Latest Recommendations From
Queen Victoria Hospital East
Grinstead
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Finger Avulsion injuries
Tendon injuries of the hand
Flexor sheath infections of the hand
Finger and finger tip amputations
Pulp lacerations
Nail bed lacerations
Subungal Haematoma
Burns less than10%
Paronychia
Injection injuries
Pretibial lacerations
Referrals must include accurate note taking. A picture of the wound via
telemedicine. A telephone referral with the trauma coordinator or the burns unit.
Olive Davies (ENP) September 2010
1.Finger avulsion injuries
Circumferential laceration on the digit, which de-gloves the skin distally, may
initially cause a skin wound and ultimately lead to complete division of
arteries, veins and nerves or even complete avulsion amputation. These
wounds must be taken seriously and referred.
2. Tendon Injuries of the hand
It is important to remember that movement may be preserved where there is
a significant partial division of the tendon. If there is an suspicion these
wounds need to be explored, a secondary repair later can be difficult or
impossible. Refer
3.Flexor sheath infection of the finger
Patient usually presents with a finger which is generally swollen, often red and
which they are reluctant to move. Please refer.
4. Finger tip amputations
Firstly the amputated part should be kept and stored appropriately
Appropriate storage of amputated parts, including finger tips and entire fingers
includes cleaning the part with normal saline, wrapping it in a saline moistened
gauze, placing the gauze within a sealed plastic bag, immersing the bag in a
bucket/kidney dish with ice-slush. Over cooling can produce freezing injury,
therefore direct contact with ice or co2 are contra-indicated.
The digit involved must be x-rayed along with the amputated part.
The wound should be lightly dressed with jelonet and moistened gauze and if
appropriate splinted. The hand should be elevated and appropriate antibiotics,
analgesia and tetanus cover provided.
5.Pulp laceration
Olive Davies (ENP) September 2010
Simple lacerations should be sutured with 6 or 5/0 nylon in A&E. Soft tissue
loss of more than 1cm of maximum diameter will often require skin grafting.
Refer and discuss. If the loss is less than 1cm then conservative Rx will often be
appropriate but these patients should be followed up in a hand clinic.
7. Nail bed injuries
Nail bed injuries can lead to aberrant and troublesome nail deformity. For
sharp lacerations involving the nail plate and nail bed, where the former is
minimally displaced, it may be appropriate to manage the nail bed laceration
by suturing the nail plate itself. Refer.
8. Subungual haematoma
A subungal haematoma of less than 25% of the nail bed area and with no
associated fracture, trephine is recommended and discharge.
For subungal haematomas greater than 25%, or those associated with a
fracture, the nail plate must be removed because there is almost always a
significant nail bed laceration that should be repaired.
9.Burns
Burns less than 5% can usually be dealt with in A&E or community.
De-roof large blisters to assess correctly the burn depth and to avoid painful
tense blisters which can become secondarily infected.
Simple dressings with paraffin gauze and generous amounts of gauze and a
crepe bandage is recommended.
Burns between 5-10%
Analgesia and wound cleansing and de-roofing blisters should occur for these
burns and a temporary dressing with cling film should be used.
In certain cases review by the burns centre may not be on the same day, in
such cases apply a simple paraffin gauze dressing as for burns less than 5 %.
Also Refer
 Any burn in a child under 5 or an adult over 60
Olive Davies (ENP) September 2010
 Any burn with partial or full thickness loss to the face, perineum, hands
or feet.
 Any circumferential dermal or full thickness burn
 Any significant inhalation injury with a burn
 Any burn over 5%
 Any burn with a suspicion of NAI or DSH
 Any burn in a patient with significant co-morbidities
 Any burn taking more than 2 weeks to heal
 Any infected burn.
10 Pre-tibial lacerations
Stretching of the skin is no longer advised.
Gently laying the skin down so the edges meet then steri-stripping is advised.
If the edges do not meet then simply applying mepitel or paraffin gauze to the
edges and arrange practise nurse follow up.
If the gap between the edges is more than 1 cm wide, then apply mepitel and
refer to QVH. These patients get followed up by a nurse from the QVH in the
community.
11. Paronychia
Most can be treated in A&E but follow up is important either A&E or GP.If
there is a subcutaneous abscess to the pulp then please refer
12. Injection injuries
Injection injuries can be caused by injection of a substance by equipment
capable of achieving pressures sufficient to breach human skin i.e grease guns,
spray guns, diesel fuel injectors, cement injectors to name but a few. The less
the viscosity the more it will spread. (paint thinner spreads further than paint)
These are serious and may initially appear trivial. There is usually significant
hidden damage with wide penetration. Most commonly seen in the hand.
Following assessment x-ray and refer.
Olive Davies (ENP) September 2010