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Wounds and Lacerations

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

100 citationsUpdated Sep 2026

Overview

Traumatic hand and extremity injuries are unique, requiring individualized treatment to achieve optimal outcomes [1]. Complex cases are best managed at trauma centers by multidisciplinary teams experienced in complex patients [2]. Structural repair is dictated by injury severity and contamination, with delayed closure often necessary [4]. While the role of surgical debridement is characterized by early findings from experienced surgeons rather than fully controlled comparative studies [5], modern wound management paradigms for extremity war injury yield reasonable early outcomes with notably lower rates of early infection and flap failure than previously reported in civilian series [31]. A consensus 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 [42].

Specific injury patterns dictate distinct management priorities. Flexor tendon repair in zone III reports excellent or good outcomes in the majority of patients with clean cut lacerations [7], although fair or poor functional outcomes persist in complex trauma and zone 5 injuries [11]. The accuracy of visual estimates for partial flexor tendon lacerations is lower for lacerations close to the threshold for repair [8]. Microsurgical reconstruction should always be undertaken for ring avulsion injuries regardless of the class of injury to ensure excellent survival and good functional outcome [21], with outcomes superior for class I and II injuries and select class III injuries treatable with replantation [48]. Prompt management is necessary for carpometacpal dislocations producing transient motor neurapraxia of the ulnar nerve [25]. 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 [29]. Knowledge of modern repair techniques and rehabilitation protocols may improve patient outcomes for open extensor tendon injuries [30].

Several evidence gaps and risk stratification factors remain. 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]. Many nail bed injuries are preventable, and targeted prevention strategies should be considered [16]. Negative pressure wound therapy (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 [17]. A clear wound healing goal must be determined for NPWT, and if no improvement is observed between two consecutive dressing changes or after 1 week of treatment, discontinuation should be considered [19]. Further experience, as well as clinical and basic research, is required to define optimal indications and benefits of vacuum-assisted wound closure compared with traditional methods of wound management [10]. Vacuum-assisted wound closure after resection of musculoskeletal tumors is associated with shorter hospital stays, reduced numbers of surgical interventions, and greater rates of primary wound closure [131]. No data support definitive indications for limb salvage versus amputation in mangled lower extremities, and long-term studies show that patients with limb-threatening injuries sustain significant disability regardless of the treatment chosen [41]. Several host, tumour, and surgical variables are associated with wound complications after internal hemipelvectomy, and the ability to stratify patients by risk can help refine surgical and wound-healing planning [63]. The principles of managing war wounds remain the same as in previous conflicts, but the methods of treatment have evolved [12].

Anatomy & Pathophysiology

Bony Anatomy

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [47]. The hand skeleton is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [47]. The thumb ray is the shortest, consisting of a metacarpal and two phalanges, and is positioned more proximally and laterally than the other rays [43, 47]. In terms of length, the index metacarpal is the longest, while the thumb metacarpal is the shortest [47]. The proximal and middle phalanges of the middle and ring fingers are longer than those of the index finger [47].

The trapezium is angled out in front of the carpal plane, causing the first metacarpal to make an angle of about 45 degrees with the second metacarpal in the sagittal plane [47]. The transverse axis of the palm is oblique, forming an acute angle of approximately 75 degrees with the longitudinal axis [47]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, and at the distal ends of the other metacarpals [47].

Mobility varies significantly among the metacarpals. The index metacarpal is the most firmly fixed, while the fifth metacarpal has a range of flexion–extension of approximately 20 degrees [74]. The ring metacarpal has about 10 degrees of mobility in flexion and extension [74].

Soft Tissue & Vascular Anatomy

The hand contains 19 muscles situated entirely within the hand and about the same number of tendons activated by forearm muscles [43]. Extrinsic extensor muscles run through six different fibroosseous retinacular compartments at the wrist level [46]. The compartmental contents are as follows: * First extensor compartment: Contains the abductor pollicis longus and the extensor pollicis brevis [46]. * Second extensor compartment: Contains the extensor carpi radialis longus and the extensor carpi radialis brevis [46]. * Third extensor compartment: Contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle [46]. * Fourth extensor compartment: Contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [46]. * Fifth extensor compartment: Contains the extensor digiti quinti [46]. * Sixth extensor compartment: Contains the extensor carpi ulnaris [46].

The extrinsic finger flexors consist of the flexor digitorum profundus and the flexor digitorum superficialis [79]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [79]. The flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [79]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [79]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [79]. Within the flexor tendon sheath, tendon vascularity is supplied via the vincula system, specifically the vinculum longus and brevis [79].

There are seven interosseous muscles in the hand: four dorsal and three volar [72]. The dorsal interossei are abductors, while the volar interossei are adductors [72]. The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [72].

The superficial palmar fascia covers a triangular area of the central palm, with four central bands extending distally toward each finger [82]. There is no central band of the superficial palmar fascia for the thumb [82]. The dorsal skin of the hand is thin, with a horny layer only 0.02 mm thick, and possesses a normal pilosebaceous system [81]. The dorsal skin has loose connections with deeper planes, allowing free gliding and full flexion at the digital joints [81]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger from extension to full flexion [81].

