Traumatic hand injuries: the emergency clinician's evidence-based approach

At the start of your Saturday afternoon shift, you are not surprised to see that several patients are waiting to be seen for physical injuries. The first patient is a 34-year-old woman who sustained injury to her hand while skiing, 2 hours prior to her arrival. She reports falling with her hand still tethered to the pole's grip, landing on her outstretched right hand. She felt a painful snap in her right thumb, which still hurts, but otherwise she did not sustain any other trauma. Her only complaint currently is pain at the base of the right thumb. The patient is otherwise completely healthy, has no past medical or surgical history, and takes no medications. Upon examination, the affected hand appears to be surprisingly normal except for mild tenderness and swelling over the ulnar aspect of her first metacarpophalangeal joint and mildly decreased strength in her pincher grasp. X-ray reveals no fracture. You wonder if there is additional testing that should be done to evaluate this injury. You move on to a second patient, a 24-year-old man who cut his ring finger knuckle when he punched a wall 2 days ago. Physical examination reveals a small puncture wound over the IV metacarpophalangeal joint with mild swelling, erythema, warmth, and decreased range of motion secondary to pain. X-ray reveals no fracture, but there's something suspicious about this case. A third patient is a 37-year-old industrial worker whose finger contacted the stream of a high-powered grease injector. Physical examination reveals a small puncture wound over the volar proximal interphalangeal joint of his left long finger, mild tenderness to palpation over the area, and slight decreased range of motion secondary to pain. You wonder if the injury is as benign as it looks.