Hand tendon injuriesMANAGEMENT

FOREARM, WRIST & HAND · 12 SECTIONS

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487 items

☷ Legend

01Approach to the Critical Patient/attcp67

Immediate priorities

›Time-critical threats

›Exsanguinating hemorrhage from hand or wrist laceration

›Direct pressure

›Tourniquet for uncontrolled bleeding

›Limb ischemia

›Absent or weak radial or ulnar pulse

›Doppler-only signals

›Open fracture or gross contamination

›Antibiotics within 60 minutes for open injury (Class I)

›Tetanus prophylaxis

›Compartment syndrome of hand or forearm

›Pain out of proportion

›Pain with passive stretch of digits

›High-pressure injection injury mimic

›Small puncture with severe pain and swelling

›Initial stabilization

›Hemorrhage control before detailed tendon testing

›Direct pressure dressing

›Tourniquet time documentation

›Remove constriction

›Rings and bracelets

›Tight dressings

›Analgesia plan

›Local anesthesia first when feasible

›Procedural sedation pathway if extensive exploration needed (ACEP Level B)

›NPO status if operative likelihood

›Complex laceration with tendon discontinuity

›Multiple structure injury concern

›Limb threat documentation

›Neurovascular exam before any splinting or local anesthesia

›Radial pulse

›Ulnar pulse

›Capillary refill

›Two-point discrimination

›Motor screening before anesthesia

›Median nerve

›Ulnar nerve

›Radial nerve

›Tendon function before anesthesia

›Flexor cascade at rest

›Independent DIP and PIP flexion

›Escalation triggers

›Immediate hand surgery consultation

›Open tendon laceration with functional deficit

›Volar wrist laceration

›Associated nerve deficit

›Associated vascular injury

›Immediate transfer to hand-capable center

›Replantation consideration

›Complex zone II flexor injury

›Multiple digit tendon injuries

›Antibiotic timing for open injury

›If open fracture or gross contamination

›Cefazolin IV 2 g

›Repeat dosing every 8 hours while inpatient

›If farm or soil contamination

›Add gentamicin IV 5 mg/kg

›Add metronidazole IV 500 mg every 8 hours for anaerobes

›If saltwater exposure

›Doxycycline 100 mg PO or IV every 12 hours

›Add ceftazidime IV 2 g every 8 hours

›If freshwater exposure

›Ciprofloxacin 400 mg IV every 12 hours

›Hemodynamic targets

›Normothermia

›Normotension

›Pain control without oversedation

02History/hx47

Mechanism and context

›Injury context

›Mechanism

›Knife or glass laceration

›Crush with laceration

›Avulsion or degloving

›Sports hyperextension

›Time since injury

›<6 hours

›6-24 hours

›>24 hours

›Hand dominance

›Dominant hand involvement

›Occupational demands

›Contamination

›Soil

›Freshwater

›Saltwater

›Bite exposure

›Symptoms suggesting tendon injury

›Loss of active flexion or extension

›DIP flexion loss

›PIP flexion loss

›MCP extension lag

›Pain with attempted motion

›Sudden snap sensation

›Locked digit

›Resting posture change

›Loss of normal flexor cascade

›Abnormal finger alignment

›Associated injury risk

›Neurovascular symptoms

›Numbness

›Tingling

›Cold digit

›Foreign body concern

›Glass

›Metal

›Patient factors

›Immunocompromise

›Diabetes

›Chronic steroid use

›Medications

›Anticoagulants

›Antiplatelets

›Tetanus status

›Last booster date

›Incomplete vaccination series

03Physical Exam/exam54

Inspection and function

›Wound and posture

›Laceration location

›Volar finger

›Dorsal finger

›Palm

›Volar wrist

›Resting cascade

