Hand Injuries

Quick Reference

Critical Alerts

• High-pressure injection injuries are surgical emergencies: Paint, grease, or hydraulic fluid injection causes extensive tissue necrosis and carries amputation rates of 30-50% if delayed beyond 6 hours [1]
• Examine tendons against resistance: Partial tendon injuries (> 50%) may have preserved passive range of motion but weak active motion
• Test 2-point discrimination for nerve injury: less than 6 mm is normal; > 10 mm indicates nerve injury requiring repair [2]
• Examine throughout full range of motion: Tendon lacerations may only be visible in specific positions due to tendon excursion
• Fight bites (clenched fist injury) are high-risk: Human bite over MCP joint penetrates joint space in 62% of cases with high infection risk from oral flora [3]
• Flexor tendon injuries need urgent hand surgery referral: Zone 2 injuries ("no man's land") require specialist repair within 7-10 days for optimal outcomes [4]
• Assess for compartment syndrome: Hand compartments (thenar, hypothenar, adductor, 4 interossei, central palm) require high index of suspicion [5]
• Scaphoid fractures have AVN risk: Proximal pole fractures have 30% nonunion rate due to retrograde blood supply [6]

Key Structures to Assess

Emergency Treatments

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Definition

Overview

Hand injuries encompass a spectrum of pathology including lacerations, fractures, tendon injuries, nerve injuries, vascular injuries, and compartment syndrome. The hand contains complex functional anatomy with minimal margin for error—even subtle injuries can result in significant lifelong disability if missed or mismanaged. Careful systematic examination of tendons, nerves, vessels, and bones is essential in every case. Many injuries appear deceptively minor on initial presentation but carry high risk of complications (high-pressure injection, fight bite, scaphoid fracture). [7,8]

Classification

By Structure Injured:

Flexor Tendon Zone Classification [4,9]:

Extensor Tendon Zone Classification [10]:

Epidemiology

• Extremely common presentation: Hand injuries account for 10-20% of all ED visits and 20% of workplace injuries [11]
• Work-related injuries predominant: 65% occur in males aged 20-40 years, industrial machinery and tools most common [11]
• High-pressure injection: Grease guns (4,000-10,000 PSI) and paint sprayers (3,000-7,000 PSI) cause 600-800 cases annually in US with 30-50% amputation rate [1]
• Fight bite: 15-20% of all hand infections in urban EDs; human oral flora more virulent than dog bites [3]
• Boxer's fracture: 5th metacarpal neck fracture accounts for 10% of all hand fractures, 90% in males [12]
• Scaphoid fracture: Most common carpal bone fracture (70% of carpal fractures); 30% of proximal pole fractures develop AVN or nonunion [6]
• Sports injuries: Ball-handling sports, falls onto outstretched hand (FOOSH mechanism)

Functional Anatomy

Flexor Tendons:

Extensor Tendons:

Nerve Distribution [2]:

Vascular Anatomy:

• Dual arch system: Deep palmar arch (radial dominant) and superficial palmar arch (ulnar dominant) with multiple anastomoses
• Digital arteries: Paired radial and ulnar digital arteries per finger (proper digital arteries)
• Allen test: Assesses radial-ulnar communication; abnormal test (> 5 sec reperfusion) suggests incomplete arch—radial artery harvest contraindicated [13]

Hand Compartments [5]:

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Clinical Presentation

History

Mechanism-Specific Questions:

Additional Critical History:

• Time of injury: Replantation viability, contamination duration, compartment syndrome timeline
• Hand dominance: Impacts functional recovery and return to work
• Occupation: Manual laborer, musician, surgeon—precision vs power grip requirements
• Contamination: Soil (Clostridium risk), freshwater (Aeromonas), saltwater (Vibrio), animal/human saliva
• Tetanus status: Last booster > 5 years for clean wounds, > 3 years for contaminated [14]
• Medical comorbidities: Diabetes (infection risk), anticoagulation (hematoma), smoking (healing), immunosuppression
• Prior hand surgery: Previous injuries, tendon transfers, hardware

Physical Examination

Systematic Approach - Never Skip Steps:

1. Inspection:

2. Tendons (Must Test Each Independently):

3. Nerves [2]:

4. Vascular [13]:

5. Bones and Joints:

6. Special Tests:

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Red Flags

Life-Threatening / Limb-Threatening Injuries

High-Risk Injury Patterns Requiring Specialist Referral

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Specific Injuries

High-Pressure Injection Injury

Critical Emergency - Do Not Underestimate

Flexor Tendon Injuries

Zone-Specific Management

Zone I (Distal to FDS Insertion - FDP Only) [4,9]:

