair if uncertain depth

›Urgent hand surgery follow up within 24 to 72 hours

Neurovascular injury management

›Neurovascular pathway

›Digital nerve laceration suspected

›Early hand surgery referral

›Sensory mapping documentation pre anesthesia when possible

›Arterial injury suspected

›Immediate hand surgery consult

›Warmth and elevation while awaiting definitive care

Imaging and testing sequence

›Diagnostic sequencing

›Radiographs if foreign body concern

›Ultrasound if tendon continuity unclear

Antibiotics and tetanus

›Antibiotic strategy

›Clean simple laceration without deep injury

›No antibiotics routine

›Consider if high risk host

›Bite wound or gross contamination

›Amoxicillin clavulanate PO 875 mg twice daily

›Duration 3 to 5 days prophylaxis local protocol dependent

›Penicillin allergy option local protocol dependent

›Doxycycline PO 100 mg twice daily

›Add metronidazole PO 500 mg twice daily if anaerobe coverage needed

›Tetanus prophylaxis

›Unknown or incomplete vaccination and dirty wound

›Tdap

›Tetanus immune globulin per local protocol

›Up to date vaccination

›Booster timing based on wound type

Closure and immobilization

›Closure considerations

›Delayed primary closure if heavily contaminated

›Avoid tight closure if swelling expected

›Splinting

›Suspected flexor tendon injury

›Dorsal blocking splint

›Wrist flexion and MCP flexion position per hand surgery protocol

›Suspected extensor tendon injury

›Extension splinting across involved joint

›Maintain joint alignment

Reassessment loop

›Reassessment

›Neurovascular recheck after anesthesia and after splint

›Pain reassessment within 30 to 60 minutes

›Bleeding reassessment after closure and dressing

17Disposition/dispo21

Admit and OR pathway

›Admission or urgent OR

›Arterial injury requiring repair

›Open fracture

›Joint violation requiring washout

›Flexor tenosynovitis concern

›High pressure injection injury

Observation pathway

›Observation

›Uncertain tendon injury with high functional risk

›Pain control requiring parenteral meds

Discharge criteria

›Discharge criteria

›Hemostasis achieved

›Normal perfusion

›No concern for complete tendon laceration requiring immediate repair

›Reliable follow up within 24 to 72 hours

›Splint and dressing tolerated

Follow up timing

›Follow up

›Hand surgery within 24 to 72 hours for tendon or nerve concern

›Wound check in 2 days if high risk wound

›Suture removal timing by location

›Hand and fingers often 10 to 14 days local protocol dependent

›Palm often 14 days local protocol dependent

18Discharge Instructions/di23

Copy discharge instructions

›Summary

›You have a cut on your hand that may involve deeper structures like tendons that move the finger

›Your hand has been cleaned and dressed and may be splinted to protect healing

›Wound care

›Keep the dressing clean and dry for 24 hours

›After 24 hours gentle soap and water around the wound

›No soaking in a bath pool or hot tub until healed

›Splint care

›Keep the splint on at all times unless told otherwise

›Do not test finger strength against resistance

›Medications

›Take pain medicine as directed

›If antibiotics were prescribed take all doses as directed

›Follow up

›Hand specialist follow up within ___ days

›Wound check within ___ days if instructed

›Return to ED now for

›Finger becomes cold pale or blue

›New numbness or worsening numbness

›Increasing pain not controlled with medication

›Increasing swelling redness warmth or pus

›Fever

›Bleeding that does not stop with 10 minutes of firm pressure

19References/r6

Guidelines and core sources

›Key references

›CDC Tetanus prophylaxis guidance 2024

›IDSA Skin and soft tissue infections guideline 2014

›American Society for Surgery of the Hand acute hand injury resources 2023

›British Society for Surgery of the Hand standards for hand trauma care 2020

›AAOS management of open fractures and antibiotic prophylaxis resources 2022

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.