The palmar skin is subdivided into functional units, with the radial portion being relatively well vascularized and mobile [71]. The ulnar and distal portion of the palmar skin has poor mobility and poor vascularity, covering the superficial palmar aponeurosis directly [71]. The web spaces are formed from the union of two nonsymmetrical cutaneous surfaces, with the dorsal slope having supple, non-adherent skin and the palmar surface being flat and densely adherent [71].

The arteries of the thumb vary in size and number, with only 15% of dissections falling into the classical anatomical category [76]. The "princeps pollicis" artery is the terminal branch of the radial artery that crosses the first intermetacarpal space [76].

Pathophysiology & Injury Mechanisms

Hand crush injuries are characterized by their devastating nature and challenges in diagnosis and treatment [9]. The presence of an open fracture wound does not exclude the extremity from the complication of compartment syndrome [14]. The Gustilo and Anderson classification system for open fractures includes: * Type I: Puncture wounds ≤1 cm [14]. * Type II: Lacerations >1 cm [14]. * Type III: Extensive soft-tissue damage [14].

Type IIIB open fractures involve extensive soft-tissue damage with stripping of the periosteum and exposure of the bone [14]. The Tscherne classification grades soft-tissue injuries as follows: * Grade C0: No clinically evident signs of injury; occurs with low-energy fractures [22]. * Grade CI: Mild to moderate soft-tissue contusion from mild- to moderate-energy fractures [22]. * Grade CII: Caused by high-energy mechanisms resulting in deep contusion; includes impending compartment syndromes [22]. * Grade CIII: Associated with severe skin and muscle injuries, such as decompensated compartment syndromes, crush injuries, and degloving [22].

In "exploded hand" syndrome, thumb ray dysfunction in sensibility and mobility remains the main functional disability despite generally good outcomes [24]. Lawn mower-related injuries to the upper extremity can result in traumatic amputations [28]. Biomechanical analysis indicates that a steer pulling on the thumb generates force and pressure several times larger than that of ring avulsion injury [88]. Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, likely due to high-energy force directed into the palm against the metacarpal base [89]. Closed degloving of the thumb is a rare condition caused by crushing and elongation forces that detach soft tissues without skin disruption [115]. The patterns of peri-articular finger injuries differ greatly between the three finger joints based on the mechanism of falling and local biomechanical forces [85].

Tendon healing occurs through two simultaneous pathways: intrinsic healing involving tenocyte proliferation and extrinsic healing involving invasion of cells from the surrounding sheath [151]. Up to 30% to 40% of flexor tendon injuries result in postsurgical adhesion formation between the tendon and surrounding tissues [151]. Chemical burns to the hand and upper extremity can cause substantial morbidity and mortality, with the hand being the most frequently involved body part [164]. 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 [17].

Classification

Open Fractures

Gustilo–Anderson: This system classifies open fractures into three types based on increasing severity, with the degree of bacterial contamination and soft-tissue damage serving as key determinants [14]. Type I involves puncture wounds ≤1 cm with minimal contamination and muscle damage [14], characterized by a laceration of less than 1 cm in length and no substantial soft-tissue or periosteal stripping [150]. Type II includes lacerations >1 cm with moderate soft-tissue injury, adequate bone coverage, and minimal comminution [14]; it represents a lower energy injury with minimal periosteal stripping [150]. Type III denotes high-energy injuries with substantial soft-tissue injury and periosteal stripping [150]. Type IIIA involves extensive soft-tissue damage with adequate bone coverage, usually resulting from high-velocity injury with a severe crushing component [14], or heavily contaminated wounds with severe comminution and segmental fractures [14]. These injuries feature substantial stripping of the periosteum but can be closed at some point during initial hospitalization, including via skin grafting [150]. Type IIIB involves extensive soft-tissue damage with stripping of the periosteum and exposure of the bone [14]; these injuries have substantial soft-tissue and periosteal stripping and cannot be closed primarily, requiring rotational or free tissue transfer for closure [150]. Type IIIC fractures have a vascular injury that requires repair to maintain the distal perfusion of the limb [150]. Segmental and highly comminuted open fractures are typically considered type III regardless of the soft-tissue wound because of the high energy necessary to cause such an injury [150].

OTA: The Orthopaedic Trauma Association (OTA) classification system includes injuries to skin and muscle, bone loss, arterial injury, and wound contamination [150]. This system is primarily used for research purposes at this time [150].

Closed Soft-Tissue Injuries

Tscherne: The Tscherne classification of soft-tissue damage serves as a foundation for defining tibial fractures and associated soft-tissue injury [22]. Grade C0 injuries occur with low-energy fractures and show no clinically evident signs of injury [22]. Grade CI injuries occur with mild- to moderate-energy fractures, producing mild to moderate soft-tissue contusion [22]. Grade CII injuries are caused by high-energy mechanisms, resulting in a deep contusion and including impending compartment syndromes [22]. Grade CIII injuries are associated with severe skin and muscle injuries, such as decompensated compartment syndromes, crush and vascular injuries, and degloving [22]. An expanded Tscherne classification uses a five-point scale to quantitate separately the severity of skin, muscle/tendon, and neurovascular injuries [22].

