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dx.
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Hand tendon injuries
Shoulder & Clavicle
AC separation
Biceps tendon rupture
Clavicle fracture
Humerus proximal fracture
Rotator cuff tear
Scapular fractures
Shoulder dislocations
SLAP tear
Sternoclavicular dislocation
Arm & Elbow
Compartment syndrome (anterior, lateral, deep - superficial posterior)
Coronoid process fracture
Elbow dislocations
Epicondylar fracture
Humeral shaft fracture
Intercondylar and condylar region fracture
Olecranon fracture
Radial head fracture (Mason I-IV)
Supracondylar fracture (pediatric and adult)
Triceps tendon rupture
Forearm, Wrist & Hand
Carpal bones fractures
Carpal dislocations and ligament injuries
Distal radius and ulna fracture
Fight bite (human bite over MCP)
Finger dislocations by joint
Finger open fractures - amputations
Forearm fractures
Hand and finger tendon and ligament injuries
Hand tendon injuries
Metacarpal fractures
Nail bed injuries
Phalangeal fractures
Tuft fracture
Spine
Cervical spine fracture (C1-C7)
Cord syndromes
Sacrum and coccyx fracture
Thoracic and lumbar spine fracture
Pelvis & Hip
Acetabular fractures
Hip dislocations
Pelvis fractures
Proximal femur fractures
Thigh & Knee
Distal femur fractures
Femoral shaft fractures
Knee dislocation
Knee ligament injuries
Patellar dislocation
Patellar fracture
Patellar tendon rupture
Pes anserine bursitis
Prepatellar bursitis
Quadriceps tendon rupture
Tibial plateau fracture
Tibial spine fracture
Tibial tubercle fracture
Leg & Shin
Achilles tendon rupture
Fibular shaft fracture
Proximal fibula fracture
Stress fracture (tibia-fibula)
Tibial and Fibular shaft fracture
Tibial shaft fracture
Toddler's fracture
Ankle
Ankle dislocation
Ankle fractures
Ankle sprain
Maisonneuve fracture (proximal fibula and syndesmosis)
Peroneal tendon dislocation or tear
Peroneal tendon tear or dislocation
Subtalar dislocation
Syndesmotic injury (high ankle sprain)
Foot
Calcaneus fracture
Cuboid fracture
Cuneiform fractures
Dancer's fracture (5th MT spiral shaft)
Jones fracture (5th MT base - metadiaphyseal junction)
Lisfranc injury (tarsometatarsal dislocation)
March fracture (metatarsal stress fracture)
Metatarsal fractures (1st-5th)
Navicular fracture
Plantar fascia rupture
Talus fracture
Tibialis posterior tendon dysfunction
Toe dislocations
Hand tendon injuries
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ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
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
History
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
Physical Exam
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
Differential Diagnosis
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
Laboratory Tests
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
Diagnostic Tests
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
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
Disposition
Specialist involvement and follow-up
Copy
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
Treatment
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
Special Populations
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
Background
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)
Patient Discharge Instructions
Copy discharge instructions
Copy
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
References
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
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Orthopedic Injuries
Hand tendon injuries