Orthopaedic Emergencies 299INJURIES TO THE WRIST AND HAND2 The main problem is the associated soft-tissue injury to the nail and pulp
space.
MANAGEMENT1 Provide adequate protection by using a plastic mallet-finger splint, elevate
the hand and give analgesics.
2 Fingernail injuries
(i) Cover the exposed bed with soft paraffin gauze if the nail is
avulsed, and give tetanus prophylaxis and flucloxacillin 500 mg
orally q.d.s. for 5 days.
(ii) If the nail is partially avulsed from the base:
(a) administer a ring block (see p. 491)
(b) remove the nail to exclude an underlying nailbed injury
(c) debride and clean the area, then replace the nail as a splint to
the nail matrix, and as a dressing to the nailbed
(d) reposition the nail bed with one or two fine sutures inserted
into the sides of the tip of the finger, not into the nailbed.
(iii) Dress the area, give tetanus prophylaxis and antibiotics, and
elevate the hand in a high-arm sling.
3 Subungual haematoma
Relieve this by trephining the nail with a red-hot paper clip to release the
blood under tension. This is a painless procedure bringing instant relief.
Dislocation of the phalanges
DIAGNOSIS AND MANAGEMENT
1 Dislocations of the phalanges result from hyperextension injuries and must
be X-rayed to exclude an associated fracture. They almost always displace
dorsa lly or to one side.
2 Reduce under a ring block by traction applied to the finger, followed by a
repeat X-ray to confirm adequate reduction (see p. 491).
3 Immobilize by buddy-strapping and encourage active finger movements.
Refer the patient to the next fracture clinic.
4 Complications include:
(i) Rupture of the middle slip of the extensor tendon following
proximal interphalangeal joint dislocation.
(ii) Avulsion of the volar plate.
(iii) Rupture of one or both collateral ligaments. An accompanying
small avulsion flake fracture may be seen on X-ray.
(iv) Button-holing of the head of the phalanx through the volar plate,
necessitating open operation for a failed reduction.