The Dorsum of the Hand

A radial nerve block is an excellent alternative to local infiltration for anesthesia on the dorsum of the hand. The skin on the dorsum of the hand is quite thin and can be difficult to approximate. Simple interrupted sutures using 5-0 nonabsorbable material are usually adequate. Since the dorsum of the hand is a cosmetically important area, alternatives include a dermal pull-through using 5-0 polypropylene or subcuticular sutures using 5-0 absorbable material ( Fig.40-6).

Lacerations over the metacarpophalangeal (MCP) joints suggest a potential clenched-fist injury (CFI) or "fight bite," a laceration sustained with a closed fist to the mouth of another person during a fight. Patients may be reluctant to admit to the mechanism but should be warned of the serious risk of infection. These wounds should be inspected carefully with the digits flexed, reproducing the position at the time of injury. Any visible laceration of the extensor tendon or the joint capsule overlying the MCP joint indicates possible joint penetration, and a hand surgeon should be consulted. Radiographs should be obtained to evaluate for underlying foreign bodies, fracture, and air in the MCP joint. Even if the evaluation finds no evidence of joint penetration or deeper injury, it is probably best to assume that all lacerations over the MCP joints sustained in fights are too contaminated for primary closure, and such wounds should be allowed to heal by secondary intention. The wound should be irrigated and dressed and the hand splinted. The patient should be placed on a 5-day course of an oral antibiotic to cover mouth flora. The patient should be reevaluated in 2 to 3 days, or sooner if signs of infection develop.

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