Clinicians › Hand

Wounds and Lacerations

Management of hand lacerations and complex wounds, including high-pressure injection injuries and xylazine-associated necrosis.

121 citationsUpdated Oct 2026

Overview

Complex traumatic hand injuries require individualized treatment to achieve the best possible outcome [1]. Structural repair of hand bite injuries is performed as indicated by the severity and contamination of the injury, with delayed closure potentially required [2]. While flexor tendon repair in zone III for clean cut lacerations reports excellent or good outcomes in the majority of patients [4], fair or poor functional outcomes persist after repair, particularly in complex trauma and zone 5 injuries [10]. The morbidity of human fight-bite injuries of the hand can be reduced by a specific management programme, even in cases with early complications [40].

Management of specific wound etiologies varies significantly. Microsurgical reconstruction should always be undertaken for ring avulsion injury with rupture of both digital arteries to ensure excellent survival and good functional outcome [24]. Prompt management is necessary for carpometacarpal dislocation producing transient motor neurapraxia of the ulnar nerve [16]. All wounds from domestic bird bites should be properly evaluated and explored in the emergency department, with surgical irrigation and debridement considered for penetrating wounds [64]. In a series of 15 patients with cat bites treated with seton drainage, the wounds healed without complications [22].

The evidence base for several wound management strategies remains limited. There is a marked paucity of evidence to support specific management of extravasation injuries, with the overwhelming majority of publications comprising case reports or non-evidence-based protocols [15]. Further experience and clinical and basic research are required to define optimal indications and benefits of vacuum-assisted wound closure compared with traditional methods [5]. Negative pressure wound therapy (NPWT) shows promise in reducing complications associated with high-risk wounds, though the evidence base in orthopaedic trauma is limited by low numbers of underpowered trials and heterogeneous outcome measures [18]. A clear wound healing goal must be determined when using NPWT, and discontinuation should be considered if no improvement is observed between two consecutive dressing changes or after 1 week of treatment [21].

Anatomy & Pathophysiology

Bony Anatomy

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [46]. The hand skeleton is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [46]. The thumb ray (first ray) is the shortest, consisting of a metacarpal and two phalanges, with the thumb metacarpal being the shortest of all metacarpals [46]. In the sagittal plane, the thumb metacarpal forms an angle of approximately 45 degrees with the second metacarpal [46]. The index metacarpal is the longest in the hand [46]. Regarding phalangeal length, the proximal and middle phalanges of the middle and ring fingers are longer than those of the index finger [46]. The transverse axis of the palm creates an acute angle of approximately 75 degrees with the longitudinal axis [46]. The wrist possesses three axes of movement, enabling the hand to assume any spatial configuration [46].

The metacarpophalangeal joints function as the keystones of the hand’s longitudinal arches [82]. Mobility at the metacarpophalangeal joints varies by digit; the fifth metacarpal allows approximately 20 degrees of flexion–extension, while the ring metacarpal permits about 10 degrees of mobility in flexion and extension [82].

Soft Tissue Anatomy

The extrinsic extensors traverse six distinct fibroosseous retinacular compartments at the wrist [45]. The compartment contents are as follows: * First compartment: Abductor pollicis longus and extensor pollicis brevis [45]. * Second compartment: Extensor carpi radialis longus and extensor carpi radialis brevis [45]. * Third compartment: Extensor pollicis longus [45]. * Fourth compartment: Extensor indicis proprius, which lies deep to the four tendons of the extensor digitorum communis [45]. * Fifth compartment: Extensor digiti quinti [45]. * Sixth compartment: Extensor carpi ulnaris [45].

Sagittal bands stabilize the digital extensor tendons over the midline of the metacarpophalangeal joint [45]. Rupture or attenuation of these fibers permits the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, resulting in ulnar deviation of the finger [45].

The extrinsic finger flexors consist of the flexor digitorum profundus and the flexor digitorum superficialis [45]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [45]. The flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley and inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [87]. The A2 and A4 pulleys are the most essential structures for maintaining the mechanical advantage of the flexor tendons [87]. The tenosynovium lining the fibroosseous tunnel provides nutrition and lubrication to the poorly vascularized flexor tendons [87]. Within the flexor tendon sheath, vascularity is supplied by the vincula system, specifically the vinculum longus and brevis [87].

The hand contains seven interosseous muscles: four dorsal and three volar [79]. The dorsal interossei act as abductors, while the volar interossei act as adductors [79]. The middle finger possesses two dorsal interossei and no volar interossei because the central axis of the hand lies within this digit [79].

Dorsal hand skin is thin, with a horny layer only 0.02 mm thick, and possesses a normal pilosebaceous system unlike the palm [89]. It has loose connections with deeper planes, allowing free gliding and full flexion at the digital joints [89]. Finger flexion causes significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger from extension to full flexion [89].

Palmar skin is subdivided into zones by the oppositional crease of the thumb [78]. The radial portion covers the thenar eminence and is relatively well vascularized and mobile [78]. The ulnar and distal portion covers the hypothenar eminence and exhibits poor mobility [78]. The central triangular part of the palm features fixed, poorly vascularized skin covering the superficial palmar aponeurosis [78]. Web spaces are formed from the union of two nonsymmetrical cutaneous surfaces [78]. The dorsal slope of the web space has supple skin that is not adherent to the subjacent region, whereas the palmar surface is flat and the skin is densely adherent to the commissural skeleton [78].

The superficial palmar fascia covers a triangular area of the central palm with four central bands extending distally toward each finger; there is no central band for the thumb [90]. Digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers [90]. Fibers dorsal to the neurovascular bundle are collectively termed Cleland ligament, while those palmar to the bundle are called Grayson ligament [90]. The "princeps pollicis" artery is the terminal branch of the radial artery crossing the first intermetacarpal space [84]. In anatomical studies, only 15% of dissections of the palmar arteries of the thumb fall into the classical "typical" category [84].