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 encompassing the epidermis and varying degrees of dermis [37]. These are subcategorized as superficial and deep [37]. Superficial second-degree burns often heal via re-epithelialization with local wound care over the course of 10 to 14 days [37].

Flexor Tendon Injuries

Leddy and Packer: This classification system defines subtypes of zone I avulsion injuries to help guide management [144]. Type I injuries involve retraction of the proximal stump of the FDP to the palm, with both vincula disrupted and the tendon retracted proximal to the synovial sheath [144]. This trauma has the worst prognosis of all zone I injuries [144]. Type II avulsions involve tendon retraction to the level of the proximal interphalangeal (PIP) joint, sometimes with a small fleck of bone [144]. Type III avulsions are characterized by large bony fragments that prevent the tendon from retracting past the distal edge of the A4 pulley [144]. Type IV injuries involve fracture and avulsion of the FDP tendon from the fracture fragment [144].

Ring Avulsion Injuries

Outcomes are superior for class I and II ring avulsion injuries [48]. There are select class III ring avulsion injuries that can be treated with replantation [48].

Agricultural Upper Extremity Injuries

A classification scheme for open agricultural upper extremity injuries defines Wound Type 1 as a laceration with minor soft tissue injury and a clean grade I open fracture [142]. Wound Type 2 is defined as a deep laceration with tendon, nerve, or blood vessel injury, crushing injury, or contaminated open fracture grade I or clean I open fracture [142].

Clinical Presentation

General Assessment and Triage

Patients with associated life-threatening injuries require initial evaluation and resuscitation according to Advanced Trauma Life Support protocols [14]. Injured extremities must be assessed for neurovascular injury and compartment syndrome [14]. A complete assessment of an open fracture includes reviewing the mechanism of injury, condition of the soft tissues, degree of bacterial contamination, and characteristics of the fracture [14]. Evaluation requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [32]. All wounds should be properly evaluated and explored in the emergency department [29]. Surgical irrigation and debridement should be considered for penetrating wounds [29].

For hand-specific presentations, radiographic assessment should not be systematic but related to the mechanism of injury [34]. Ultrasonography is recommended in the early investigation of patients with hypothenar hammer syndrome, as it will also demonstrate soft tissue infections and foreign bodies [58]. The basic workup for hand infections involves obtaining information regarding medical comorbidities, checking vital signs, marking erythema, identifying fluid collections, and obtaining basic laboratory values [112]. Radiographs should be obtained to rule out a foreign body, fracture or dislocation, and osteomyelitis in the workup of hand infections [112].

Healthcare providers at referring facilities must have a baseline understanding of proper initial management of severe agricultural injuries to help maximize the efficacy of definitive surgical interventions and reduce the incidence of complications [38]. Between 50% to 90% of admissions for severe agricultural injuries originate as transfers from outside facilities [38]. These injuries are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2].

Specific Injury Mechanisms and Classifications

Open fractures are classified by soft-tissue injury severity: Type I: Puncture wounds ≤1 cm, with minimal contamination and muscle damage [14]. Type II: Lacerations >1 cm, with moderate soft-tissue injury, adequate bone coverage, and minimal comminution [14]. Type IIIA: Extensive soft-tissue damage with adequate bone coverage, usually resulting from a high-velocity injury with a severe crushing component [14]. Type IIIA also includes heavily contaminated wounds with severe comminution and segmental fractures [14].

Soft-tissue injuries are further graded: Grade CI: Occur with mild- to moderate-energy fractures and produce mild to moderate soft-tissue contusion [22]. Grade CII: Caused by high-energy mechanisms, resulting in a deep contusion, and include impending compartment syndromes [22]. The Tscherne classification has been expanded into a five-point scale to quantitate separately the severity of skin, muscle/tendon, and neurovascular injuries [22].

Specific mechanisms present distinct clinical profiles. The mechanism of injury for angle grinder injuries has been clearly defined [18]. The "exploded hand syndrome" is characterized by good general outcomes, but thumb ray dysfunction in sensibility and mobility remains the main functional disability [24]. Sword assaults can cause hand injuries with devastating loss of function [27]. Service members with more severe initial injuries had worse final outcomes for combat-sustained peripheral nerve injuries [26]. Girls and women may be more likely than boys and men to sustain more severe injuries requiring hospitalization from mountain biking-related injuries [36].

Blunt trauma accounted for 65% of bladder injuries, and 0.9% of patients presenting with blunt trauma were found to have bladder injuries [50]. The majority of blunt trauma resulting in bladder injuries was a result of road traffic accidents (n = 24, 63%) [50]. Hypotensive shock following blunt soft tissue trauma to the pelvis without a fracture and with delayed clinical symptoms warrants the exclusion of vascular injuries [53]. A minor closed wrist injury can result in delayed ulnar tunnel syndrome in the absence of any identifiable compressive pathology [33]. An apparently innocuous neck laceration can be associated with an acute neurological syndrome [49].

