Emergency Medicine

298 Orthopaedic Emergencies

INJURIES TO THE WRIST AND HAND

4 Isolated, little-finger knuckle ‘boxer’s injury’

Many different methods of reduction and splintage have been tried.

(i) Simple ‘buddy-strapping’ of the little finger to the ring finger, a

padded crêpe bandage, a sling and analgesia are as effective as

any, particularly if angulation is less than 45°.

(ii) Remember that if the knuckle struck a tooth and the skin has

been broken, this is a potentially serious injury. It may involve

underlying tendons or penetration of the joint capsule and there

is high risk of infection

(a) explore the wound in both the neutral position and with the

fist clenched. If there is any suggestion of penetration into

the joint space or tendon, refer the patient immediately to the

orthopaedic team for surgical exploration and debridement.

Give flucloxacillin 2 g i.v.

(b) otherwise, take a wound swab for bacterial culture and

irrigate the wound with normal saline. Give the patient

amoxicillin 875 mg and clavulanic acid 125 mg, one tablet

b.d. for 5 days and tetanus prophylaxis

(c) review the wound within 24 h.

Fractures of the proximal and middle phalanges

DIAGNOSIS

1 Similar mechanisms of injury and rules of management apply, as described

previously for metacarpal fractures.

2 Examine all cases for rotational deformity. Check that on f lexing the fingers

into the palm, the tips all point to the scaphoid.

3 X-ray all injuries to look for fractures, dislocations, subluxations and radio-

opaque foreign bodies.

MANAGEMENT

1 Refer all multiple, compound, angulated or rotated fractures, and those

associated with marked soft-tissue damage or involving a joint surface, to

the orthopaedic team.

2 Otherwise, buddy-strap the finger, give the patient a high-arm sling to

prevent oedema, and give an analgesic such as paracetamol 500 mg and

codeine phosphate 8 mg. Refer to the next fracture clinic.

Fractures of the distal phalanges

DIAGNOSIS

1 These fractures are usually caused by a crushing injury resulting in a commi-

nuted fracture of the bone.