The High-Stakes Hand: ED Injuries That Matter

Hand injuries may look minor, but missed diagnoses can mean permanent disability. In this episode, EMRA*Cast host Maiya Smith, MD, is joined by PGY-3 Orthopedic Surgery resident Dr. Tyler Thorne to break down the high-yield hand exam and walk through can't-miss cases like Seymour fractures, central slip injuries, and perilunate dislocations.

Overview

Hand injuries are some of the most common complaints in the ED—but they're also some of the easiest to underestimate.

In this episode, Dr. Tyler Thorne, PGY-3 orthopedic surgery resident, breaks down a practical, high-yield approach to evaluating hand injuries in the ED. We cover:

• High-yield hand anatomy and the ED hand exam
• Seymour fractures and their management
• Central slip injuries after PIP dislocations and how to avoid missing them
• Felon management and safe drainage techniques
• Perilunate dislocations and key X-ray findings that are commonly overlooked
• How to think about and manage finger tip avulsion injuries

Whether you're a resident or early attending, this episode will help you recognize the injuries that matter and manage them correctly.

Objectives

1. Perform a systematic ED hand exam, including tendon isolation testing, rotational alignment assessment, and neurovascular evaluation.
2. Recognize Seymour fractures and explain why they require treatment as open fractures with urgent specialist follow-up.
3. Identify signs of central slip injury after PIP dislocation and describe appropriate splinting and disposition.
4. Differentiate felon infections and outline appropriate ED management, including how to drain
5. Recognize perilunate lunate dislocations on imaging and describe initial ED management and consultation needs
6. Learn how to best manage finger tip avulsions

References

• Kiely AL, Nolan GS, Cooper LRL. The optimal management of Seymour fractures in children and adolescents: a systematic review protocol. Syst Rev. 2020;9(1):150. Published 2020 Jun 23. 
• Childress MA, Olivas J, Crutchfield A. Common Finger Fractures and Dislocations. Am Fam Physician. 2022;105(6):631-639.
• Gottlieb M, Long B. Management of Finger Felons and Paronychia: A Narrative Review. J Emerg Med. 2025;78:1-11. 
• Stanbury SJ, Elfar JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg. 2011;19(9):554-562.