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Introduction

Lacerations to the hand are very common injuries which account for 10-20% of emergency room visits.1  Lacerations can be superficial or deep.  Superficial lacerations cut the epidermis and dermis if they are full thickness lacerations.  Deep lacerations cut into the subcutaneous tissues.  Whether a broken piece of glass or a knife passed through the subcutaneous tissue to damage underlying structures at risk can be difficult to assess.  This can be particularly difficult with an uncooperative patient or a terrified child with a bleeding hand.

Despite the emergent nature of the injury, a careful examination is necessary in order to evaluate the underlying structures.  One-half of the lacerations that occur in the hand and wrist and enter the subcutaneous tissues cause damage to the underlying structures.2,3  When a laceration enters the subcutaneous tissue, then the deeper structures at risk can be damaged.  As a knife, for example, passes through the subcutaneous tissues, the Structures At Risk include:

  1. Cutaneous nerves like the dorsal radial sensory nerve
  2. Extensor and flexor tendons
  3. Major nerves like the median nerve, ulnar nerve, common digital nerve and digital nerve
  4. Bone – a circular saw can easily lacerate the skin; subcutaneous tissues; extensor tendons and fracture the underlying bone
  5. Joint – depending on the exact location of the laceration, the knife may cut the joint capsule, injure joint cartilage or ligaments and contaminate the joint space
  6. Arteries and veins – depending on location of injury, the radial artery, the ulnar artery or a major vein like the cephalic vein can be transected during a wrist laceration.2,3

Untidy wounds that have a crush or skin avulsion component are even more likely to be associated with damage to the deeper structures.

Related Anatomy

  • Skin
  • Subcutaneous tissue
  • Other related anatomic structures will depend on the depth of the wound.  Theoretically, any digit, hand, wrist or forearm structure can be at risk for injury secondary to a deep laceration.

Incidence and Related Conditions

Incidence:  The incidence of hand, wrist and forearm injuries presenting to the emergency room is substantial.  Nascab and his authors’ review found rates of hand injuries between 6.6% and 21% of injuries presenting to the emergency department occurred in the hand.2 Glass and knife injuries account for the majority of the hand lacerations.3  Sixty percent of these lacerations had at least one deeper structure cut and 15% of the lacerations had combined injuries involving arteries, nerves and/or tendons.

Related injuries include amputations, partial amputations, crush injuries, avulsion injuries and burns.

Differential Diagnosis

None

ICD-10 Codes
  • LACERATION (OPEN WOUND)