›Normal progressive flexion from index to small finger

›One digit extended at rest suggesting flexor disruption

›Swelling and hematoma

›Localized swelling along tendon sheath

›Diffuse swelling suggesting infection or crush

›Flexor tendon exam

›FDP function

›Isolated DIP flexion with PIP held in extension

›Painful weak DIP flexion suggesting partial laceration

›FDS function

›Isolated PIP flexion with adjacent digits held in extension

›Absent isolated PIP flexion suggesting FDS laceration

›Tenodesis effect

›Wrist extension producing passive finger flexion

›Loss of expected finger flexion suggesting flexor discontinuity

›Extensor tendon exam

›Zone-based extension

›DIP extension

›PIP extension

›MCP extension

›Terminal tendon integrity

›DIP extensor lag

›Mallet posture

›Central slip integrity

›PIP extensor lag

›Elson test abnormal

›Neurovascular exam

›Vascular status

›Capillary refill

›Digital artery Doppler signals if pulses unclear

›Sensory status

›Two-point discrimination by digit

›Light touch in median, ulnar, radial distributions

›Motor status

›Thumb IP flexion

›Thumb IP extension

›Finger abduction and adduction

›Red flags and pitfalls

›Partial tendon laceration

›Painful active motion

›Triggering or catching

›Normal extension despite laceration

›Juncturae tendinum masking MCP extension loss

›Wrist extension and tenodesis mimicking active extension

›Digital block masking deficits

›Motor testing before anesthesia

›Sensory testing before anesthesia

04Differential Diagnosis/ddx32

Tendon injury patterns and mimics

›Traumatic tendon disruption

›Flexor tendon laceration (ICD-10 S66.1-)

›FDP laceration

›FDS laceration

›Extensor tendon laceration (ICD-10 S66.3-)

›Terminal extensor laceration

›Central slip laceration

›Closed tendon rupture

›Jersey finger (FDP avulsion) (ICD-10 S63.6-)

›Ring finger common

›DIP flexion loss

›Mallet finger (terminal extensor disruption) (ICD-10 M20.0)

›DIP extensor lag

›Sagittal band rupture

›Extensor tendon subluxation at MCP

›Fracture or avulsion mimics

›Distal phalanx fracture with mallet posture (ICD-10 S62.6-)

›Dorsal avulsion fragment

›Middle phalanx fracture with central slip injury

›PIP extensor lag

›Infection and inflammatory mimics

›Flexor tenosynovitis (ICD-10 M65.14)

›Kanavel signs

›Extensor tenosynovitis

›Dorsal swelling and pain with extension

›Neurovascular injury mimics

›Median nerve injury (ICD-10 S64.1-)

›Thenar weakness

›Radial three-and-a-half digit sensory loss

›Ulnar nerve injury (ICD-10 S64.0-)

›Intrinsic weakness

›Ulnar one-and-a-half digit sensory loss

05Laboratory Tests/lt27

Labs by scenario

›Routine labs

›No labs for isolated clean tendon laceration with stable patient

›Baseline labs for operative pathway

›CBC for anemia or major bleeding concern

›Electrolytes for comorbidity or IV antibiotics

›Creatinine for contrast planning or nephrotoxic antibiotics

›Infection concern

›Inflammatory markers

›CRP for suspected deep infection

›ESR for suspected deep infection

›Blood cultures

›Fever

›Systemic toxicity

›Bite wounds

›Wound culture

›Purulence

›Failed initial therapy

›Tetanus status documentation

›Vaccination record check

›Crush or ischemia concern

›Rhabdomyolysis screen

›CK

›Creatinine

›Potassium

›Coagulation studies

›Anticoagulant use

›Significant bleeding

06Diagnostic Tests/dt50

Scoring Systems

›Anatomic classification systems

›Flexor tendon zones (Verdan)