Zone II ("No Man's Land") - FDP + FDS in Fibro-osseous Canal [4,9]:

Zone III (Palm) and Zone IV (Carpal Tunnel) [4]:

• Better prognosis than Zone II (more space, less adhesion risk)
• Zone IV: Check for median nerve injury (common with carpal tunnel lacerations)
• Requires specialist repair but less technically demanding than Zone II
• ED: Splint, hand surgery referral less than 7 days

Zone V (Distal Forearm) [4]:

• Muscle-tendon junction injury
• Good prognosis with repair
• Often associated with median or ulnar nerve injury (check carefully)
• ED: Splint, hand surgery referral less than 7 days

Extensor Tendon Injuries

Zone I - Mallet Finger [20]:

Zone II - Middle Phalanx:

• Rare injury; usually closed contusion
• May evolve to boutonniere if central slip injured (see Zone III)

Zone III - Central Slip at PIP Joint (Boutonniere Deformity) [10]:

Zone IV - Proximal Phalanx:

• Less common; extensor tendons broad and flat here
• Repair by hand surgeon

Zone V - MCP Joint (Extensor Hood and Sagittal Bands) [22]:

Zones VI-VIII:

• Zone VI (dorsal hand): ED repair feasible if experienced; 4-0 nonabsorbable horizontal mattress
• Zones VII-VIII (wrist/forearm): Hand surgery referral (complex anatomy with retinaculum and muscle-tendon junctions)

Metacarpal and Phalangeal Fractures

Boxer's Fracture (5th Metacarpal Neck) [12]:

Bennett Fracture (Thumb Base Fracture-Dislocation) [18]:

Rolando Fracture [18]:

Phalangeal Fractures [12]:

Universal pitfall: Rotational deformity is the most commonly missed indication for surgery; always check finger cascade alignment [12]

Scaphoid Fracture [6,23]:

Gamekeeper's / Skier's Thumb (UCL Thumb Injury) [16,24]:

Fight Bite (Clenched Fist Injury) [3]:

Subungual Hematoma [25]:

Compartment Syndrome of the Hand [5]:

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Diagnostic Approach

Imaging

X-Ray [7]:

Advanced Imaging:

Foreign Body Detection [26]:

Compartment Pressure Measurement [5]:

• Technique: Needle manometry (Stryker device) or arterial line transducer setup
• Interpretation: Absolute pressure > 30 mmHg OR delta pressure less than 30 mmHg (delta = diastolic BP - compartment pressure)
• Limitations: Requires measurement in ALL compartments (10 in hand); time-consuming; clinical diagnosis often sufficient
• When to use: Equivocal clinical presentation, unconscious patient, unreliable exam

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Treatment

General Wound Care [14,27]:

Irrigation:

Anesthesia:

• Digital block (preferred for finger lacerations): 1% lidocaine without epinephrine, 2-3 mL each side at base of finger (dorsal approach or volar approach at web space) [28]
• Local infiltration: 1% lidocaine with or without epinephrine (epinephrine safe in fingers despite old teaching—duration of ischemia is limited and safe) [28]
• Hematoma block: For fracture reduction (1% lidocaine into fracture hematoma)
• Maximum lidocaine dose: 4.5 mg/kg (plain) or 7 mg/kg (with epinephrine); 1% = 10 mg/mL

Debridement:

• Remove devitalized tissue (non-bleeding, non-viable)
• Preserve viable tissue even if questionable (hand surgery can revise later)
• Do NOT debride facial nerve, tendon, or bone unless obviously necrotic

Tetanus Prophylaxis [14]:

Closure:

Antibiotics [3,14,27]:

Tendon Injury Management

Key Principle: Do NOT repair flexor tendons in the ED unless you are a hand surgeon. Extensor tendons over MCP/hand (zones V-VI) may be repaired by experienced ED providers; all others require specialist referral [4,22].