    Diagnostic Guide Name

    LACERATION (OPEN WOUND)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    LACERATION, FINGER/THUMB (OPEN WOUND) WITHOUT FOREIGN BODY    
    - WITH DAMAGE TO NAIL    
     - INDEX S61.311_S61.310_ 
     - MIDDLE S61.313_S61.312_ 
     - RING S61.315_S61.314_ 
     - LITTLE S61.317_S61.316_ 
     - THUMB S61.112_S61.111_ 
    - WITHOUT DAMAGE TO NAIL    
     - INDEX S61.211_S61.210_ 
     - MIDDLE S61.213_S61.212_ 
     - RING S61.215_S61.214_ 
     - LITTLE S61.217_S61.216_ 
     - THUMB S61.012_S61.011_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S61 AND S63
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Hand Surgery Resource's SAR (Structures at Risk) Tool Dorsum of Digit & Hand
  • Dorsal laceration over base of fingernail and distal phalanx. Structures at Risk: 1. Fingernail and germinal matrix; 2. Skin; 3.Bone. (Click on structure to see exam)
    Dorsal laceration over base of fingernail and distal phalanx. Structures at Risk: 1. Fingernail and germinal matrix; 2. Skin; 3.Bone. (Click on structure to see exam)
  • Dorsal laceration over DIP joint. Structures at Risk: 1. Skin; 2. Extensor Tendon; 3.DIP Joint; 4. Bone. (Click on structure to see exam)
    Dorsal laceration over DIP joint. Structures at Risk: 1. Skin; 2. Extensor Tendon; 3.DIP Joint; 4. Bone. (Click on structure to see exam)
  • Dorsal laceration over mid-section of the middle phalanx. Structures at Risk: 1. <a href="/taxonomy/term/450">Skin</a>; 2.Dorsal Veins;  3. <a href="/taxonomy/term/275">Extensor Tendon</a>;  4. <a href="/taxonomy/term/238">Bone Middle Phalanx</a>  (Click on structure to see exam)
    Dorsal laceration over mid-section of the middle phalanx. Structures at Risk: 1. Skin; 2.Dorsal Veins; 3. Extensor Tendon; 4. Bone Middle Phalanx (Click on structure to see exam)
  • Dorsal laceration over PIP joint. Structures at Risk: 1. Skin; 2. Extensor Tendon-Central Slip; 3.Extensor Tendon-Lateral Bands; 4. PIP Joint; 5. Bone. (Click on structure to see exam)
    Dorsal laceration over PIP joint. Structures at Risk: 1. Skin; 2. Extensor Tendon-Central Slip; 3.Extensor Tendon-Lateral Bands; 4. PIP Joint; 5. Bone. (Click on structure to see exam)
  • Dorsal laceration over mid-section of proximal phalanx . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3.Extensor Tendon-Lateral Bands; 4. Bone. (Click on structure to see exam)
    Dorsal laceration over mid-section of proximal phalanx . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3.Extensor Tendon-Lateral Bands; 4. Bone. (Click on structure to see exam)
  • Dorsal laceration over MP joint . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3.Extensor Tendon-Sagittal Bands; 4. Bone; 5.MP Joint; 6. Dorsal Veins; 7.Juncturae Tendinum. (Click on structure to see exam)
    Dorsal laceration over MP joint . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3.Extensor Tendon-Sagittal Bands; 4. Bone; 5.MP Joint; 6. Dorsal Veins; 7.Juncturae Tendinum. (Click on structure to see exam)
  • Dorsal laceration over little MP joint . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3. Extensor Tendon-Sagittal Bands; 4.Extensor Tendon- EDM; 5. Bone; 6. MP Joint; 7. Dorsal Veins; 8.Juncturae Tendinum. (Click on structure to see exam)
    Dorsal laceration over little MP joint . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3. Extensor Tendon-Sagittal Bands; 4.Extensor Tendon- EDM; 5. Bone; 6. MP Joint; 7. Dorsal Veins; 8.Juncturae Tendinum. (Click on structure to see exam)
  • Dorsal laceration over index MP joint . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3. Extensor Tendon-Sagittal Bands; 4. Extensor Tendon- EIP; 5. Bone; 6. MP Joint; 7. Dorsal Veins. (Click on structure to see exam)
    Dorsal laceration over index MP joint . Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3. Extensor Tendon-Sagittal Bands; 4. Extensor Tendon- EIP; 5. Bone; 6. MP Joint; 7. Dorsal Veins. (Click on structure to see exam)
  • Dorsal laceration over right hand. Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3. Extensor Tendon- EDM; 4. Extensor Tendon- EIP; 5. Bone; 6. Dorsal Veins; 7. Dorsal Radial Sensory Nerve; 8. Dorsal Ulnar Sensory Nerve.  (Click on structure to see exam)
