Evaluating Hand Injuries in the ED

Authors: Anthony Rodriguez, MD (EM Resident Physician, Denver Health); Spencer Tomberg, MD (EM Attending Physician, Denver Health); and Matthew Folchert, MD (Orthopedic-Hand Attending Surgeon, Denver Health) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Manny Singh, MD (@MPrizzleER); Brit Long, MD (@long_brit)


A 35-year-old right hand dominant male presents to your ED with a deep laceration to his left pinky finger that occurred while working as a chef. He reports he has numbness to the palmer aspect of his left pinky finger, and as part of your musculoskeletal exam you evaluate for neurovascular and tendon injury. Prior to performing a digital nerve block to repair the laceration, you should evaluate the following



  • Check capillary refill (should be less than 2-3 seconds)
  • Attach a pulse oximeter to the injured digit
    • Should be ≥ 90% with a good plethysmogram
  • Use a doppler to evaluate the radial & ulnar digital arteries
    • If you obtain a signal on the pulp, then the digit is being perfused
    • Make sure to check DISTAL to the laceration


Flexor Tendons

  • Flexor Digitorum Profundus (FDP)
    • Mechanism: flexes the distal interphalangeal joint (DIP)
    • Evaluation: hold the proximal interphalangeal joint (PIP) in extension while the patient attempts to flex the DIP joint
  • Flexor Digitorum Superficialis (FDS)
    • Mechanism: flexes the proximal interphalangeal joints (PIP)
    • Evaluation: hold adjacent fingers in extension while the patient attempts to flex injured finger at the PIP joint


Extensor Tendons

  • Mechanism: extends/straightens the DIP and PIP joint
  • Evaluation: ask patient to straighten the digit out.
  • These tendons have lateral bands and a central slip near the PIP joint
    • Central Slip Evaluation:
  • Have patient bend at the PIP and provide resistant distal to the PIP joint
  • Ask patient to hold extension at the digit
  • Normal result: DIP joint should remain loose
    • This is known as the “Elson Test”
  • Abnormal result: DIP joint would become rigid
    • This is due to the force being transferred to the lateral bands down into the DIP joint, instead of through the central slip



  • If available, can use two-point discriminator tool
    • Normal sensation should be detected between 4-6 mm
  • Otherwise, use a bent paper clip and measure 4-6 mm between points
  • Start by assessing a non-injured digit or opposite hand to have a control result
  • Always ask patients to close their eyes
  • Begin with widest measurement and move towards shorter measurement
  • Provide support to the digit being tested
  • Make sure to test IN-LINE (or vertical) to evaluate a single nerve’s dermatome
    • Testing across (or horizontal) the digit can pick up-cross innervation from the adjacent digital nerve

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