Flexor Tendons [4]:

• All zones: Hand surgery referral within 7-10 days for primary repair
• ED management:
  • Irrigate and dress wound (sterile saline-soaked gauze)
  • "Splint in protective position: wrist 20° flexion, MCP 70° flexion, PIP/DIP 10-20° flexion"
  • Antibiotics if contaminated wound (see above)
  • Arrange urgent hand surgery follow-up
• Do NOT: Probe wound looking for tendon, attempt ED repair, primarily close wound over lacerated tendon

Extensor Tendons [10,22]:

Repair Technique for Extensor Zone V-VI (if ED provider experienced) [22]:

1. Anesthesia: Digital or wrist block
2. Irrigation and debridement
3. Identify tendon ends (may need to extend wound proximally/distally)
4. 3-0 or 4-0 nonabsorbable (nylon, Prolene) horizontal mattress or figure-of-8 suture
5. Test repair by passively flexing and extending finger (tendon should glide smoothly)
6. Close skin
7. Splint: Wrist 30° extension, MCP 0° extension, PIP/DIP free × 3-4 weeks
8. Hand therapy referral for controlled mobilization starting week 3-4

Fracture Management

General Principles:

• Reduce if displaced, splint in safe position, arrange orthopedic/hand surgery follow-up
• Safe position of hand: Wrist 20-30° extension, MCP 70-90° flexion, PIP/DIP 10-20° flexion (intrinsic plus position) - prevents stiffness [7]
• Never splint hand flat (MCP extended, PIP extended) - causes MCP collateral ligament contracture and permanent stiffness

Specific Fracture Splinting [7]:

Reduction Techniques:

Indications for Operative Fixation (Hand Surgery Referral) [12]:

• Rotational deformity (any)
• Intra-articular fracture with displacement > 1-2 mm
• Open fracture
• Angulation exceeding acceptable limits (see Boxer's fracture)
• Multiple metacarpal fractures
• Unstable fracture (loss of reduction after splinting)
• Bennett, Rolando fractures (nearly all)
• Displaced scaphoid fracture (> 1 mm) or proximal pole scaphoid fracture

Splinting Techniques

Materials:

• Plaster: Easier to mold, sets faster, cheaper; gets soft if wet
• Fiberglass: Stronger, lighter, waterproof; harder to mold

Thumb Spica [7]:

• Indications: Scaphoid fracture, Bennett/Rolando fracture, thumb collateral ligament injury, de Quervain tenosynovitis
• Technique:
  • Volar or radial surface of forearm to thumb tip
  • Include wrist (neutral to slight extension)
  • Thumb in abducted, opposed position (like holding a can)
  • Leave thumb IP free (short thumb spica) OR include thumb IP (long thumb spica for scaphoid)
  • Mold around thenar eminence and first web space

Ulnar Gutter [7]:

• Indications: Boxer's fracture, 4th-5th metacarpal fracture, proximal/middle phalanx fracture (4th-5th digits)
• Technique:
  • Ulnar forearm from below elbow to distal palmar crease
  • Include 4th and 5th metacarpals
  • "Position: Wrist 20° extension, MCP 70-90° flexion, PIP/DIP 10-20° flexion"
  • Mold over dorsum of hand and intermetacarpal spaces

Volar Wrist Splint:

• Indications: Wrist sprain, distal radius fracture (after reduction), carpal tunnel syndrome
• Technique: Volar forearm from just below elbow to palmar crease; wrist neutral to 20° extension

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Disposition

Discharge Criteria

• Simple lacerations repaired with good hemostasis
• Stable fractures splinted with orthopedic follow-up arranged
• Extensor tendon injuries managed conservatively (mallet splint, boutonniere splint)
• Wound care and splint care instructions provided (verbal + written)
• Pain controlled with oral analgesics
• Follow-up arranged (hand surgery, orthopedics, or wound check)
• Patient reliable and understands warning signs

Admission Indications

• Fight bite with MCP joint involvement (IV antibiotics + operative irrigation)
• High-pressure injection injury (emergent operative debridement)
• Open fracture Type II/III (IV antibiotics + operative irrigation/debridement)
• Compartment syndrome (emergent fasciotomy)
• Complete digital amputation (replantation consideration)
• Severe crush injury with vascular compromise
• Necrotizing soft tissue infection (rare)
• Unreliable patient with serious injury requiring close monitoring

Referral to Hand Surgery

Follow-Up

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Patient Education

Wound Care

• Elevation: Keep hand elevated above heart level as much as possible for first 48-72 hours (reduces swelling and pain)
• Dressing: Keep clean and dry; change daily or if soiled; if steri-strips used, leave in place until they fall off (10-14 days)
• Bathing: Cover splint with plastic bag; do not submerge wound until sutures removed and cleared by provider
• Activity: Avoid heavy lifting, gripping, or strenuous hand use until cleared