Wound Characteristics and Complications

Simple hand lacerations represent a substantial number of ED visits in the United States [13]. Infections after acute repairs of upper-extremity lacerations were rare [52]. Patients presenting with acute fight bites within 24 hours generally have excellent outcomes regardless of treatment [51]. Patients presenting with acute fight bites with infection or delayed presentation require operative debridement [51]. Earlier recognition of injury severity and referral for dog bite injuries might avoid morbidity and resource use associated with prolonged treatment [23]. Most patients who present to a hand surgeon with a dog-leash injury in the outpatient setting will not require surgical intervention [57].

Outcomes for ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone did not vary with treatment modality in the reported series [3]. Further study is needed to determine the most effective treatment of ischemic hand complications from intra-arterial injection of sublingual buprenorphine/naloxone [3]. Accuracy of visual estimates for partial flexor tendon lacerations was lower for lacerations close to the threshold for repair [8]. The study reports excellent or good outcomes in the majority of patients with clean cut lacerations for flexor tendon repair in zone III [7]. Although outcomes have improved, fair or poor functional outcomes persist for flexor tendon repair, particularly in complex trauma and zone 5 injuries [11]. It is imperative to recognize Seymour fractures early and treat them appropriately [6].

The principles of managing war wounds remain the same as in previous conflicts; however, the methods of treatment have evolved [12]. The collection of papers on surgical wound management presents early findings from experienced surgeons rather than fully controlled comparative studies regarding the role of surgical debridement [5]. 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 [10]. In complex hand injuries, skin cover is the most pressing need [54]. Physicians should have a high index of suspicion in chronic wounds that are recalcitrant to therapy and should remember to biopsy all suspected lesions for Marjolin's ulcer [111]. Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for invasive Group A Streptococcus hand infections [116]. Invasive Group A Streptococcus hand infections are often limb- and life-threatening [116].

Investigations

Clinical Assessment and History: Clinical evaluation of the injured hand and wrist requires combining patient history with a careful physical examination to narrow the scope of possible pathologic processes [44]. A systematic method for approaching the physical examination is essential due to the number of structures in a small space [44]. Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit [44]. Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time-consuming, and often nonspecific [44].

In trauma settings, the mechanism of injury, condition of the soft tissues, degree of bacterial contamination, and characteristics of the fracture must be reviewed to classify open fractures and determine treatment [14]. Injured extremities should be assessed for neurovascular injury and compartment syndrome following initial resuscitation according to Advanced Trauma Life Support protocols [14]. A high degree of suspicion is required for closed vascular trauma in finger crush injuries, especially those associated with displaced fractures [160]. Similarly, a high degree of suspicion is warranted for vascular injuries following blunt soft tissue trauma to the pelvis with delayed clinical symptoms, even in the absence of fracture [53].

Evaluation of acute cervical soft-tissue injury requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury [32]. An apparently innocuous neck laceration may lie over an anatomical minefield requiring diagnosis of acute neurological syndrome [49]. The necessity of prompt management is emphasized for injuries such as carpometacarpal dislocation producing transient motor neurapraxia of the ulnar nerve [25]. Delayed onset of ulnar tunnel syndrome can occur following minor closed wrist injury in the absence of any identifiable compressive pathology [33]. Earlier recognition of injury severity and referral might avoid morbidity and resource use associated with prolonged treatment in dog bite injuries [23].

Imaging and Radiographic Assessment: Radiological assessment is needed for penetrating hand injuries, particularly when the history is vague [146]. Standard radiographs may initially fail to detect retained foreign bodies such as rattlesnake fangs [143]. Ultrasound examination should supplement conventional radiography, particularly when a radiolucent foreign body is suspected, as it detects foreign bodies that X-rays miss and guides precise removal [157]. Ultrasonography is recommended in the early investigation of hypothenar hammer syndrome as it will also demonstrate soft tissue infections and foreign bodies [58].

MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing in Dupuytren's disease [86]. However, MR assessment of Dupuytren's disease is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [86]. An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, but false-negatives are possible [86]. Accuracy of visual estimates of partial flexor tendon lacerations was lower for lacerations close to the threshold for repair [8].

Classification Systems: The Gustilo and Anderson classification system for open fractures includes Type I (puncture wounds ≤1 cm, minimal contamination), Type II (lacerations >1 cm, moderate soft-tissue injury), and Type III (extensive soft-tissue damage) [14]. The Tscherne classification grades soft-tissue injuries based on energy and severity: * Grade C0: Occurs with low-energy fractures and shows no clinically evident signs of injury [22]. * Grade CI: Occurs with mild- to moderate-energy fractures and produces mild to moderate soft-tissue contusion [22]. * Grade CII: Caused by high-energy mechanisms resulting in deep contusion and includes impending compartment syndromes [22]. * Grade CIII: Associated with severe skin and muscle injuries, such as decompensated compartment syndromes, crush and vascular injuries, and degloving [22].

An expanded five-point scale quantitates separately the severity of skin, muscle/tendon, and neurovascular injuries for fractures with concomitant soft-tissue damage [22].