›Zone I

›Zone II

›Zone III

›Zone IV

›Zone V

›Extensor tendon zones

›Zone I

›Zone II

›Zone III

›Zone IV

›Zone V

›Zone VI

›Zone VII

›Zone VIII

›Management implications

›Zone II flexor injuries as high adhesion risk and typically operative repair

›Zone V wrist injuries as high risk for neurovascular injury

Radiographs

›Plain radiographs

›Indications

›Glass or metal foreign body concern

›Bite wound with crush

›Mallet finger or jersey finger suspicion

›Views

›3-view finger or hand

›Wrist views for wrist laceration mechanism

›Key findings

›Avulsion fracture at distal phalanx dorsal base

›Avulsion fracture at volar base of distal phalanx

›Joint subluxation

›Radiopaque foreign body

MRI

›MRI indications

›Closed tendon rupture with uncertain exam

›Suspected FDP avulsion with equivocal motion

›Suspected central slip injury with equivocal exam

›Chronic or delayed presentation

›Retraction assessment for surgical planning

›Limitations

›Limited availability for ED decision-making

›Typically outpatient or specialist-directed

›CT indications

›Complex intra-articular fracture with tendon avulsion

›Mallet fracture with subluxation

›PIP fracture-dislocation

›Foreign body evaluation

›Radiolucent foreign body with persistent suspicion after radiographs

›Limitations

›Radiation exposure

›Rarely required for isolated tendon laceration

07Disposition/dispo26

Specialist involvement and follow-up

›Operative pathway

›Immediate hand surgery consultation

›Complete tendon laceration with functional deficit

›Flexor zone II injury

›Volar wrist laceration

›Associated nerve injury

›Associated vascular injury

›Timing considerations

›Primary repair usually within days for clean lacerations

›Earlier repair for retraction-prone injuries

›ED discharge with urgent follow-up

›Criteria

›Hemostasis achieved

›No ischemia

›No uncontrolled pain

›Reliable follow-up within 24-72 hours

›Follow-up timing

›Hand surgery within 24-48 hours for suspected tendon laceration

›Earlier for flexor injuries than extensor

›Admission or transfer

›Indications

›Open fracture requiring operative management

›Neurovascular compromise

›Uncontrolled bleeding

›Deep space infection concern

›Inability to secure urgent hand follow-up locally

08Treatment/t94

Immediate life-saving interventions

›Hemorrhage and perfusion

›Bleeding control

›Direct pressure

›Hemostatic dressing

›Tourniquet for refractory bleeding

›If ischemic digit

›Dressing loosening

›Splinting in position that maximizes perfusion

›Immediate hand surgery consultation

›Infection prevention for open injury

›Antibiotics when indicated

›Open fracture or gross contamination

›Bite wound involving tendon sheath

›Tetanus prophylaxis

›Tdap if >10 years since booster

›Tdap if >5 years for dirty wound

›TIG for unknown or incomplete series with dirty wound

Immobilization and Splinting

›Splint selection and position

›Flexor tendon injury splinting

›Dorsal blocking splint

›Wrist 20-30 degrees flexion

›MCP 50-70 degrees flexion

›IP joints near extension

›Extensor tendon injury splinting

›Zone I mallet posture

›DIP full extension

›PIP free

›Zone III central slip concern

›PIP full extension

›DIP free

›Zone V-VI dorsal hand laceration

›Wrist slight extension

›MCP extension support as needed

›Post-splint checks

›Capillary refill

›Sensation

›Pain trend

Reduction

›Joint alignment issues

›Indications

›Fracture-dislocation with tendon avulsion

›DIP or PIP subluxation with mallet fracture

›Analgesia and anesthesia

›Local anesthesia options

›Digital nerve block

›Lidocaine 1% 3-5 mL per digit

›With epinephrine per local protocol

›Wrist block for multiple digits

›Median nerve block

›Ulnar nerve block

›Systemic analgesia options

›Acetaminophen PO 1000 mg

›Maximum 4000 mg per 24 hours

›Ibuprofen PO 400-600 mg

›Avoid in renal failure or high bleed risk

›Morphine IV 0.05-0.1 mg/kg

›Repeat every 5-10 minutes to effect

›Procedural sedation if required (ACEP Level B)

›Ketamine IV 1 mg/kg

›Additional 0.5 mg/kg as needed

›Continuous monitoring

›Airway-ready setup

›Reduction principles

›Gentle traction and countertraction

›Reverse mechanism when clear

›Avoid repeated forceful attempts

›Post-reduction

›Neurovascular re-check

›Post-reduction radiographs

›Immobilization in stable position

Open fracture medications and timing

›Antibiotics and wound care

›Timing

›First dose within 60 minutes for open fracture (Class I)