    Dorsal laceration over right hand. Structures at Risk: 1. Skin; 2. Extensor Tendon-EDC; 3. Extensor Tendon- EDM; 4. Extensor Tendon- EIP; 5. Bone; 6. Dorsal Veins; 7. Dorsal Radial Sensory Nerve; 8. Dorsal Ulnar Sensory Nerve. (Click on structure to see exam)
Hand Surgery Resource's SAR (Structures at Risk) Tool Dorsal & Radial Right Wrist and Distal Dorsal Forearm
  • Dorsal laceration over right wrist. Structures at Risk: 1. Skin; 2. Extensor Tendons -EDU,ECM,EDC,EIP,EPL,ECRL&B, EPB&AbPL; 3. Wrist Joint; 4. Carpal Bones; 5. Dorsal Veins; 6. Dorsal Radial Sensory Nerve; 7. Dorsal Ulnar Sensory Nerve; 8. Radial Artery.  (Click on structure to see exam)
    Dorsal laceration over right wrist. Structures at Risk: 1. Skin; 2. Extensor Tendons -EDU,ECM,EDC,EIP,EPL,ECRL&B, EPB&AbPL; 3. Wrist Joint; 4. Carpal Bones; 5. Dorsal Veins; 6. Dorsal Radial Sensory Nerve; 7. Dorsal Ulnar Sensory Nerve; 8. Radial Artery. (Click on structure to see exam)
  • Dorsal laceration over radial right wrist. Structures at Risk: 1. Skin; 2. Extensor Tendons - EPL,ECRL, EPB&AbPL; 3. Flexor Tendons - FCR;  4. Wrist Joint; 5. Carpal Bones; 6. Dorsal Veins; 7. Dorsal Radial Sensory Nerve; 8. Dorsal Branch of Radial Artery.  (Click on structure to see exam)
    Dorsal laceration over radial right wrist. Structures at Risk: 1. Skin; 2. Extensor Tendons - EPL,ECRL, EPB&AbPL; 3. Flexor Tendons - FCR; 4. Wrist Joint; 5. Carpal Bones; 6. Dorsal Veins; 7. Dorsal Radial Sensory Nerve; 8. Dorsal Branch of Radial Artery. (Click on structure to see exam)
  • Dorsal laceration over distal right forearm. Structures at Risk: 1. Skin; 2. Extensor Tendons -EDU,ECM,EDC,EIP,EPL,ECRL&B, EPB&AbPL; 3. Wrist Joint; 4. Radius&Ulna Bones; 5. Dorsal Veins; 6. Dorsal Radial Sensory Nerve; 7. Dorsal Ulnar Sensory Nerve.  (Click on structure to see exam)
    Dorsal laceration over distal right forearm. Structures at Risk: 1. Skin; 2. Extensor Tendons -EDU,ECM,EDC,EIP,EPL,ECRL&B, EPB&AbPL; 3. Wrist Joint; 4. Radius&Ulna Bones; 5. Dorsal Veins; 6. Dorsal Radial Sensory Nerve; 7. Dorsal Ulnar Sensory Nerve. (Click on structure to see exam)
Hand Surgery Resource's SAR (Structures at Risk) Tool Dorsum of Thumb
  • Dorsal laceration over right Thumb IP Joint. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL; 3. Thumb IP Joint.  (Click on structure to see exam).
    Dorsal laceration over right Thumb IP Joint. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL; 3. Thumb IP Joint. (Click on structure to see exam).
  • Dorsal laceration over right Thumb Proximal Phalanx. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL; 3. Bone Proximal Phalanx.  (Click on structure to see exam).
    Dorsal laceration over right Thumb Proximal Phalanx. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL; 3. Bone Proximal Phalanx. (Click on structure to see exam).
  • Dorsal laceration over right Thumb MP Joint. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL,EPB, Extensor Hood; 3. Thumb MP Joint; 4. Dorsal Radial Sensory Nerve Branch.  (Click on structure to see exam).
    Dorsal laceration over right Thumb MP Joint. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL,EPB, Extensor Hood; 3. Thumb MP Joint; 4. Dorsal Radial Sensory Nerve Branch. (Click on structure to see exam).
  • Dorsal laceration over right Thumb Metacarpal. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL&EPB; 3. Thumb Metacarpal Bone; 4. Dorsal Radial Sensory Nerve Branch; 5. Muscles - Thenar muscles, Adductor Polllicis, Adductor Pollicis & First Dorsal Interosseous; 6. Deep dorsal branch of Radial Artery.  (Click on structure to see exam).
    Dorsal laceration over right Thumb Metacarpal. Structures at Risk: 1. Skin; 2. Extensor Tendons -EPL&EPB; 3. Thumb Metacarpal Bone; 4. Dorsal Radial Sensory Nerve Branch; 5. Muscles - Thenar muscles, Adductor Polllicis, Adductor Pollicis & First Dorsal Interosseous; 6. Deep dorsal branch of Radial Artery. (Click on structure to see exam).
Hand Surgery Resource's ASAR (Anatomic Structures at Risk) Tool Palmar Finger, Hand, Thumb and Wrist
