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October 2015: Extremity

A 27-year-old tankerman reported to the medic with a cut to his finger. He stated that he was moving cases of cleaner on the deck without his gloves when he brushed his hand against a metal casing. He noticed a sharp pain in his finger and bleeding.

On review of systems he denies any numbness or tingling in his finger. He is on day 2/21 of his hitch.

  • Past History: Diabetes (NIDDM)
  • Past Surgical History: None
  • Current Medications: Metformin (Glucophage) 500 mg bid
  • Immunization Status: Tetanus and Influenza are up to date
  • Social History: Social drinker, smokes ½ pack a day
  • Family History: Mother with diabetes, father with high blood pressure

Vitals

  • Temp: 98.7
  • Pulse: 68
  • Respirations: 12
  • Blood pressure: 127/72
  • Pulse Ox: 97% RA

Physical Exam

  • General: Alert and Oriented x 4, no acute distress, appears comfortable
  • Extremities: No clubbing, cyanosis or edema, flexion and extension normal, normal sensation distally, capillary refill <2 sec
  • Wound:  curvilinear flap laceration approximately 2 cm in length on the dorsal surface of the left second digit crossing the proximal interphalangeal (PIP) joint with the base of the flap oriented radially. Hemostasis achieved with pressure. Wound margins approximate well

How would you approach this patient?

Diagnosis: Open wound on finger without tendon involvement

Treatment:

  • Clean wound with soap and water
  • Rinse with sterile saline
  • Consider digital block for diagnostic wound exploration
  • Begin secondary cleaning of finger and wound removing as much dirt and grease as possible from surrounding area
  • Prep finger in sterile fashion with betadine three (3) times
  • Explore wound in sterile fashion to ensure no tendon involvement removing any remaining debris
  • Use tincture of benzoin around the wound and begin covering with Steri-Strips
  • Place bulky dressing around finger to protect wound from contamination during next tour
  • Check wound and change dressing daily for ten (10) days

 

 

Discussion:

 

According to the International Association of Drilling Contractors (IADC), 34% of recordable incidents and 20% of lost time incidents are due to injuries to hands and fingers(1). By focusing on preventative measures, we may be able to reduce this statistic. Key preventative measures include using your personal protective equipment at all times and recognizing potential hazards.

When approaching wounds on fingers it is important to remember that these are very complex structures and anatomy must be taken into consideration prior to repair. After ascertaining the neuro status of the finger by 2 point discrimination, a digital block can be performed for diagnostic purposes. Medications that could be used include 1% or 2% lidocaine without epinephrine or bupivacaine. Please note that we do not use epinephrine containing solutions on fingers as this could cut off blood supply to the finger. Following the digital block the wound should be thoroughly explored in order to check the structural integrity of the underlying tendons, muscles and bones. This also provides a good opportunity to thoroughly clean the wound.

When placing Steri-Strips on fingers, remember that the strips should be placed in a barber pole fashion, not circumferential, to avoid potentially cutting off the blood supply. Tincture of benzoin should also be used to increase the adhesion of the strips as the patient will be returning to the work environment. A bulky dressing should be placed over the wound to prevent contamination. It also limits movement of the joint without having to use a hard splint. The wound should be checked daily for any redness, swelling, or drainage and all bandages should be kept clean until the Strips fall off on their own. In this case the patient was able to return to full duty once the dressing was applied.

1. IADC’s 2009 Incident Statistics Program
Photo Sources: RemoteMD

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