Splint Care

• Keep dry: Moisture weakens plaster; cover with plastic bag during bathing
• Do not remove: Unless specifically instructed (e.g., for bathing if removable splint prescribed)
• Skin checks: Check for pressure sores, skin breakdown, or excessive tightness daily
• If too tight: Swelling causes tightness in first 24-48 hours; elevate hand; if numbness, tingling, or severe pain, loosen ace wrap or return to ED
• Mallet splint: DO NOT remove even briefly for 6-8 weeks; even 5 minutes restarts the clock; skin care by sliding splint slightly while maintaining DIP extension [20]

Pain Management

• First-line: Acetaminophen 1000 mg q6h scheduled (not PRN) for first 48 hours
• Second-line: Ibuprofen 600 mg q6h with food (if no contraindications)
• Opioids: Usually not needed; if prescribed, use for 2-3 days maximum; risk of dependence
• Ice: 20 minutes on, 40 minutes off for first 48 hours (over splint is fine)

Warning Signs to Return to ED

Return to Work/Activity

• Sedentary work (typing, desk work): Usually 1-2 weeks with accommodations (splint on, modified duties)
• Manual labor: 6-12 weeks depending on injury (fracture healing, tendon repair strength)
• Sports: Varies by injury; buddy taping may allow early return for stable injuries; contact sports typically 6-12 weeks
• Driving: Avoid until splint removed and full grip strength (unable to control vehicle safely with splint)

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Special Populations

Pediatric Considerations

• Physis (growth plate) injuries common; Salter-Harris classification applies
• Higher healing capacity but also higher risk of growth arrest if physis injured
• Remodeling potential is excellent in children less than 10 years; accept more angulation
• Operative fixation across physis avoided if possible (use smooth K-wires, avoid screws)
• Child abuse consideration if mechanism inconsistent with injury pattern

Elderly Considerations

• Osteoporosis increases fracture risk from low-energy mechanisms
• Comminuted fractures more common, harder to stabilize
• Healing slower; immobilization leads to rapid stiffness
• Early mobilization critical; consider operative fixation for fractures to allow earlier ROM
• Anticoagulation common (warfarin, DOACs); hold if operative intervention needed (discuss with hand surgeon)

Diabetic Patients

• Infection risk significantly higher (impaired neutrophil function, microvascular disease)
• Lower threshold for admission and IV antibiotics for contaminated wounds
• Wound healing impaired; close follow-up essential
• Neuropathy may mask pain; examine carefully for occult injury

Immunocompromised

• HIV, transplant patients, chemotherapy, chronic steroids
• Infection risk very high; aggressive antibiotic coverage
• Consider admission for wounds that would be outpatient in immunocompetent patient
• Infectious disease consultation if necrotizing infection suspected

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Quality Metrics

Performance Indicators

Documentation Requirements

• Mechanism of injury (sharp, crush, avulsion, bite, injection, etc.)
• Dominance and occupation
• Time of injury
• Tetanus status and prophylaxis given
• Examination findings:
  • "Tendons: FDP (each digit), FDS (each digit), extensors (each digit) - individually tested and documented"
  • "Nerves: 2-point discrimination (each digital nerve), motor function (median, ulnar, radial)"
  • "Vascular: Capillary refill, Allen test if indicated, Doppler if vascular injury suspected"
  • "Bones: Palpation findings, rotational alignment assessed"
• X-ray interpretation (official read may be pending but ED interpretation documented)
• Treatment: Wound care (irrigation volume, debridement), closure method, antibiotics, tetanus, splint type and position
• Disposition: Discharge instructions (written), follow-up arranged (with whom, when), prescriptions, warning signs reviewed

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Key Clinical Pearls

Diagnostic Pearls

• High-pressure injection looks benign but is a surgical emergency: Small puncture wound is deceiving; ask specifically about paint guns, grease guns, pressure washers; amputation rate 30-50% if delayed [1]
• Test tendons against resistance, not just active ROM: Partial tendon lacerations may preserve weak active motion but fail strength testing
• Fight bite over MCP = joint penetration until proven otherwise: 62% penetrate joint when fist clenched; assume worst and treat aggressively [3]
• Scaphoid tenderness = scaphoid fracture even if X-ray negative: 15-20% are X-ray occult; splint and re-image in 10-14 days or get MRI [6,23]
• Rotational deformity is the most commonly missed surgical indication: Always have patient make gentle fist and observe finger alignment; any crossing mandates operative fixation [12]
• 2-point discrimination less than 6 mm is normal; > 10 mm = nerve injury: Use bent paper clip 5 mm apart; test longitudinally on pulp [2]
• Central slip injuries often look minor acutely but evolve to boutonniere: Elson test is key; splint PIP in extension if positive [10]
• Compartment syndrome of hand is easily missed: 10 compartments, tense swelling, pain with passive stretch; measure pressures if equivocal [5]