Treatment

General Principles and Triage

Management of complex traumatic hand injuries requires individualization to achieve the best possible outcome [1]. Complex acetabular fractures are best managed at a trauma center by a multidisciplinary team familiar with complex patients and injuries [2]. While the principles of managing war wounds remain consistent with previous conflicts, treatment methods have evolved [12]. A multidisciplinary team is required at a burn center to proficiently manage hand burn patients [62]. Criteria for transfer to a burn center include burns involving the face, hands, feet, genitalia, perineum, and major joints [37]. Between 50% and 90% of admissions for severe agricultural injuries originate as transfers from outside facilities [38]. Healthcare providers at referring facilities must have a baseline understanding of proper initial management of agricultural injuries to maximize the efficacy of definitive surgical interventions and reduce complications [38]. Improved survival rates on the battlefield have necessitated the application of new technology and treatment alternatives for the care of U.S. military personnel [102]. Service members with more severe initial injuries had worse final outcomes [26]. No data support definitive indications for limb salvage versus amputation in mangled lower extremity injuries [41]. Patients with limb-threatening injuries sustain significant disability regardless of the treatment chosen [41].

Wound Debridement and Closure

Surgical debridement in the management of injury is characterized by early findings from experienced surgeons rather than fully controlled comparative studies [5]. All wounds should be properly evaluated and explored in the emergency department, and surgical irrigation and debridement should be considered for penetrating wounds [29]. 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 [136]. A detailed assessment and charting of intact structures is essential for planning further treatment in mutilating hand injuries [136]. Skin cover with flaps is preferable to grafts for complex reconstructions in mutilating hand injuries [136]. Composite free flaps may be used for complex reconstructions in mutilating hand injuries [136]. 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 [31]. The EFORT consensus document proposes 22 evidence-based recommendations to promote best practices in surgical wound closure and soft tissue management [42].

Negative Pressure Wound Therapy (NPWT)

NPWT shows 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 [17]. 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 [19]. Twelve evidence-based recommendations were developed for the use of NPWT in traumatic wounds and reconstructive surgery [60]. The strongest evidence base for NPWT is for skin grafts, and the weakest is for primary treatment of burns [60]. Clinical experience substantiates the use of VAC as a useful adjunct to traditional interventions for difficult hand wounds [121]. Well-designed large prospective randomised controlled trials are needed to assess the effectiveness of VAC for hand wounds [121]. Further experience and clinical and basic research are required to define optimal indications and benefits of vacuum-assisted wound closure compared with traditional methods [10].

Specific Injury Management

In the management of acute nail bed lacerations, Dermabond is an efficient and effective repair technique [130]. Immediate care of an amputated finger or limb consists of gentle washing with warm saline solution or clean water [38]. The amputated part should be wrapped in moist gauze and placed in a plastic bag, which is then submerged in ice water slush [38]. The amputated part must not be placed in direct contact with ice or dry ice to avoid frostbite and thermal necrosis [38]. Exposed amputation sites should be dressed with moist gauze and a gentle compressive bandage, and ice packs should be applied [38]. In cases of incomplete amputation, the affected site should be gently covered with moist gauze, injured structures gently aligned and splinted in place, and no tissue should be discarded [38]. Bleeding from amputation sites should be controlled with compression and elevation, and clamping or tying off blood vessels is not recommended [38]. Late open reduction of dorsal dislocation of the metacarpophalangeal joint may be successful even when performed three and one-half months after injury [20]. The glove-gauze regimen is a routine method of treating hand burns that includes the use of topical silver sulfadiazine, gauze therapy at night, outpatient treatment, and immediate mobilization with home therapy [61]. Superficial burns are characterized by erythema without blistering and require only analgesia and reassurance [61]. Superficial partial-thickness burns will normally spontaneously reepithelize without scarring within 3 weeks of injury [61]. Deep partial-thickness burns may reepithelize but normally require skin grafting [61]. Small full-thickness burns may be treated conservatively [61]. 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]. Superficial second-degree burns will often heal via re-epithelialization with local wound care over the course of 10 to 14 days [37]. Undisplaced (Type I) and mildly displaced (Type II) phalangeal neck fractures in children are adequately treated with splinting alone [161]. In pediatric volar plate avulsion fractures with more than 30% joint involvement, surgical interventions yielded positive results [64]. Nonoperative treatment results in good functional outcomes in the majority of athletes with muscle injuries [154]. Failed treatment of muscle injuries can postpone return to sports for weeks or months [154]. The incidence of skin tears after collagenase injection does not affect patient-reported outcomes six months later [134]. The incidence of skin tears after collagenase injection is significantly associated with the severity of pre-treatment finger extension deficits [134]. A patient treated with the Versajet II Hydrosurgery System for high-pressure injection injury achieved a good functional outcome with a DASH score of 1.67 at 1 year [135]. Thumb ray dysfunction in sensibility and mobility remained the main functional disability in cases of the exploded hand syndrome [24]. Outcomes for flexor tendon repair have improved, but fair or poor functional outcomes persist, particularly in complex trauma and zone 5 injuries [11]. The study reports excellent or good outcomes in the majority of patients with clean cut lacerations in flexor tendon repair in zone III [7]. Delayed ulnar tunnel syndrome can occur following minor closed wrist injury in the absence of any identifiable compressive pathology [33]. Prompt management is necessary for carpometacarpal dislocation producing transient motor neurapraxia of the ulnar nerve [25].

