Complaint · Wrist & hand injury

Wrist & hand injury: documentation that holds up

Evidence-based · cited·Reviewed Jun 2026

Hand injuries are high-morbidity and high-liability — open finger injuries are among the most-litigated ED diagnoses. The defensible chart documents the neurovascular and tendon exam (through full range of motion), and recognizes the deceptively benign emergencies: the injection injury, the occult scaphoid, and the fight bite.

01What's at stake

Several hand injuries look trivial and aren't: a high-pressure injection puncture is a surgical emergency, an occult scaphoid fracture is normal on up to 20% of initial films, a knuckle laceration is a fight bite, and a retracted tendon end hides out of a neutral-position wound. Missing the neurovascular/tendon exam is the recurring failure.

02Can't-miss injuries

  • High-pressure injection injury — innocuous puncture; IV antibiotics + emergent hand surgery (debridement within ~6h).
  • Hand compartment syndrome — pain out of proportion, tense compartments, intrinsic-minus posture.
  • Occult scaphoid fracture — snuffbox tenderness; thumb spica + repeat films/MRI even if x-ray normal.
  • Perilunate/lunate dislocation — high-energy FOOSH; the lateral film ("spilled teacup"); often missed.
  • Fight bite — laceration over the MCP; joint/tendon involvement, Eikenella; don't close primarily.
  • Tendon/nerve/vessel injury — flexor (FDP/FDS), mallet/jersey finger, gamekeeper's thumb.

03The exam (the load-bearing note)

  • Neurovascular — two-point discrimination for radial/median/ulnar, motor (incl. Froment), Allen test; capillary refill/pulse-ox are weak for arterial injury. → document per nerve
  • Individual tendon testing — FDP and FDS separately; resisted extension.
  • Explore the wound through full range of motion in a bloodless field to the base — a retracted tendon sits out of the wound at rest. → full ROM
  • Look for rotational deformity (scissoring on flexion).

Skip the typing

Work the case in the Wrist & Hand Injury Workup — it records the snuffbox exam, the neurovascular hand exam, scaphoid/arc imaging, and the thumb-spica plan, and assembles an MDM that documents the can't-miss injuries were addressed.

04Imaging & management

  • X-rays with dedicated views (scaphoid for snuffbox tenderness, Roberts for thumb, 3-view for fight bite/metacarpals); CT/MRI for occult fracture; ultrasound for tendon or radiolucent foreign body.
  • Scaphoid precautions: snuffbox tenderness with normal films → thumb spica, hand-surgery referral, repeat films at 10–14 days.
  • High-pressure injection: IV antibiotics, immediate hand surgery — do not be reassured by a benign appearance.
  • Fight bite: amoxicillin-clavulanate, leave open, hand surgery for joint/tendon involvement.
  • Splint in the intrinsic-plus position (mallet finger = DIP-only in extension, not buddy-tape); lidocaine with epinephrine is safe in digits (except ischemia risk); refer tendon repairs within ~7 days.

05What to document

▼ weak
"Hand laceration, cleaned and sutured. Neurovascularly intact. Discharged."
▲ defensible
"Volar laceration; before anesthesia — sensation intact to two-point discrimination in radial/median/ulnar distributions, FDP and FDS intact individually, extensors intact. Explored through full flexion and extension in a bloodless field to the base — no tendon/joint involvement, no foreign body (x-ray negative). Mechanism not a clenched-fist injury. Irrigated, closed; tetanus updated. (Snuffbox nontender — no scaphoid precautions needed.) Return/wound-check precautions; hand-surgery follow-up if any concern."

06Where charts fail

  • Exploring/clearing a wound without full range of motion — missing a retracted tendon.
  • Calling an injection injury benign, or not consulting hand surgery emergently.
  • "Wrist sprain" with snuffbox tenderness and a normal x-ray (missed scaphoid) — no spica/repeat imaging.
  • Closing a knuckle laceration without recognizing the fight bite.
  • Documenting "neurovascularly intact" without the per-nerve/tendon exam, or missing compartment syndrome.

07Sources

  • Bowen WT, Slaven EM. Evidence-based management of acute hand injuries in the emergency department. Emergency Medicine Practice (EB Medicine). 2014;16(12).
  • Carpenter CR, Pines JM, Schuur JD, et al. Adult scaphoid fracture (diagnostic accuracy). Acad Emerg Med. 2014;21(2):102-121.
  • Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop Relat Res. 1987;220:237-240.
  • Bruno MA, Weissman BN, Kransdorf MJ, et al. ACR Appropriateness Criteria: acute hand and wrist trauma. American College of Radiology. 2013.

© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from EB Medicine and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.

← All guides Open the Wrist & Hand Injury builder