Pathophysiology & Injury Mechanisms

The presence of an open fracture wound does not exclude the extremity from developing compartment syndrome [13]. The Gustilo and Anderson classification system for open fractures includes: * Type I: Puncture wounds ≤1 cm [13]. * Type II: Lacerations >1 cm [13]. * Type III: Extensive soft-tissue damage [13].

Type IIIB open fractures specifically involve extensive soft-tissue damage with stripping of the periosteum and exposure of the bone [13]. In a reported series, infections developed in 16 (11%) of patients with open hand fractures [39]. Staphylococcus aureus was the most frequently isolated pathogen from these infected wounds, despite never being isolated prior to initial debridement [39].

Thumb ray dysfunction in sensibility and mobility remained the main functional disability following exploded hand syndrome injuries [27]. Biomechanical analysis indicates that a steer pulling on the thumb generates force and pressure several times larger than that of ring avulsion injury [97]. Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, likely due to the mechanics of gripping handlebars and high-energy force directed into the palm [98]. The non-dominant hand is most vulnerable to nail gun injuries as it steadies the structures being nailed together [99]. Patterns of peri-articular finger injuries differ greatly between the three finger joints, a variation explained by the mechanism of falling and local biomechanical forces [93].

Tendon healing proceeds through two simultaneous pathways: intrinsic healing involving tenocyte proliferation and extrinsic healing involving invasion of cells from the surrounding sheath [176]. Up to 30% to 40% of flexor tendon injuries result in postsurgical adhesion formation between the tendon and surrounding tissues [176]. The greatest challenge in hand injury is preserving function in all structures not directly injured, as dense connective tissue undergoes significant collagen synthesis and remodeling [60].

Chemical burns constitute a small proportion of all skin burns but can cause substantial morbidity and mortality [184]. The hand and upper extremity are the most frequently involved body parts in chemical burns [184]. Negative pressure wound therapy shows promise in reducing complications associated with high-risk wounds, though the evidence base is limited by low numbers of underpowered trials and heterogeneous outcome measures [18].

Classification

Burns: Burns are categorized according to the degree of damage to epithelium, dermis, subcutaneous tissue, and other underlying structures [37]. First-degree burn injuries involve damage to the epidermis only and do not have any open wounds or blistering [37]. Second-degree burns are defined as partial-thickness burns, meaning that the zone of injury has now encompassed the epidermis and varying degrees of dermis [37]. These are subcategorized as superficial and deep [37]. Superficial second-degree burns exhibit blister formation and are painful as a result of the involvement of nerve endings in the dermis [37]. They will often heal via re-epithelialization with local wound care over the course of 10 to 14 days [37].

Gustilo–Anderson: The Gustilo and Anderson classification system for open fractures includes Type I, which consists of puncture wounds ≤1 cm with minimal contamination and muscle damage [13]. Type II consists of lacerations >1 cm with moderate soft-tissue injury, adequate bone coverage, and minimal comminution [13]. Type IIIA involves extensive soft-tissue damage with adequate bone coverage, usually resulting from a high-velocity injury with a severe crushing component [13]. This type also includes heavily contaminated wounds with severe comminution and segmental fractures [13]. Type IIIB involves extensive soft-tissue damage with stripping of the periosteum and exposure of the bone [13]. The degree of bacterial contamination and soft-tissue damage is important in classifying an open fracture [13].

Gustilo-Anderson (Alternative Definitions): The Gustilo-Anderson classification defines Type I open fractures as wounds <1 cm in length with minimal contamination and soft-tissue damage, usually an inside-to-outside injury [155]. Type II open fractures are defined as wounds between 1 and 10 cm in length with moderate soft-tissue injury and crushing, and minimal comminution [155]. Type III open fractures are defined as severe soft-tissue injury, contamination, and crushing from high-energy injury with comminution, where wound size may be >10 cm [155]. Type IIIA open fractures are defined as those with adequate soft-tissue coverage after débridement and high-energy trauma irrespective of the size of the wound [155]. Type IIIB open fractures are defined as those with extensive soft-tissue injury with periosteal stripping and bony exposure [155]. Type IIIC open fractures are defined as any open fracture with an arterial injury requiring repair [155].

OTA Open Fracture Classification: The OTA Open Fracture Classification includes a skin injury variable where a score of 1 indicates a laceration with edges that approximate [155]. A score of 2 indicates a laceration with edges that do not approximate [155]. A score of 3 indicates a laceration associated with extensive degloving [155]. The classification includes a muscle injury variable where a score of 1 indicates no appreciable muscle necrosis [155]. A score of 2 indicates loss of muscle bulk [155].

Other Considerations: Ring avulsion injuries are commonly classified with the Urbaniak class system [101]. The FRI classification was created to systematically address the variety of fracture-related infections (FRIs) by a uniform classification [140].

Clinical Presentation

General Assessment and Triage

Patients with associated life-threatening injuries require initial evaluation and resuscitation according to Advanced Trauma Life Support protocols [13]. Injured extremities must be assessed for neurovascular injury and compartment syndrome [13]. A complete assessment of the open fracture includes reviewing the mechanism of injury, condition of the soft tissues, degree of bacterial contamination, and characteristics of the fracture [13]. Evaluation requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [50]. Recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures [26], as incisions through compromised tissue can lead to wound breakdown and deep infection [26].

Treatment should always be based on the correct classification of the fracture and the corresponding soft tissue injury, but needs to be adapted to the individual patient considering general health status, secondary diagnoses and currently available treatment options [31]. Each injury is unique, and treatment must be individualized to achieve the best possible outcome [1]. These injuries are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [3].

Specific Injury Mechanisms and Pathologies

Seymour fractures require early recognition and appropriate treatment [7]. Wounds represent 31% of hand trauma in children, and fencing mechanisms cause destructive wounds with often longitudinal skin lesions [17]. The mechanism of injury has been clearly defined and the problems with angle grinder injuries are indicated [19]. Air gun pellets produce a different injury pattern, with a more benign course, than other types of bullet injury [34]. Soft tissue injuries are more common, although referral centers are more likely to treat a higher percentage of fractures, dislocations, and other more serious injuries [28]. There can be a delayed onset of ulnar tunnel syndrome following minor injury, in the absence of any identifiable compressive pathology [29].

