Wound Care: Understanding the injured hand: management of the first 48 hours
Understanding the injured hand:
management of the first 48 hours
Smart H, RN, MA(Nur), PG Dip(UK), IIWCC(Toronto)
Correspondence to: Hiske Smart, [email protected]
Wound Healing Southern Africa 2010;3(2):25-26
Introduction
Step-by-step application
Correct positioning of the injured hand in the first 48 hours after injury
The optimal-stretch hand stabilisation technique can enable the
is critical to ensure that optimal mobility of the hand is preserved.1
clinician to preserve optimal function of the injured hand as an
With the cooling-off regimen indicated in burns, dressings must
interim measure (Figure 3), until a more permanent device can be
be in contact with the burnt skin, with added dressings to keep
fitted to maintain anatomical position of the hand for a prolonged
those in place,2 limiting hand mobility for that period. The extensor
period of time.
collateral ligaments are the weakest at preserving mobility, and
Step 1
shortening of the collateral ligaments of the metacarpophalangial
In the case of a burnt hand, apply the standard cooling-off treatment
joints (MCP joints), proximal interphalangial joints (PIP joints) and
regimen. Ensure that every finger, apart from the thumb, is covered
distal interphalangial joints (DIP joints) occurs very quickly with
individually. Seat the patient on a chair and ask him or her to place
incorrect positioning of the hand.2 Collateral ligament shortening is
his or her elbow on the dressing table with the hand in the air. The
an irreversible condition, leading to major loss of hand function and
aim is to get the fingers in the right position by tilting the wrist
adding to the development of contractures on either side of the hand,
slightly, with the palmar part of the hand facing upwards. The fingers
depending on which ligaments are damaged.3 The ideal position for
will then curl back towards the hand automatically. The ultimate
the MCP joints is at a 90° angle, if the flat hand is taken as the 0°
bandage position will be different from this, but this position gives
starting point (Figure 1 and 2).4 For the PIP and DIP joints, 10-15°
the best stability as a starting point.
flexion is needed for optimal protection and preservation of hand
functionality.4
Figure 1: Correct positioning of the injured hand4
Figure 2: Incorrect positioning of the injured hand4
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2010 Volume 3 No 2
Wound Care: Understanding the injured hand: management of the first 48 hours
Step 2
Theory in practice
Then, lower the hand onto the dressing table, with the wrist facing
This technique was first taught in South Africa in the early 1970s
upwards and the hand slightly to the anterior side of the arm, with
by an orthopaedic surgeon from the University of Edinburgh,
the fingers curled back towards the wrist. Following application of
Dr JIP James (Ziervogel FJ 2009, personal communication). It
the burns dressing, cover the hand with half a roll of orthopaedic
is, therefore, still fondly referred to by some as the “JIP James
cotton wool, from halfway up the arm towards the tips of the fingers.
bandage”.
Step 3
The hand is now in anatomical position, with the extensor collateral
Place the remaining half of the roll of orthopaedic wool in the palm
ligaments in optimal-stretch position: 70-90° at the MCP joint, 1015° at the PIP joints, and 10-15° at the DIP joints.4 The patient will
of the patient’s hand, and ask him or her to grip it gently. With the
wrist bent slightly back, the position will look like a claw. The MCP
be able to move his or her fingertips easily, and the hand is stable,
joints are now folded over the roll of orthopaedic wool, almost in a
but not immobilized, with the added benefit of pain control. Repeat
90° position, which is optimal-stretch position.
the procedure in 24 hours, if needed.
4
Step 4
Conclusion
Apply a 100 mm crepe bandage from halfway up the arm, up to the
This bandage technique may be used as protective measure for
wrist, in a spiral formation. Once at the wrist, stretch the bandage
hand function, until a full decision is reached on the treatment plan
to over the dorsal part of the fingers, leaving the fingertips slightly
and surgery that may be required. It may be combined with plaster
open. Then, bring it back over the palm of the hand diagonally toward
of Paris volar splints, but the basic hand position must remain the
the wrist, take it around the wrist again, and repeat to form a figure-
same.
of-eight on the palmar side of the hand, forcing the fingertips to lie
comfortably over the roll of cotton wool that is now enclosed within
References
the bandage, and providing slight flexion of 10-15° for the PIP and
1. Newmeyer WL, Kilgore ES Jr. Management of the burnt hand. Phys Ther 1977;57(1):16-23.
DIP joints.
2. Laskowski-Jones L. First aid for burns. Nursing 2006;36(1):41-43.
4
3. Sprague BL. Proximal interphalangial joint injuries and their initial treatment. J Trauma
1975;15(5):380-385.
Step 5
4. Rondinelli, RD, Genovese, E, Katz T, et al. Guides to the evaluation of permanent impairment. 6th ed.
American Medical Association; 2008.
Fixate the bandage on the wrist side. The thumb must not be included
in the bandage and, should the thumb have an injury, it must be
dressed separately. If the fingertips are injured, these should also
be dressed, and the edges of the bandage should be pulled gently
together to cover the fingertips. Fix the bandage edges together with
tape strips.
Step 1
Step 2
Step 3
Step 4
Figure 3: Anatomical position of the hand with the optimal-stretch hand stabilisation technique1, 3,4
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Step 5