Treatment Pearls

• Do NOT repair flexor tendons in the ED: Specialized technique required; poor outcomes if improperly repaired; refer to hand surgery [4]
• Mallet finger: Splint DIP in extension continuously × 6-8 weeks: Even brief removal restarts clock; compliance is key [20]
• Boxer's fracture: Acceptable angulation is 40-70° (controversy exists): Rotational deformity is NOT acceptable; ulnar gutter in safe position (MCP 70-90° flexion) [12]
• Thumb injuries: Use thumb spica, not buddy tape: Thumb requires separate immobilization for scaphoid, Bennett, gamekeeper injuries
• Never splint hand flat (MCP extended): Causes collateral ligament contracture and permanent stiffness; always splint in intrinsic plus (MCP flexed 70-90°) [7]
• Epinephrine IS safe in fingers: Old teaching was wrong; duration of ischemia is limited and safe; useful for hemostasis [28]
• Fight bites require IV antibiotics and often operative exploration: Amoxicillin-clavulanate or ampicillin-sulbactam to cover Eikenella; admit if joint violated [3]
• Leave bite wounds open: Primary closure dramatically increases infection risk [3,27]

Disposition Pearls

• High-pressure injection, compartment syndrome, complete amputation = emergent hand surgery consult from ED: Do not delay these
• Flexor tendon, jersey finger, open central slip = hand surgery within 7-10 days: Can discharge with urgent outpatient follow-up
• Bennett, Rolando, displaced scaphoid = urgent orthopedic/hand referral within 24-48h: Splint and arrange follow-up
• Suspected scaphoid with negative X-ray = thumb spica + follow-up in 10-14 days: Repeat X-ray or MRI; do not clear based on negative initial X-ray [6]
• All tendon and nerve injuries need follow-up within 1 week: Even if conservative management, ensure no missed injury

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Pitfalls and How to Avoid Them

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Evidence-Based Controversy

Boxer's Fracture: Acceptable Angulation

• Controversy: Some sources accept up to 70° angulation for 5th metacarpal neck; others recommend surgery for > 40° [12]
• Evidence: Functional outcomes similar for 40-70° angulation; cosmetic "knuckle loss" may be unacceptable to some patients
• Recommendation: Shared decision-making; less than 40° = non-operative; > 70° = operative; 40-70° = discuss with patient and orthopedics

Scaphoid Fracture: Cast vs Splint

• Controversy: Thumb spica cast (circumferential) vs splint for non-displaced scaphoid fractures [6]
• Evidence: Union rates similar; splint allows monitoring for compartment syndrome and is removable for hygiene
• Recommendation: Splint acutely in ED; orthopedics may convert to cast at follow-up

Mallet Finger: Continuous vs Night-Only Splinting

• Controversy: Continuous 24/7 splinting vs night-only after initial weeks [20]
• Evidence: Compliance with 24/7 is poor; outcomes may be similar with night splinting after 4-6 weeks
• Recommendation: Continuous 6 weeks minimum, then transition to night-only × 2-4 additional weeks

Epinephrine in Finger Blocks

• Old teaching: Never use epinephrine in fingers (risk of ischemia)
• Current evidence: Epinephrine is safe in finger blocks; no increased amputation risk; useful for hemostasis [28]
• Recommendation: Epinephrine acceptable in fingers; avoid in compromised vascular supply (severe PVD, vasospasm disorder)

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References

1. Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma. 2006;20(7):503-511. doi:10.1097/00005131-200608000-00010

2. Jaquet JB, Luijsterburg AJ, Kalmijn S, Kuypers PD, Hofman A, Hovius SE. Median, ulnar, and combined median-ulnar nerve injuries: functional outcome and return to productivity. J Trauma. 2001;51(4):687-692. doi:10.1097/00005373-200110000-00011

3. Talan DA, Abrahamian FM, Moran GJ, et al. Clinical presentation and bacteriologic analysis of infected human bites in patients presenting to emergency departments. Clin Infect Dis. 2003;37(11):1481-1489. doi:10.1086/379331