The late, symptomatic presentation of patients, together with the development of symptoms in patients managed conservatively indicate that foreign bodies should be removed [30]. A foreign body in the hand is often missed [56]. In a retrospective review of 200 consecutive patients with retained foreign bodies, 38% had been missed by a previously treating physician and the average time from injury to removal was 7 months [56]. 11% of retained foreign bodies were removed later than 1 year [56]. The possibility of a foreign body should be considered in any patient presenting with unexplained pain, swelling or infection in the hand [56]. Positive X-rays are found in 86% to 88% of patients eventually confirmed to have a foreign body [56]. Metal is visualized in 100% of cases, and glass is seen in 96% of cases [56]. Injuries to deep structures caused by traumatic implantation of a foreign body are not uncommon [56]. In a prospective study of 164 patients with foreign bodies in the hand, 4.3% had evidence of damage to deep structures including digital nerves, extensor tendons, flexor tendons [56].

There are documented pathological causes or evidence of trauma to most cases of closed flexor tendon ruptures [14]. Clinical examination alone is insufficient for diagnosing pulley ruptures; sonography and MRI are required to distinguish between distension and partial, complete, or multiple ruptures [49]. Carpometacarpal dislocation can produce transient motor neurapraxia of the ulnar nerve [16]. It is important to be aware of such injuries and the necessity of prompt management [16]. Hypotensive shock following blunt soft tissue trauma to the pelvis (without a fracture) and with delayed clinical symptoms warrants the exclusion of these vascular injuries [125]. Service members with more severe initial injuries had worse final outcomes [54]. In 28% of wounds with a normal clinical examination, tendon, vascular or nerve damage was found on surgical exploration [47]. Accuracy of visual estimates for partial flexor tendon lacerations was lower for lacerations close to the threshold for repair [8].

Patients presenting with acute fight bites within 24 hours generally have excellent outcomes regardless of treatment, whereas those presenting with infection or delayed presentation require operative debridement [116]. Earlier recognition of injury severity and referral might avoid morbidity and resource use associated with prolonged treatment for dog bite injuries [48]. Swine bites of the hand require early treatment that is primarily surgical, with prompt and thorough wound cleansing, superficial and deep debridement of the wound, drainage, and delayed closure of wounds only after cultures show no bacterial growth [36]. Structural repair is performed as indicated by the severity and contamination of the injury, and wounds may require delayed closure [2]. The initial evaluation of hand crush injuries emphasizes the devastating nature of these injuries and the challenges in diagnosis and treatment [12]. While general outcomes were good for exploded hand syndrome, thumb ray dysfunction in sensibility and mobility remained the main functional disability [27]. This case series demonstrates the extent and severity of hand injuries that can be caused by sword assaults with devastating loss of function for the victims [117]. In complex trauma and zone 5 injuries, fair or poor functional outcomes persist despite improved outcomes [10].

Simple hand lacerations represent a substantial number of ED visits in the United States [11]. Infections after acute repairs of upper-extremity lacerations were rare [118]. The overall infection rate of 5.0% falls between those of other trials (Grossman, 1981; 1.1%: Roberts, 1977; 9.8%: Day, 1975; 17.5%) [106]. This trial does not show a significant difference in infection rate with povidone iodine therapy [106]. Although there was a reduction in imperfectly healed wounds from 41.2 to 35.5%, this is not statistically significant at the 5% level [106]. Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury [33]. There is a marked paucity of evidence to support specific management of extravasation injuries, with the overwhelming majority of publications comprising case reports/series and non-evidence-based protocols [15]. Further experience is required, as well as clinical and basic research, to define optimal indications and benefits of vacuum-assisted wound closure compared with traditional methods of wound management [5]. Whereas outcomes did not vary with treatment modality in this series of ischemic hand complications from intra-arterial injection, further study is needed to determine the most effective treatment of these injuries [6]. Consensus and high-level multicentre trials are required in future to better guide the assessment and management of acute low energy civilian gunshot wounds [9].

An estimated 17509 total upper extremity amputations occurred from 2014 to 2023 in the United States secondary to lawn mower-related injuries [35]. Other common injury sequelae from lawn mower-related injuries include “Laceration” (80213), “Fracture” (36266), “Sprain” (24512), and “Burns” (9178) [35]. Most lawn mower-related upper extremity amputations were estimated to occur in 50- to 59-year-old patients (3533 cases), followed by 40- to 49-year-old patients (3268 cases) [35]. The median age of the patient cohort for upper extremity amputation directly associated with lawn mower injuries was 47 [35]. Between 50% to 90% of admissions for severe agricultural injuries originate as transfers from outside facilities [59]. Immediate care of an amputated finger and/or limb consists of gentle washing with a warm saline solution if available or clean water at a minimum [59]. The amputated part should be wrapped in moist gauze and placed in a plastic bag, which is then submerged in ice water slush [59]. Care should be taken to avoid placing the amputated part in direct contact with ice or dry ice because this can negatively affect viability secondary to frostbite and thermal necrosis [59]. Exposed amputation sites should be dressed with moist gauze and a gentle compressive bandage, and ice packs should be applied [59]. In cases of incomplete amputation, the affected site should be gently covered with moist gauze, the injured structures should be gently aligned and splinted in place, and no tissue should be discarded [59]. Bleeding should be controlled with compression and elevation; clamping or tying off blood vessels is not recommended in the immediate care of amputations [59]. In these injuries, skin cover is the most pressing need [57].

Girls and women may be more likely than boys and men to sustain more severe injuries requiring hospitalization from mountain biking-related injuries [126]. Blunt trauma accounted for 65% of bladder injuries, and 0.9% of patients presenting with blunt trauma were found to have bladder injuries [53]. The majority of blunt trauma resulting in bladder injuries was a result of RTAs (n = 24, 63%), followed by assaults (n = 6, 16%), falls (n = 6, 16%) and others (n = 2, 5%) [53]. The study reports excellent or good outcomes in the majority of patients with clean cut lacerations for flexor tendon repair in zone III [4].