  • Palmar laceration over neck of the index middle phalanx. Structures at Risk: 1. Skin; 2.Tendon - FDP; 3. Digital Nerves; 4. Digital Arteries; 5. Bone; 6. Possibly DIP Joint. Note green stars at dorsal end of flexion creases.  The neurovascular bundle is immediately volar to these stars. (Click on structure to see exam)
    Palmar laceration over neck of the index middle phalanx. Structures at Risk: 1. Skin; 2.Tendon - FDP; 3. Digital Nerves; 4. Digital Arteries; 5. Bone; 6. Possibly DIP Joint. Note green stars at dorsal end of flexion creases. The neurovascular bundle is immediately volar to these stars. (Click on structure to see exam)
  • Palmar laceration over mid-third of the index proximal phalanx. Structures at Risk: 1. Skin; 2.Tendons - FDP&FDFS; 3. Digital Nerves; 4. Digital Arteries; 5. Bone; 6. Possibly PIP Joint; 7. Distal edge of A-2 Pulley. Note green stars at dorsal end of flexion creases.  The neurovascular bundle is immediately volar to these stars. (Click on structure to see exam)
    Palmar laceration over mid-third of the index proximal phalanx. Structures at Risk: 1. Skin; 2.Tendons - FDP&FDFS; 3. Digital Nerves; 4. Digital Arteries; 5. Bone; 6. Possibly PIP Joint; 7. Distal edge of A-2 Pulley. Note green stars at dorsal end of flexion creases. The neurovascular bundle is immediately volar to these stars. (Click on structure to see exam)
  • Palmar laceration the MP joints of the index & long. Structures at Risk: 1. Skin; 2.Tendons - FDP II&III and FDS II & III; 3. Digital Nerve Radial Index and Common Digital Nerves II-III web & III-IV; 4. Digital and Common Digital Arteries; 5. Bone - Metacarpal II & III; 6. Possibly MP Joints.   Note green stars at dorsal end of flexion creases.  The neurovascular bundle is immediately volar to these stars. (Click on structure to see exam)
    Palmar laceration the MP joints of the index & long. Anatomic structures at Risk: 1. Skin; 2.Tendons - FDP II&III and FDS II & III; 3. Digital Nerve Radial Index and Common Digital Nerves II-III web & III-IV; 4. Digital and Common Digital Arteries; 5. Bone - Metacarpal II & III; 6. Possibly MP Joints. Note green stars at dorsal end of flexion creases. The neurovascular bundle is immediately volar to these stars. (Click on structure to see exam)
  • Palmar laceration through Guyon's Canal, distal Carpal Tunnel & base of Thenar Muscles. Structures at Risk: 1. Skin; 2.Tendons - all FDP and all FDS; 3. Nerves - Ulnar, Median or its branches; 4. Ulnar Artery, Superficial Arch & Deep Arch; 5. Bone - Metacarpal Bases or Carpal Bones.; 6. Possibly CMC Joints.   Green Kaplan's line cross yellow at median motor branch.  (Click on structure to see exam)
    Palmar laceration through Guyon's Canal, distal Carpal Tunnel & base of Thenar Muscles. Structures at Risk: 1. Skin; 2.Tendons - all FDP and all FDS; 3. Nerves - Ulnar, Median or its branches; 4. Ulnar Artery, Superficial Arch & Deep Arch; 5. Bone - Metacarpal Bases or Carpal Bones.; 6. Possibly CMC Joints. Green Kaplan's line cross yellow at median motor branch. (Click on structure to see exam)
  • Palmar laceration through volar wrist. Structures at Risk: 1. Skin; 2.Tendons - all FDP & FDS, FCR,FCU,PL; 3. Nerves - Ulnar & Median; 4. Ulnar & Radial Arteries; 5. Bone - Carpal Bones; 6. Carpal Joints.  (Click on structure to see exam)
    Palmar laceration through volar wrist. Structures at Risk: 1. Skin; 2.Tendons - all FDP & FDS, FCR,FCU,PL; 3. Nerves - Ulnar & Median; 4. Ulnar & Radial Arteries; 5. Bone - Carpal Bones; 6. Carpal Joints. (Click on structure to see exam)
  • Palmar laceration over thumb proximal phalanx base. Structures at Risk: 1. Skin; 2.Tendons - FPL; 3. Digital Nerves; 4. Digital Arteries; 5. Bone - Proximal phalanx; 6. Distal edge of A-2 Pulley. (Click on structure to see exam)
    Palmar laceration over thumb proximal phalanx base. Structures at Risk: 1. Skin; 2.Tendons - FPL; 3. Digital Nerves; 4. Digital Arteries; 5. Bone - Proximal phalanx; 6. Distal edge of A-2 Pulley. (Click on structure to see exam)
Symptoms
History of bleeding wound
History of injury from broken glass or knife
Numbness
Decreased active motion
Typical History