4. Tang JB. Outcomes and evaluation of flexor tendon repair. Hand Clin. 2013;29(2):251-259. doi:10.1016/j.hcl.2013.02.007

5. Shaikh AF, Blazar PE, Earp BE, Zhang D. Acute compartment syndrome of the upper extremity. J Hand Surg Am. 2026;51(1):114-120. doi:10.1016/j.jhsa.2025.07.021

6. Bhashyam AR, Mudgal C. Scaphoid and carpal bone fracture: the difficult cases and approach to management. Hand Clin. 2023;39(3):265-277. doi:10.1016/j.hcl.2023.02.003

7. Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg. 1999;33(4):423-426. doi:10.1080/02844319950159145

8. Ootes D, Lambers KT, Ring DC. The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (N Y). 2012;7(1):18-22. doi:10.1007/s11552-011-9383-z

9. Tang JB. Extensor tendon injuries: a new classification, strong repairs, and easier therapy. Plast Reconstr Surg. 2025. doi:10.1097/PRS.0000000000012483

10. Geoghegan L, Wormald JCR, Adami RZ, Rodrigues JN. Central slip extensor tendon injuries: a systematic review of treatments. J Hand Surg Eur Vol. 2019;44(8):825-832. doi:10.1177/1753193419845311

11. de Putter CE, Selles RW, Polinder S, Hartholt KA, Looman CW, Panneman MJ, et al. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J Bone Joint Surg Am. 2012;94(9):e56. doi:10.2106/JBJS.K.00561

12. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am. 2013;38(5):1021-1031. doi:10.1016/j.jhsa.2013.02.029

13. Jarvis MA, Jarvis CL, Jones PR, Spyt TJ. Reliability of Allen's test in selection of patients for radial artery harvest. Ann Thorac Surg. 2000;70(4):1362-1365. doi:10.1016/s0003-4975(00)01801-3

14. Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015;29(1):1-6. doi:10.1097/BOT.0000000000000262

15. Austin GJ, Leslie BM, Ruby LK. Variations of the flexor digitorum superficialis of the small finger. J Hand Surg Am. 1989;14(2 Pt 1):262-267. doi:10.1016/0363-5023(89)90018-5

16. Mohseni M, Sina RE, Graham C. Ulnar Collateral Ligament Injury (Gamekeeper's Thumb). StatPearls Publishing; 2025.

17. Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury. 2000;31(1):33-40. doi:10.1016/s0020-1383(99)00196-5

18. Bloom JM, Khouri JS, Hammert WC. Current concepts in the evaluation and treatment of Bennett, Rolando, and Vertical Oblique Fractures. Hand Clin. 2023;39(2):171-182. doi:10.1016/j.hcl.2022.12.002

19. Al-Qattan MM. Type 5 avulsion of the insertion of the flexor digitorum profundus tendon. J Hand Surg Br. 2001;26(5):427-431. doi:10.1054/jhsb.2001.0595

20. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev. 2004;(3):CD004574. doi:10.1002/14651858.CD004574.pub2

21. Collocott S, Wang A, Hirth MJ. Systematic review: Zone IV extensor tendon early active mobilization programs. J Hand Ther. 2023;36(2):316-331. doi:10.1016/j.jht.2022.12.001

22. Newport ML, Blair WF, Steyers CM Jr. Long-term results of extensor tendon repair. J Hand Surg Am. 1990;15(6):961-966. doi:10.1016/0363-5023(90)90024-h

23. Gray RRL, Halpern AL, King SR, Anderson JE. Scaphoid fracture and nonunion: new directions. J Hand Surg Eur Vol. 2023;48(2_suppl):4S-10S. doi:10.1177/17531934231165419

24. Katholiek JC, Osterman AL. Thumb collateral ligament injuries. J Hand Ther. 2023;36(2):184-191. doi:10.1016/j.jht.2022.11.007

25. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999;24(6):1166-1170. doi:10.1053/jhsu.1999.1166

26. Dean AJ, Gronczewski CA, Costantino TG. Technique for emergency medicine bedside ultrasound identification of a radiolucent foreign body. J Emerg Med. 2003;24(3):303-308. doi:10.1016/s0736-4679(02)00825-8

27. Berk WA, Welch RD, Bock BF. Controversial issues in clinical management of the simple wound. Ann Emerg Med. 1992;21(1):72-80. doi:10.1016/s0196-0644(05)82239-1

28. Lalonde DH. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013;21(8):443-447. doi:10.5435/JAAOS-21-08-443