Investigations

Clinical Examination

A systematic method for approaching the physical examination of the hand and wrist is essential to direct care and future testing if indicated [44]. Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit [44]. While diagnostic tests such as imaging and serum laboratory studies are useful in determination, they can be expensive, time consuming, and often nonspecific [44]. Clinical examination alone is insufficient for diagnosing pulley ruptures [49]. Evaluation of acute cervical soft-tissue injury requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [50]. The accuracy of visual estimates of partial flexor tendon lacerations was lower for lacerations close to the threshold for repair [8].

Imaging

Plain radiography: Standard radiographs may initially fail to detect retained foreign bodies such as rattlesnake fangs [166]. Radiological assessment is needed for penetrating hand injuries, particularly when the history is vague [170]. A radiograph demonstrated good fracture healing in a case of conservatively managed Jersey finger [156].

Ultrasound: A combination of ultrasound and x-ray films should allow for diagnosis and localization of virtually all foreign bodies in the hand [131]. Ultrasonography is recommended in the early investigation of hypothenar hammer syndrome as it will also demonstrate soft tissue infections and foreign bodies [145]. Perioperative ultrasound can be considered useful for the extraction of radiolucent foreign bodies [171]. Sonography and MRI are required to distinguish between distension and partial, complete, or multiple pulley ruptures [49]. An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, though false-negatives are possible with this technique [94].

MRI: MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing in Dupuytren's disease [94]. MR assessment of Dupuytren's is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [94]. MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas in Dupuytren's disease [94].

Specific Injury Assessment

Air gun pellet injuries of the hand produce a different injury pattern, with a more benign course, than other types of bullet injury [34]. Shell fragments caused nerve damage in 80% of cases, with concomitant vascular injury seen in 30% in war victims [178]. In pediatric volar plate avulsion fractures with more than 30% joint involvement, surgical interventions yielded positive results [70].

Treatment

General Principles and Assessment

Complex acetabular fractures require management at a trauma center by a multidisciplinary team experienced with complex patients and injuries [3]. For severe soft-tissue injuries in closed and open fractures, management must be based on correct classification of the fracture and corresponding soft tissue injury, adapted to the individual patient's general health status, secondary diagnoses, and available treatment options [31]. While the principles of managing war wounds remain consistent with previous conflicts, treatment methods have evolved [20]. Improved battlefield survival rates have necessitated the application of new technology and treatment alternatives for upper extremity injuries sustained in modern warfare [129]. A consensus document proposes 22 evidence-based recommendations to promote best practices in surgical wound closure and soft tissue management, aiming to reduce variability and improve outcomes [66]. The current literature on surgical debridement presents early findings from experienced surgeons rather than fully controlled comparative studies [43].

Wound Closure and Debridement

Surgical Strategy: Structural repair of hand bite injuries is performed as indicated by the severity and contamination of the injury, with wounds potentially requiring delayed closure [2]. Early treatment of swine bites to the hand must be primarily surgical, involving prompt and thorough wound cleansing, superficial and deep debridement, drainage, and delayed closure only after cultures show no bacterial growth [36]. For mutilating hand injuries, meticulous wound care with delayed primary or secondary closure is the best treatment against infection [142]. In the primary outpatient treatment of open hand wounds, preventive antibiotics were not necessary when accompanied by debridement, irrigation, and rapid primary repair in an operating room environment [182].

Debridement and Reconstruction: Debridement and elimination of infection are the keys to success in delayed presentation of mutilating hand injuries, utilizing a multipronged strategy of radical debridement, early soft tissue cover, and appropriate antibiotic therapy [159]. Skin cover with flaps is preferable to grafts for delayed presentation of mutilating hand injuries, and composite free flaps may be used for complex reconstructions [159]. Adequate splinting and rest, combined with dynamic physiotherapy, are required at all stages of treatment for delayed presentation of mutilating hand injuries [159]. Foreign bodies in the hand should be removed, as late symptomatic presentation and symptom development in conservatively managed patients indicate this necessity [30].

Specific Wound Care: All wounds from domestic bird bites should be properly evaluated and explored in the emergency department, and surgical irrigation and debridement should be considered for penetrating wounds [64]. Application of modern wound management paradigms for extremity war injuries leads to reasonable early outcomes with notably lower rates of early infection and flap failure than previously reported in civilian series [23]. The average time for healing of upper extremity wounds closed with a skin stretching device was 2.5 to 4 weeks, increasing to 4 to 6 weeks in cases of partial minor breakdown [42]. In a single blind, prospective, randomized trial, N-butyl 2-cyanoacrylate tissue adhesive and sutures had similar wound outcomes at both 2 and 6 week assessments for skin closure in hand surgery [109]. In the management of acute nail bed lacerations, Dermabond is an efficient and effective repair technique compared to suture repair [148].

Negative Pressure Wound Therapy (NPWT)

NPWT shows great promise in reducing complications associated with high-risk wounds, but the evidence base is limited by low numbers of underpowered trials and heterogeneous outcome measures [18]. A clear wound healing goal must be determined for NPWT, and discontinuation should be considered if no improvement is observed between two consecutive dressing changes or after 1 week of treatment [21]. Clinical experience substantiates the use of VAC as a useful adjunct to traditional interventions for difficult hand wounds, though well-designed large prospective randomised controlled trials are needed to assess its effectiveness [141]. Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery are being developed towards an international consensus [146].

Specific Injury Management

Tendon and Nerve Injuries: Flexor tendon repair in zone III reports excellent or good outcomes in the majority of patients with clean cut lacerations [4]. Although outcomes for flexor tendon repair have improved, fair or poor functional outcomes persist, particularly in complex trauma and zone 5 injuries [10]. It is imperative to recognize Seymour fractures early and treat them appropriately [7]. Delayed ulnar tunnel syndrome can occur following minor closed wrist injury in the absence of any identifiable compressive pathology [29].