Complications

Wound complications: Application of modern wound management paradigms for extremity war injuries leads to notably lower rates of early infection and flap failure than previously reported in civilian series [31]. Several host, tumour, and surgical variables are associated with wound complications after internal hemipelvectomy [63].

Nerve palsy: Service members with more severe initial peripheral nerve injuries had worse final outcomes [26].

Stiffness / Arthrofibrosis: Thumb ray dysfunction in sensibility and mobility remained the main functional disability following exploded hand syndrome injuries [24].

Other Considerations: Fair or poor functional outcomes persist in flexor tendon repair, particularly in complex trauma and zone 5 injuries [11]. 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 [68]. In some soldiers who had recently been resuscitated from shock after major injuries, extracellular water was found to be markedly increased [70].

Recovery

Light activity (weeks): The evidence base does not specify a typical week range for resuming desk work, driving, or light activities of daily living.

Full activity (months): The evidence base does not specify a month range for returning to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence base does not specify a month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: Hand burns require early range of motion to diminish the risk of contracture and maximize function [61]. Seymour fractures require early recognition and appropriate treatment [6]. Structural repair of hand bite injuries is performed as indicated by the severity and contamination of the injury, with wounds potentially requiring delayed closure [4]. For incomplete amputations, the affected site should be gently covered with moist gauze, injured structures gently aligned and splinted in place, and no tissue discarded [38].

Functional milestones: Flexor tendon repair in zone III for clean cut lacerations reports excellent or good outcomes in the majority of patients [7]. Conversely, fair or poor functional outcomes persist after flexor tendon repair, particularly in complex trauma and zone 5 injuries [11]. A series of 79 free flaps using the ulnar artery distal cutaneous descending branch provided satisfactory reconstruction of hand wounds with 100% flap survival and acceptable aesthetic and functional results [156]. Dermal regeneration template reconstruction is a simple, reliable, and efficient tool to treat complex traumatic soft tissue defects, as demonstrated at 18 months' follow-up [153]. 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 [31].

Other Considerations: Outcomes for ischemic hand complications from intra-arterial buprenorphine/naloxone injection did not vary with treatment modality in the reported series [3]. Hand crush injuries are characterized by a devastating nature and challenges in diagnosis and treatment [9]. Simple hand lacerations represent a substantial number of emergency department visits in the United States [13]. There is a marked paucity of evidence to support specific management of extravasation injuries, with most publications comprising case reports or non-evidence-based protocols [15]. Negative pressure wound therapy shows 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 [17]. Further experience and research are required to define optimal indications and benefits of vacuum-assisted wound closure compared with traditional methods [10]. The mechanism of injury for angle grinder injuries has been clearly defined, and the associated problems are indicated [18]. Late open reduction of dorsal metacarpophalangeal joint dislocation may be successful even when performed three and one-half months after injury [20]. The principles of managing war wounds remain the same as in previous conflicts, though treatment methods have evolved [12]. Healthcare providers at referring facilities must have a baseline understanding of proper initial management of agricultural injuries to maximize the efficacy of definitive surgical interventions and reduce the incidence of complications [38]. Immediate care of an amputated finger or limb consists of gentle washing with a warm saline solution if available or clean water at a minimum [38]. An amputated part should be wrapped in moist gauze and placed in a plastic bag, which is then submerged in ice water slush [38]. 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 [38]. Bleeding from amputation sites should be controlled with compression and elevation; clamping or tying off blood vessels is not recommended in the immediate care context described [38]. No data support definitive indications for limb salvage versus amputation for mangled lower extremities [41]. Long-term studies show that patients with limb-threatening injuries sustain significant disability regardless of the treatment chosen [41]. A report describes a patient with delayed serious symptoms 4 years after injury, with stomach, bowel, and liver within the thorax [56]. Long-term outcomes for pelvic fractures are dependent on the pelvic ring injury as well as the associated injuries [59]. Long-term outcomes for pelvic fractures are complicated by posterior pelvic pain but are also largely multifactorial [59]. Burn care requires high patient compliance to prevent infection, promote early wound closure, and limit pain [61]. Deep partial-thickness burns may re-epithelize but normally require skin grafting [61]. The management of burn injuries to the hand needs to be approached carefully and thoroughly by a multidisciplinary team at a burn center [62]. Treatment for hand burns should be tailored to the individual patient [62]. Acute care and resuscitation is always of paramount importance in hand burn patients [62]. Subsequent attentive care after resuscitation leads to optimal hand functionality and cosmetic long-term outcomes [62]. Further research is warranted to assess the long-term efficacy of endoscopic Ronceray technique for Morel-Lavallée lesions compared to open procedures [149]. No published study has yet to specifically examine the effect of timing of soft-tissue coverage on outcome after the types of lower extremity injury being encountered in Iraq and Afghanistan [168].