A typical patient is a right-handed woman who was preparing a salad and cut her left palm with a knife.  She was trying to remove an avocado pit with a sharp, thin knife when the knife slipped off the pit and into her palm at the base of the index finger.  The wound bled briskly.  The woman quickly applied a temporary pressure dressing.  She noted immediately that she had numbness on one side of the index finger and difficulty flexing the index finger.  Her husband drove her to the emergency room where a laceration with secondary tendon and digital nerve injuries were diagnosed.  The laceration was irrigated and debrided and sutured.  The patient was referred to a hand surgeon for urgent care of her tendon and nerve injuries.  

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify structures at risk
  • Care for the laceration
  • Repair all injured deeper structures
Conservative
  • Severely contaminated wounds or neglected wounds, especially in immune compromised patients, may be best served by irrigation, debridement, dressing change therapy with delay closure of the wound or by allowing the wound to close by secondary intent.
Operative
  • Simple superficial lacerations of the hand may be cleaned and sutured or glued if seen within 24 hours.4,5
  • Deeper laceration that go into the subcutaneous tissue should undergo:
    • Cleaning and temporarily suturing with a plan for urgent hand or emergency hand surgery.

In either case, the primary laceration should be irrigated, debrided and closed and all injured structures at risk repaired as soon as possible.

The rehabilitation after hand lacerations will depend on the extent of the wound and the number and type of repaired deep structures.

CPT Codes for Treatment Options

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CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Complications
  • Ischemia to digit or hand
  • Infection
  • Neuroma or neuroma-in-continuity
  • Scars, hypertrophic scars and scar contractures
  • Missed partial tendon lacerations6
Outcomes

All lacerations have a scar;, however, most properly treated superficial lacerations heal and leave minimal residual functional deficit and an acceptable cosmetic result.  

Deep laceration outcomes will depend on the injury to the Structures At Risk.  Flexor tendon lacerations and nerve lacerations rarely have perfect results, particularly in adult patients or very young patients.

Key Educational Points
  • Missed injury to Structures At Risk is a common cause of malpractice actions against emergency medicine physicians because of failure to identify deep injury Structures At Risk.1
  • Ideally, lacerations are closed soon after injury or at least within 24 hours.  Later closures increase the risk of infection.
  • In lacerations with continued bleeding despite pressure dressings, look for partially transected artery or vein may be found at surgical exploration.
  • Non-medical glues such as superglue should not be used for closing lacerations.5
  • Have a high index of suspicion for injury to Structures At Risk because 30% of these injuries can be missed by emergency physicians and hand surgeons.1
  • Significant gaps in tendons and nerves usually require delayed complex reconstruction.
  • Emergency hand surgery intervention is indicated if the viability of a digit or hand is in question and/or when there are open joint injuries or open fractures.
References

Cited and New References

  1. Coll JP, Harris PA, Percival NJ.  Hand lacerations: An audit of clinical examination.  J Hand Surg 1998;23B;4:482-484.
  2. Nassab R, Kok K, Constantinides J, Rajaratnam V. The diagnostic accuracy of clinical examination in hand lacerations.  International J Surg 2007;5:105-108.
  3. Tuncali D, Yavaz N, Terzioglu A, Asian G.  The rate of upper extremity deep-structure injuries through small penetrating lacerations. Annals Plast Surg 2005; 55(2):146-148.
  4. Strauss EJ, Weil WM, Jordan C, Paksima N.  Octylcyanoacrylate* versus suture repair for nail bed injuries.  J Hand Surg 2008; 33A:250-253 (*Dermabond; Ethicon Inc. Somerville, NJ).
  5. Wang AA, Martin CH.  Full-thickness skin necrosis of the fingertip after application of superglue.  J Hand Surg 2003; 28A:696-698.
  6. Al-Qattan MM. Conservative management of zone II partial flexor tendon lacerations greater than half the width of the tendon. J Hand Surg 2000; 25A:1118-1121.
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