Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXII: Wounds and Injuries of the Hand
United States Department of Defense
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Delayed closure of the wound is performed several days after the initial debridement. In this way, one can be sure that the wound is free of sepsis and necrotic tissue prior to closure. Although it is possible to perform primary closure in certain wounds of the hand, the possibility of deep sepsis and wound breakdown does not justify the risk of primary closure in the combat situation.
At the time of wound closure (i.e., within 3-5 days postdebridement), unstable fractures or dislocations may be stabilized with small Kirschner wires. Stability thus achieved results in a hand which can be actively moved in the post-wound period, lessening the development of later deformity. Internal fixation other than small Kirschner wires should not be used by the forward surgeon.
Dressing
The dressing consists of well-fluffed gauze, applied evenly and snugly over a layer of fine-mesh gauze. Petrolatum-impregnated gauze impedes healing and should not be used. The deeper parts of the wound must not be plugged. The fingers are spread without tension, with the thumb in opposition. Padding is placed between the fingers. An attempt is made to align all fractures while applying the dressing.
The dressing should cover the entire wound, but should not constrict it. It is reinforced with layers of sterile absorbent cotton covered by a firm pressure bandage. Only fractured fingers are splinted. Unaffected digits are left free to move. Whenever possible, the tips of all fingers are left exposed allowing periodic inspection to determine the adequacy of distal perfusion.
Splinting
The hand is supported in the position of function on a molded volar plaster splint with the wrist dorsiflexed approximately 30°, the metacarpophalangeal joints at 70°, and the interphalangeal joints at 10° flexion. The slightly-flexed thumb should be placed in 45° of palmar abduction. This is the position of the hand holding a water glass.
Postoperative Management
After operation, the hand and arm are elevated. Movement of all uninvolved joints is enforced.
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