›Earlier for gross contamination

›Regimens

›Cefazolin IV 2 g

›Repeat every 8 hours while inpatient

›If beta-lactam anaphylaxis

›Clindamycin IV 600-900 mg every 8 hours

›If severe contamination

›Add gentamicin IV 5 mg/kg

›Add metronidazole IV 500 mg every 8 hours

›Local wound care

›Saline irrigation

›Nonadherent dressing

›Avoid tight circumferential wraps

DVT prophylaxis when relevant

›VTE prevention considerations

›Upper extremity immobilization

›No routine pharmacologic prophylaxis for isolated hand injury

›Consider prophylaxis only with major risk factors and prolonged immobility

›High-risk features

›Active cancer

›Prior VTE

›Major trauma with multisystem injury

›Prolonged hospitalization

09Special Populations/sp29

Pregnancy

›Pregnancy considerations

›Imaging

›Radiographs with shielding when needed

›MRI preferred for soft tissue if required

›Analgesia

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›Infection management

›Antibiotic selection aligned to pregnancy safety

›Tetanus prophylaxis as usual

Geriatric

›Geriatric considerations

›Skin fragility

›Lower threshold for pressure injury prevention

›Extra padding under splints

›Comorbidities

›Anticoagulant use

›Diabetes and wound healing risk

›Disposition

›Lower threshold for admission if functionally unsafe at home

Pediatrics

›Pediatric considerations

›Exam challenges

›Cooperation limitations

›Pain-limited tendon testing

›Imaging

›Lower threshold for radiographs with avulsion concerns

›Growth plate injury assessment

›Splinting

›Emphasis on immobilization adherence strategies

›Early specialist follow-up for suspected tendon injury

10Background/b31

Epidemiology

›Epidemiology and risk

›Common mechanisms

›Glass lacerations

›Knife injuries

›Sports-related closed ruptures

›Higher-risk anatomic areas

›Volar wrist as tendon, nerve, artery density region

›Flexor zone II as sheath-constrained region

Pathophysiology

›Injury mechanics

›Flexor tendon laceration

›Loss of active flexion

›Retraction proximal to laceration

›Extensor tendon laceration

›Loss of active extension

›Juncturae causing preserved extension in some zones

›Closed rupture

›FDP avulsion from distal phalanx

›Terminal extensor disruption at DIP

Therapeutic Considerations

›Management principles

›Flexor tendon injuries as operative in most complete lacerations

›Early repair to reduce retraction and scarring

›Zone II complexity and adhesion risk

›Extensor tendon injuries with more nonoperative options in select zones

›Mallet finger splinting as first-line for many closed injuries

›Central slip injury splinting to prevent boutonniere deformity

›Partial laceration risks

›Delayed rupture

›Triggering and functional loss

›Antibiotic stewardship

›No prophylaxis for clean simple lacerations without contamination or bite

›Prophylaxis for bite wounds to hand (Class IIa)

11Patient Discharge Instructions/pdi24

Copy discharge instructions

›Discharge instructions

›Splint care

›Keep splint clean and dry

›Do not remove splint unless instructed by specialist

›Elevation above heart level for 48-72 hours

›Wound care

›Keep dressing dry for 24-48 hours

›Return for increasing redness or drainage

›Activity limits

›No lifting or gripping with injured hand

›Avoid active motion that stresses suspected tendon

›Pain control

›Acetaminophen as directed on label

›Ibuprofen as directed on label if safe for patient

›Return to ED now

›Increasing pain not controlled with medication

›New numbness or tingling

›Pale or cold finger

›Increasing swelling or tightness in splint

›Bleeding through dressing

›Fever

›Follow-up

›Hand surgery or plastics within 24-48 hours for suspected tendon injury

›Earlier if worsening function or neurovascular symptoms

12References/r6

Guidelines and evidence sources

›Reference set

›ACEP procedural sedation clinical policy for ED sedation (ACEP Level B)

›Open fracture antibiotic timing principles (Class I)

›Hand bite wound prophylaxis recommendations (Class IIa)

›American Society for Surgery of the Hand guidance on tendon injury and rehabilitation

›Internal project instructions :contentReference[oaicite:0]{index=0}

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 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.