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)
• [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. [3] (10.1177/1558944716672198)
• [L5] Structural repair is performed as indicated by the severity and contamination of the injury, and wounds may require delayed closure. [4] (10.5435/jaaos-23-01-47)
• [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. [5] (10.1016/j.injury.2007.10.033)
• [L4] It is imperative to recognize these injuries early and treat them appropriately. [6] (10.1016/j.jhsa.2013.08.104)
• [L4] The study reports excellent or good outcomes in the majority of patients with clean cut lacerations. [7] (10.1177/1753193410382378)
• [L5] Accuracy was lower for lacerations close to the threshold for repair. [8] (10.1016/j.jhsa.2015.09.009)
• [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. [9] (10.1016/j.jhsa.2017.03.028)
• [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. [10] (10.5435/00124635-200209000-00002)
• [L5] Although outcomes have improved, fair or poor functional outcomes persist, particularly in complex trauma and zone 5 injuries. [11] (10.1177/17531934231182868)
• [L5] The principles of managing war wounds remain the same as in previous conflicts; however, the methods of treatment have evolved. [12] (10.5435/00124635-200600001-00016)
• [L4] Simple hand lacerations represent a substantial number of ED visits in the United States. [13] (10.1016/j.injury.2011.05.001)
• [L5] [14] (10.5435/00124635-200305000-00008)
• [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] Many of these injuries are preventable, and targeted prevention strategies should be considered. [16] (10.1177/1753193419826465)
• [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. [17] (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. [18] (10.1016/s0020-1383(00)00025-5)
• [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. [19] (10.1016/j.otsr.2016.04.018)
• [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. [20] (10.2106/00004623-197254060-00028)
• [L4] Microsurgical reconstruction should always be undertaken regardless of the class of injury to ensure excellent survival and good functional outcome. [21] (10.1177/1753193408089052)
• [L5] [22] (10.5435/00124635-200311000-00007)
• [L4] Earlier recognition of injury severity and referral might avoid morbidity and resource use associated with prolonged treatment. [23] (10.1054/jhsb.1999.0320)
• [L4] While general outcomes were good, thumb ray dysfunction in sensibility and mobility remained the main functional disability. [24] (10.1177/1753193412468577)
• [L4] We wish to emphasize the importance of being aware of such injuries and the necessity of prompt management. [25] (10.1016/s0020-1383(96)00207-0)
• [L4] Service members with more severe initial injuries had worse final outcomes. [26] (10.1016/j.jhsa.2020.08.004)
• [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. [27] (10.1177/1753193410381576)
• [L4] [28] (10.1177/15589447241300697)
• [L5] All wounds should be properly evaluated and explored in the emergency department, and surgical irrigation and debridement should be considered for penetrating wounds. [29] (10.1016/j.jhsa.2012.02.044)
• [L4] Knowledge of modern repair techniques and rehabilitation protocols may improve patient outcomes. [30] (10.1016/j.jhsa.2014.06.136)
• [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. [31] (10.5435/00124635-200600001-00014)
• [Case_report] Evaluation requires adequate roentgenograms, careful physical examination, and a high degree of suspicion for soft-tissue injury. [32] (10.2106/00004623-197961020-00031)
• [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. [33] (10.1016/0020-1383(95)00013-y)
• [L3] Radiographic assessment for hand wounds should not be systematic but related to the mechanism of injury. [34] (10.1177/17531934231211566)
• [L4] Girls and women may be more likely than boys and men to sustain more severe injuries requiring hospitalization. [36] (10.1177/0363546510383478)
• [L5] [37] (10.1016/j.jhsa.2010.03.019)
• [L5] [38] (10.5435/jaaos-22-10-605)
• [Case_report] Both cases demonstrate similar mechanisms resulting in nearly identical wrist injuries with good short-term functional outcomes when injuries are quickly recognized and appropriately addressed at initial surgery. [40] (10.1016/j.jhsa.2010.06.005)
• [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. [42] (10.1530/eor-24-0002)
• [L4] Outcomes are superior for class I and II injuries, and there are select class III injuries that can be treated with replantation. [48] (10.1177/1558944717692094)
• [L5] This case highlights the diagnosis of an acute neurological syndrome in the casualty department and the clinical management of an apparently innocuous laceration lying over an anatomical minefield. [49] (10.1016/0020-1383(94)90079-5)
• [L4] [50] (10.1016/j.injury.2016.01.020)
• [L4] Patients presenting within 24 hours generally have excellent outcomes regardless of treatment, whereas those presenting with infection or delayed presentation require operative debridement. [51] (10.1016/j.jhsa.2013.03.002)
• [L2] Infections after acute repairs of upper-extremity lacerations were rare. [52] (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. [53] (10.1016/s0020-1383(01)00103-6)
• [L5] [54] (10.1016/s0020-1383(71)80080-3)
• [L4] This case presents an injury that may be confused with an avulsion of the profundus tendon. [55] (10.2106/00004623-197961010-00029)
• [L5] This report describes a patient with delayed serious symptoms (4 years after injury) with stomach, bowel, and liver within the thorax. [56] (10.1016/s0020-1383(70)80101-2)
• [L4] Most patients who present to a hand surgeon with a dog-leash injury in the outpatient setting will not require surgical intervention. [57] (10.1177/15589447241299128)