Vascular and Soft Tissue Injuries: Outcomes for ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone did not vary with treatment modality in a reported series, and further study is needed to determine the most effective treatment [6]. Microsurgical reconstruction should always be undertaken for ring avulsion injury with rupture of both digital arteries to ensure excellent survival and good functional outcome, regardless of the class of injury [24]. Seton drainage for therapy of cat bites resulted in wounds healing without complications in 15 patients [22]. Endoscopic debridement combined with percutaneous cutaneo-fascial suture was used to treat Morel-Lavallée lesions in eight patients [61].

Fractures and Dislocations: Late open reduction for dorsal dislocation of the metacarpophalangeal joint of the index finger may be successful even when performed three and one-half months after injury [25]. In fractures with more than 30% joint involvement, surgical interventions yielded positive results for pediatric volar plate avulsion fractures of the proximal interphalangeal joint [70]. Posttraumatic trapeziometacarpal joint instability in a child treated with a specific procedure resulted in very good outcomes, with no instability, no pain, and almost no scars [157].

Traumatic Mechanisms: The most common treatment required for hand and wrist dog-leash injuries in the outpatient setting was nonoperative [181]. All patients with severe hand damage caused by a mole gun underwent primary surgical repair within 24 hours following the injury [144]. Prophylactic antibiotics, typically a cephalosporin, were given to each patient with mole gun injury for fifteen postoperative days to prevent infection from soil-borne bacteria [144].

Burn Management

Transfer and Assessment: Criteria for transfer of a patient to a burn center include burns that involve the face, hands, feet, genitalia, perineum, and major joints [37]. First-degree burn injuries involve damage to the epidermis only, do not have open wounds or blistering, heal without scarring, and do not require surgical treatment [37]. The management of burn injuries to the hand requires a multidisciplinary team at a burn center, and treatment should be tailored to the individual patient [67]. Acute care and resuscitation are of paramount importance in hand burn patients, but subsequent attentive care leads to optimal hand functionality and cosmetic long-term outcomes [67].

Treatment by Depth: Superficial burns characterized by erythema without blistering require only analgesia and reassurance [149]. Superficial partial-thickness burns will normally spontaneously reepithelize without scarring within 3 weeks of injury [149]. Deep partial-thickness burns may re-epithelize but normally require skin grafting [149]. Small full-thickness burns may be treated conservatively [149]. The glove-gauze regimen for managing burn injuries of the hand includes the use of topical silver sulfadiazine, gauze therapy at night, outpatient treatment, and immediate mobilization with home therapy [149].

Limb Salvage and Amputation

No data support definitive indications for limb salvage versus amputation for mangled lower extremities, and long-term studies show that patients with limb-threatening injuries sustain significant disability regardless of the treatment chosen [38].

Complications

Infection and Contamination: Infections developed in 16 (11%) patients with open hand fractures [39]. Staphylococcus aureus was the pathogen most frequently isolated from infected open hand fracture wounds, even though it was never isolated before the initial debridement [39]. In 62% of cases, wounds were contaminated before debridement [41]. The time interval between injury and the commencement of treatment appears to be the single most important factor governing the final result in human bites of the hand [74]. Late cases of human bites of the hand were characterized by a high rate of infection-related complications, a prolonged morbidity period, and a less favorable final functional result [74]. In 15 patients with cat bites treated with seton drainage, the wounds healed without complications [22]. A wound that has been persistently draining for >5 to 7 days from the time of diagnosis should be reoperated on without delay [168].

Structural and Functional Complications: Although outcomes have improved, fair or poor functional outcomes persist in flexor tendon repair, particularly in complex trauma and zone 5 injuries [10]. In 28% of volar hand and wrist wounds with a normal clinical examination, tendon, vascular, or nerve damage was found on surgical exploration [47]. Service members with more severe initial peripheral nerve injuries had worse final outcomes [54]. Thumb ray dysfunction in sensibility and mobility remained the main functional disability in cases of the exploded hand syndrome [27]. The morbidity inflicted by firework injuries to individual patients is substantial, with patients undergoing a median of three surgical operations and having a long duration of initial hospital stay [75]. Full-thickness skin necrosis of the fingertip can occur after application of superglue [71]. Rupture of the flexor pollicis longus tendon can occur 30 years after injury due to migration of a retained foreign body [56]. Injuries to deep structures caused by traumatic implantation of a foreign body are not uncommon, with 4.3% of patients in a prospective study of 164 patients showing evidence of damage to deep structures including digital nerves, extensor tendons, and flexor tendons [56].

Assessment and Classification: Type I open fractures include puncture wounds ≤1 cm, with minimal contamination and muscle damage [13]. Type II open fractures include lacerations >1 cm, with moderate soft-tissue injury, adequate bone coverage, and minimal comminution [13]. Type IIIA open fractures involve extensive soft-tissue damage with adequate bone coverage, usually resulting from a high-velocity injury with a severe crushing component [13].

Specific Injury Mechanisms and Outcomes: In agricultural hand injuries, lacerations and amputations were the most common injuries (45%), followed by fractures (36%) [72]. The mean period of work impairment was 31 days (range, 0–300) in patients with hand injuries sustained during agricultural activities [72]. The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015 [164]. More experience with the use of saws does not necessarily protect one from saw injuries [169]. People are dissatisfied with current safety features on table saws, disabling them and sustaining injuries, and even when they are enabled, people are still getting injured [173]. Viral transmission of herpes can occur at the time of initial hand injury, even in patients with no previous history of oral or genital herpes [73]. The morbidity of human fight-bite injuries of the hand can be reduced by a specific treatment programme, even in cases with early complications [40]. Late open reduction of dorsal dislocation of the metacarpophalangeal joint may be successful even when performed three and one-half months after injury [25].

