The formal ER assessment then continues with a survey of the history of present illness, past medical history, and review of systems. The evaluating physician should first identify the patient’s age, handedness, and occupation. The history of present illness should focus on the circumstances surrounding the incident, including time of injury of onset of symptoms, nature of the injury, as well as the patient’s functional and pain complaints. If the injury was caused by a piece of machinery, the specifications of the machine (such as revolutions per minute or pounds of torque produced) may help further define the injury. Injuries occurring while on the job should be so noted in the medical record. In addition to such pertinent factors as major illness, medications, last tetanus immunization, previous fractures, or surgery of the injured limb, smoking history should also be queried. If surgery is anticipated, the time of the patient’s last oral intake should be determined. (See Chapter 3, History, for a further discussion of the evaluation of hand injuries.)

Next, in order to examine the hand, any initially applied splint or dressing is removed. In some extenuating circumstances, the surgeon may not examine the extremity until the patient has been transferred to the operating room. A systematic examination of the hand and arm is performed, focusing on the condition of the integument, neurologic condition (sensory and motor function), individual tendon function, vascular status, edema, gross alignment of the extremity, and skeletal integrity. Ecchymosis, deformity, or length of lacerations or skin defects should be noted in the medical record. Performing an Allen’s test can assess differential patency of the radial and ulnar arteries. A focused neurologic examination should be accomplished, assessing the motor function of the ulnar, median, and radial nerves independently. Any penetrating wound overlying the radial or ulnar artery should be suspected of involving that artery. Recent data advises to the contrary, it is better to rely on an exam. In most situations it is preferable to refrain from delivering systemic pain medications or local anesthesia until a full examination is completed. The injured extremity is always inspected with comparison made to the contralateral side. Any energy imparted to the hand and wrist region, whether resulting in a laceration or contusion, can cause a fracture or dislocation. Based on the patient’s initial survey (and once the patient is stabilized), blunt or penetrating injuries must have orthogonal, 90-degree biplanar x-rays of the appropriate body part (Table 1). If appropriate, it is preferable to obtain biplanar x-rays out of any splints applied in the field. It is also preferable that the biplanar x-rays are obtained by moving the radiographic beam and not the extremity. The consulting surgeon should be contacted if questions arise regarding appropriateness of splint removal or positioning.