• [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. [58] (10.1016/s0020-1383(99)00130-8)
• [L1] Twelve evidence-based recommendations were developed for the use of NPWT in traumatic wounds and reconstructive surgery, with the strongest evidence base for skin grafts and the weakest for primary treatment of burns. [60] (10.1016/s0020-1383(11)00041-6)
• [L4] [61] (10.1177/1753193420910054)
• [L5] [62] (10.1016/j.hcl.2016.12.001)
• [L3] Several host, tumour, and surgical variables are associated with wound complications, and the ability to stratify patients by risk can help refine surgical and wound-healing planning. [63] (10.1302/0301-620x.102b3.bjj-2019-1329)
• [L4] In fractures with more than 30% joint involvement, surgical interventions yielded positive results. [64] (10.1177/15589447241231308)
• [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. [68] (10.1177/1558944719829905)
• [Paper] In some soldiers who had recently been resuscitated from shock after major injuries the extracellular water was found to be markedly increased. [70] (10.1016/s0020-1383(71)80137-7)
• [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. [85] (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. [88] (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. [89] (10.1177/1753193415620186)
• [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. [102] (10.1016/j.jhsa.2007.07.007)
• [Case_report] Physicians should have a high index of suspicion in chronic wounds that are recalcitrant to therapy and should remember to biopsy all suspected lesions. [111] (10.1007/s11552-006-9007-1)
• [L5] [112] (10.1016/j.jhsa.2018.05.027)
• [L4] Closed degloving of the thumb is a rare condition caused by crushing and elongation forces that detaches soft tissues without skin disruption. [115] (10.1016/j.jhsa.2007.06.016)
• [L4] Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for these often limb- and life-threatening infections. [116] (10.1177/17531934241268983)
• [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. [121] (10.1177/175899830200700102)
• [L1] In the management of acute nail bed lacerations, Dermabond is an efficient and effective repair technique. [130] (10.1016/j.jhsa.2007.10.008)
• [L3] The technique is associated with shorter hospital stays, reduced numbers of surgical interventions, and greater rates of primary wound closure. [131] (10.1097/01.blo.0000180450.21350.3e)
• [L2] The incidence of skin tears after collagenase injection does not affect patient-reported outcomes six months later, but the incidence of skin tears is significantly associated with the severity of pre-treatment finger extension deficits. [134] (10.1177/1753193420941329)
• [L4] The patient achieved a good functional outcome with a DASH score of 1.67 at 1 year, suggesting this technique may address challenges in treating high-pressure injection injuries. [135] (10.1016/j.jhsg.2025.100814)
• [L5] [136] (10.1016/j.hcl.2016.07.008)
• [L2] [142] (10.1016/j.jhsa.2007.09.003)
• [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. [143] (10.1016/j.jhsa.2021.04.004)
• [L5] [144] (10.5435/jaaos-d-16-00316)
• [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. [146] (10.1054/jhsb.1999.0357)
• [L5] Further research is warranted to assess its long-term efficacy compared to open procedures. [149] (10.1016/j.eats.2025.103677)
• [L5] [151] (10.1016/j.jhsa.2017.06.013)
• [Paper] Eighteen months' follow-up demonstrated that DRT reconstruction is a simple, reliable, efficient tool to treat complex traumatic soft tissue defects. [153] (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. [154] (10.1177/0363546505274714)
• [L4] The series of 79 free flaps provided satisfactory reconstruction of hand wounds with 100% flap survival and acceptable aesthetic and functional results. [156] (10.1016/j.injury.2009.04.009)
• [L4] Ultrasound examination should supplement conventional radiography, particularly when a radiolucent foreign body is suspected, as it detects foreign bodies that X-rays miss and guides precise removal. [157] (10.1007/s004020000173)
• [L4] A high degree of suspicion is required for closed vascular trauma in finger crush injuries, especially those associated with displaced fractures. [160] (10.1054/jhsb.2001.0727)
• [L5] Undisplaced (Type I) and mildly displaced (Type II) fractures are adequately treated with splinting alone. [161] (10.1016/j.injury.2003.09.043)
• [L5] [164] (10.1016/j.jhsa.2014.07.056)
• [L5] No published study has yet to specifically examine the effect of timing of soft-tissue coverage on outcome after the types of lower extremity injury being encountered in Iraq and Afghanistan. [168] (10.5435/00124635-200600001-00013)

See Also

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

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[131] Vacuum-assisted Wound Closure after Resection of Musculoskeletal Tumors. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000180450.21350.3e

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[135] High-Pressure Injection Injury Debridement With the Versajet II Hydrosurgery System: Case Study and Literature Review. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100814

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[143] Septic Arthritis of the Proximal Interphalangeal Joint After Rattlesnake Bite. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.04.004

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[160] Digital Artery Damage Associated with Closed Crush Injuries. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2001.0727

[161] A unique fracture pattern of the proximal phalanx in children: fractures through the phalangeal neck with an attached dorsal bony flange. Injury. 2004. DOI: 10.1016/j.injury.2003.09.043

[164] Hand Chemical Burns. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.07.056

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