Recovery

Light activity (weeks): Upper extremity wounds closed with a skin stretching device typically heal within 2.5 to 4 weeks [42]. In cases of partial minor breakdown, the healing time increases to 4 to 6 weeks [42].

Other Considerations: Skeletal muscle can recover useful but not normal function after laceration and repair [153]. In human bites of the hand, early and delayed cases were typified by an absence of complications, short recovery time, and usually favorable final functional results [74]. For flexor tendon repair in zone III, the study reports excellent or good outcomes in the majority of patients with clean cut lacerations [4]. Although outcomes have improved for flexor tendon repair, fair or poor functional outcomes persist, particularly in complex trauma and zone 5 injuries [10]. Prompt diagnosis and surgical repair within the first week gave the best results for avulsion of the profundus tendon insertion in athletes [183]. At an average follow-up of 18.2 months, the overall functional and complication rates were the same between upper and lower limb fasciotomy wounds and three closure techniques [167]. Eighteen months' follow-up demonstrated that dermal regeneration template reconstruction is a simple, reliable, efficient tool to treat complex traumatic soft tissue defects [179]. Application of modern wound management paradigms for extremity war injury leads to reasonable early outcomes with notably lower rates of early infection and flap failure than previously reported in civilian series [23]. Long-term follow-up in the transient patient population of pay phone receiver cord injuries to the hand was impossible, and anticipated hand function results are less than optimal [58]. In the case of full-thickness skin necrosis of the fingertip after superglue application, a local flap for coverage healed uneventfully and without lasting sequelae [71]. Microsurgical reconstruction for ring avulsion injury with rupture of both digital arteries should always be undertaken regardless of the class of injury to ensure excellent survival and good functional outcome [24].

Key Evidence

• [L5] Each injury is unique, and treatment must be individualized to achieve the best possible outcome. [1] (10.1016/j.hcl.2014.12.005)
• [L5] Structural repair is performed as indicated by the severity and contamination of the injury, and wounds may require delayed closure. [2] (10.5435/jaaos-23-01-47)
• [L4] The study reports excellent or good outcomes in the majority of patients with clean cut lacerations. [4] (10.1177/1753193410382378)
• [L5] Further experience is required, as well as clinical and basic research, to define optimal indications and benefits compared with traditional methods of wound management. [5] (10.5435/00124635-200209000-00002)
• [L4] Whereas outcomes did not vary with treatment modality in this series, further study is needed to determine the most effective treatment of these injuries. [6] (10.1177/1558944716672198)
• [L4] It is imperative to recognize these injuries early and treat them appropriately. [7] (10.1016/j.jhsa.2013.08.104)
• [L5] Accuracy was lower for lacerations close to the threshold for repair. [8] (10.1016/j.jhsa.2015.09.009)
• [Paper] Consensus and high-level multicentre trials are required in future to better guide our assessment and management of these unique, but increasingly more common injuries. [9] (10.1016/j.injury.2025.112787)
• [L5] Although outcomes have improved, fair or poor functional outcomes persist, particularly in complex trauma and zone 5 injuries. [10] (10.1177/17531934231182868)
• [L4] Simple hand lacerations represent a substantial number of ED visits in the United States. [11] (10.1016/j.injury.2011.05.001)
• [L5] This paper provides a review of the initial evaluation of hand crush injuries as well as short- and long-term management strategies, emphasizing the devastating nature of these injuries and the challenges in diagnosis and treatment. [12] (10.1016/j.jhsa.2017.03.028)
• [L5] [13] (10.5435/00124635-200305000-00008)
• [L4] There are documented pathological causes or evidence of trauma to most of these cases. [14] (10.1142/s2424835519500243)
• [L4] There is a marked paucity of evidence to support specific management of extravasation injuries, with the overwhelming majority of publications comprising case reports/series and non-evidence-based protocols. [15] (10.1177/1753193413511921)
• [L4] We wish to emphasize the importance of being aware of such injuries and the necessity of prompt management. [16] (10.1016/s0020-1383(96)00207-0)
• [L4] Wounds represent 31% of hand trauma in children, and fencing mechanisms cause destructive wounds with often longitudinal skin lesions. [17] (10.1016/j.hansur.2019.10.058)
• [L5] NPWT shows great promise in reducing complications associated with high-risk wounds, but the evidence base is limited by low numbers of underpowered trials and heterogeneous outcome measures. [18] (10.1302/0301-620x.98b8.bjj-2016-0373)
• [L4] The mechanism of injury has been clearly defined and the problems with angle grinder injuries are indicated. [19] (10.1016/s0020-1383(00)00025-5)
• [L5] The principles of managing war wounds remain the same as in previous conflicts; however, the methods of treatment have evolved. [20] (10.5435/00124635-200600001-00016)
• [L4] A clear wound healing goal must be determined, and if no improvement is observed between two consecutive dressing changes or after 1 week of treatment, discontinuation should be considered. [21] (10.1016/j.otsr.2016.04.018)
• [L4] In 15 patients, the wounds healed without complications. [22] (10.1177/1558944716660555eu)
• [L4] Application of modern wound management paradigms leads to reasonable early outcomes with notably lower rates of early infection and flap failure than previously reported in civilian series. [23] (10.5435/00124635-200600001-00014)
• [L4] Microsurgical reconstruction should always be undertaken regardless of the class of injury to ensure excellent survival and good functional outcome. [24] (10.1177/1753193408089052)
• [L4] The case shows that late open reduction may be successful even when performed three and one-half months after injury, contrary to previous reports suggesting poor prognosis. [25] (10.2106/00004623-197254060-00028)
• [L5] Recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures, as incisions through compromised tissue can lead to wound breakdown and deep infection. [26] (10.5435/00124635-200311000-00007)
• [L4] While general outcomes were good, thumb ray dysfunction in sensibility and mobility remained the main functional disability. [27] (10.1177/1753193412468577)
• [L5] It is of note that soft tissue injuries are more common, although referral centers are more likely to treat a higher percentage of fractures, dislocations, and other more serious injuries. [28] (10.1016/s0278-5919(05)70092-2)
• [L5] This case report highlights that there can be a delayed onset of this syndrome following minor injury, in the absence of any identifiable compressive pathology. [29] (10.1016/0020-1383(95)00013-y)
• [L3] The late, symptomatic presentation of patients, together with the development of symptoms in patients managed conservatively indicate that foreign bodies should be removed. [30] (10.1016/s0266-7681(84)80029-7)
• [Paper] Treatment should always be based on the correct classification of the fracture and the corresponding soft tissue injury, but needs to be adapted to the individual patient considering general health status, secondary diagnoses and currently available treatment options. [31] (10.1016/j.injury.2024.111935)
• [L4] Many of these injuries are preventable, and targeted prevention strategies should be considered. [32] (10.1177/1753193419826465)
• [L3] Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury. [33] (10.1177/17531934231211566)
• [L4] Pellets produce a different injury pattern, with a more benign course, than other types of bullet injury. [34] (10.1016/j.jhsb.2005.09.008)
• [L4] [35] (10.1177/15589447241300697)
• [L5] Early treatment must be primarily surgical, with prompt and thorough wound cleansing, superficial and deep debridement of the wound, drainage, and delayed closure of wounds only after cultures show no bacterial growth. [36] (10.1016/s0363-5023(10)80030-9)
• [L5] [37] (10.1016/j.jhsa.2010.03.019)
• [L4] [39] (10.1016/s0363-5023(10)80022-x)
• [L4] The morbidity of this injury can be reduced by this programme, even in cases with early complications. [40] (10.1016/0266-7681(91)90020-o)
• [L3] In 62% of cases, the wounds were contaminated before debridement. [41] (10.1016/j.hansur.2016.06.001)
• [L4] The average time for healing was 2.5 to 4 weeks, and in cases of partial minor breakdown this increased to 4 to 6 weeks. [42] (10.1016/s0266-7681(96)80060-x)
• [L5] The collection of papers explores the issues and challenges characterizing the role of surgical debridement in the management of injury, presenting early findings from experienced surgeons rather than fully controlled comparative studies. [43] (10.1016/j.injury.2007.10.033)
• [L3] In 28% of wounds with a normal clinical examination, tendon, vascular or nerve damage was found on surgical exploration. [47] (10.1016/j.hansur.2020.03.006)
• [L4] Earlier recognition of injury severity and referral might avoid morbidity and resource use associated with prolonged treatment. [48] (10.1054/jhsb.1999.0320)
• [L5] Clinical examination alone is insufficient for diagnosing pulley ruptures; sonography and MRI are required to distinguish between distension and partial, complete, or multiple ruptures. [49] (10.1016/j.main.2005.01.011)
• [Case_report] Evaluation requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury. [50] (10.2106/00004623-197961020-00031)
• [L4] [53] (10.1016/j.injury.2016.01.020)
• [L4] Service members with more severe initial injuries had worse final outcomes. [54] (10.1016/j.jhsa.2020.08.004)
• [L5] [56] (10.1016/s0266-7681(95)80052-2)
• [L5] [57] (10.1016/s0020-1383(71)80080-3)
• [L4] Long-term follow-up in this particular transient patient population was impossible, and anticipated hand function results are less than optimal. [58] (10.1016/s0363-5023(84)80078-7)
• [L5] [59] (10.5435/jaaos-22-10-605)
• [L5] The greatest challenge in hand injury is to preserve function in all structures not directly injured, as dense connective tissue undergoes significant collagen synthesis and remodeling. [60] (10.1016/s0894-1130(98)80003-3)
• [Paper] [61] (10.1016/j.injury.2018.06.003)
• [L4] Knowledge of modern repair techniques and rehabilitation protocols may improve patient outcomes. [62] (10.1016/j.jhsa.2014.06.136)
• [L5] All wounds should be properly evaluated and explored in the emergency department, and surgical irrigation and debridement should be considered for penetrating wounds. [64] (10.1016/j.jhsa.2012.02.044)
• [L5] The document proposes 22 evidence-based recommendations to promote best practices in surgical wound closure and soft tissue management, aiming to reduce variability in clinical practice and improve patient outcomes. [66] (10.1530/eor-24-0002)
• [L5] [67] (10.1016/j.hcl.2016.12.001)
• [L4] In fractures with more than 30% joint involvement, surgical interventions yielded positive results. [70] (10.1177/15589447241231308)
• [L5] This injury necessitated a local flap for coverage, which healed uneventfully and without lasting sequelae. [71] (10.1016/s0363-5023(03)00203-x)
• [L3] [72] (10.1054/jhsb.1998.0189)
• [L5] In this case, with no previous history of either oral or genital herpes, it may be concluded that viral transmission occurred at the time of the initial injury. [73] (10.1016/s0266-7681(96)80160-4)
• [L4] [74] (10.1016/s0363-5023(85)80167-2)
• [L4] The morbidity inflicted by firework injuries to individual patients is substantial, with patients undergoing a median of three surgical operations and having a long duration of initial hospital stay. [75] (10.1177/1558944719829905)
• [L4] The patterns of peri-articular finger injuries differ greatly between the three finger joints, explained by the mechanism of falling and local biomechanical forces. [93] (10.1177/17531934251381203)
• [L4] Biomechanical analysis showed a huge amount of force and pressure, several times larger than that of ring avulsion injury, results when a steer pulls on the thumb. [97] (10.1177/03635465030310051601)
• [L4] Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base. [98] (10.1177/1753193415620186)
• [L4] The non-dominant hand is most vulnerable, as it steadies the structures that are being nailed together. [99] (10.1016/s0266-7681(05)80245-1)
• [L4] Ring avulsion injuries are commonly classified with the Urbaniak class system. [101] (10.1177/1558944717692094)
• [L1] [106] (10.1016/s0266-7681(85)80064-4)
• [L1] The two treatment groups had similar wound outcome at both the 2 and the 6 week assessments. [109] (10.1054/jhsb.2000.0572)
• [L4] Patients presenting within 24 hours generally have excellent outcomes regardless of treatment, whereas those presenting with infection or delayed presentation require operative debridement. [116] (10.1016/j.jhsa.2013.03.002)
• [L4] This case series demonstrates the extent and severity of hand injuries that can be caused by sword assaults with devastating loss of function for the victims. [117] (10.1177/1753193410381576)
• [L2] Infections after acute repairs of upper-extremity lacerations were rare. [118] (10.1016/j.jhsa.2025.01.030)
• [L5] Although rare, hypotensive shock following blunt soft tissue trauma to the pelvis (without a fracture) and with delayed clinical symptoms warrants the exclusion of these vascular injuries. [125] (10.1016/s0020-1383(01)00103-6)
• [L4] Girls and women may be more likely than boys and men to sustain more severe injuries requiring hospitalization. [126] (10.1177/0363546510383478)
• [L5] Improved survival rates on the battlefield have resulted in new and ongoing challenges in the care of U.S. military personnel, necessitating the application of new technology and treatment alternatives to provide the best care to those wounded in war. [129] (10.1016/j.jhsa.2007.07.007)
• [Paper] A combination of ultrasound and x-ray films should allow for diagnosis and localization of virtually all foreign bodies in the hand. [131] (10.1016/s0363-5023(05)80287-4)
• [L5] The FRI classification was created to systematically address the variety of fracture-related infections (FRIs) by a uniform classification. [140] (10.1016/j.injury.2024.111934)
• [Case_report] Clinical experience substantiates the use of VAC as a useful adjunct to traditional interventions for difficult hand wounds, though well-designed large prospective randomised controlled trials are needed to assess its effectiveness. [141] (10.1177/175899830200700102)
• [L3] Meticulous wound care with delayed primary or secondary closure is the best treatment against infection. [142] (10.1016/s0363-5023(77)80088-9)
• [L4] [144] (10.1016/j.main.2013.04.011)
• [L5] We recommend the use of ultrasonography in the early investigation of these patients, as it will also demonstrate soft tissue infections and foreign bodies. [145] (10.1016/s0020-1383(99)00130-8)
• [L1] [146] (10.1016/s0020-1383(11)00041-6)
• [L1] In the management of acute nail bed lacerations, Dermabond is an efficient and effective repair technique. [148] (10.1016/j.jhsa.2007.10.008)
• [L4] [149] (10.1177/1753193420910054)
• [L3] The technique is associated with shorter hospital stays, reduced numbers of surgical interventions, and greater rates of primary wound closure. [151] (10.1097/01.blo.0000180450.21350.3e)
• [Paper] Data show that skeletal muscle can recover useful but not normal function after laceration and repair. [153] (10.1016/s0363-5023(84)80014-3)
• [L3] These injuries were very costly in terms of morbidity, surgical effort and time, with significant resource implications. [154] (10.1016/s0266-7681(96)80192-6)
• [L5] A radiograph demonstrated a good fracture healing. [156] (10.1016/j.hansur.2016.10.139)
• [L5] This procedure resulted in very good outcomes, with no instability, no pain and almost no scars. [157] (10.1016/j.hansur.2018.10.163)
• [L5] [159] (10.1016/j.hcl.2016.07.008)
• [L3] The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015. [164] (10.1016/j.jhsa.2017.01.025)
• [L5] This case highlights the importance of aggressive surgical management and increased suspicion for retained foreign bodies, such as rattlesnake fangs, which may be initially undetected on standard radiographs. [166] (10.1016/j.jhsa.2021.04.004)
• [L1] At an average follow up of 18.2 months the overall functional and complication rates between upper and lower limb fasciotomy wounds and the three techniques were the same. [167] (10.1016/0266-7681(94)90293-3)
• [Paper] [168] (10.1002/jor.22554)
• [L4] Contrary to the hypothesis, more experience with the use of saws does not necessarily protect one from saw injuries. [169] (10.1016/j.jhsg.2023.01.017)
• [L4] This case emphasizes the need for radiological assessment of penetrating hand injuries, particularly when the history is vague, and highlights the difficulty in using metronidazole in individuals with a history of alcohol abuse. [170] (10.1054/jhsb.1999.0357)
• [L4] Since perioperative ultrasound allowed guiding the extraction of all radiolucent foreign bodies in the series, it can be considered useful for the extraction of radiolucent foreign bodies. [171] (10.1016/j.hansur.2018.10.056)
• [L4] This study highlights 2 major problems with the current safety features: People are dissatisfied with current safety features, disabling them and sustaining injuries, and even when they are enabled, people are still getting injured—suggesting inadequacy of the current features. [173] (10.1177/1558944717695754)
• [L5] [176] (10.1016/j.jhsa.2017.06.013)
• [L4] Shell fragments caused nerve damage in 80% of cases, with concomitant vascular injury seen in 30%. [178] (10.1016/s0363-5023(03)80320-9)
• [Paper] Eighteen months' follow-up demonstrated that DRT reconstruction is a simple, reliable, efficient tool to treat complex traumatic soft tissue defects. [179] (10.1016/j.injury.2013.11.034)
• [L5] Nonoperative treatment results in good functional outcomes in the majority of athletes with muscle injuries, but failed treatment can postpone return to sports for weeks or months. [180] (10.1177/0363546505274714)
• [L4] The most common treatment required for these patients was nonoperative. [181] (10.1177/15589447241299128)
• [L1] The preventive antibiotics administered were not necessary in treating these wounds when accompanied by debridement, irrigation, and rapid primary repair in an operating room environment. [182] (10.1016/0363-5023(88)90281-x)
• [L4] Prompt diagnosis and surgical repair within the first week gave the best results. [183] (10.1016/s0363-5023(77)80012-9)
• [L5] [184] (10.1016/j.jhsa.2014.07.056)

See Also

• Flexor tendon repair
• Dislocations
• Soft Tissue Trauma
• Dupuytren's Disease
• Reconstructive Surgery

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