Hand Injuries at Work

Manufacture Alabama Conference- July 30, 2025

Donald Herip, MD, MPH, FACOEM

donald.herip@atipt.com

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Learning Objectives

1. Describe the epidemiology of occupational hand injuries.
2. Illustrate how hand injuries effect work comp claims and cost.
3. Explain the initial management of hand injuries.
4. Identify the indications for surgical referral for hand injuries.

Epidemiology of Work Injuries

This Photo by Unknown Author is licensed under CC BY-SA-NC

Nonfatal Occupational Injuries and Illness

https://www.bls.gov/news.release/osh.t02.htm

https://www.osha.gov/sites/default/files/OSHA_2023_Work-Related_Injury_and_Illness_Summary.pdf

https://www.osha.gov/sites/default/files/OSHA_2023_Work-Related_Injury_and_Illness_Summary.pdf

Hand Injuries

Each hand contains:

• 27 bones
• 29 major joints
• 123 ligaments
• 34 muscles
• 48 nerves
• 30 arteries

Occupational Hand Injuries�2019 (Bureau of Labor Statistics)

• Nonfatal occupational injuries to hands and wrists
• Hand/finger injuries acct for 30% of all work-related injuries.
• Median days away from work (DAFW)
• Hand injuries median days: 5
• Wrist injuries median days: 15

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• https://www.energyworkforce.org/wp-content/uploads/2019/02/Ringers-Hand-Safety-Presentation-.pdf
• Oleske DM, Hahn JJ. Work-related injuries of the hand: data from an occupational injury/illness surveillance system. J Community Health. 1992 Aug;17(4):205-19.

Costs of a Work Comp Injury

• Direct costs: Medical care
• Indirect costs > Direct costs
• Wages during work stoppage after injury: Time for medical treatment.
• Recovery of lost production: OT pay, hiring temp workers, decreased productivity.
• Additional human resources: legal counsel, medical advisor.
• Administrative time: documentation, investigation, coordinate RTW.
• Enforcement actions: Admin time, consultant fees, challenge citations.
• Increase in WC coverage: higher premiums (experience modification)

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https://amerisafegroup.com/the-real-cost-of-a-workplace-injury/#:~:text=Direct%20Costs,-The%20direct%20costs&text=While%20the%20cost%20can%20range,Workers%20Compensation%20Statistical%20Plan%20database.

Hand Injury--- Patient Approach

• Patient and clinician-- comfort and safety
• Syncope: Lie patient supine and raise feet 6-12 inches.
• Universal precautions: Treat all blood and body fluids as infectious.
• Blood loss: Direct pressure- simple compression
• Jewelry removal: Rings, watches, bracelets, etc.
• Pain relief: Gentle handling, immobilize injured part, elevate, ice.
• Wound care if delayed- Use saline moistened dressings

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Wound Assessment

• Where is the wound? Near artery, nerve, tendon?
• How deep is the wound, can you see the underlying tissue?
• Bleeding control- Simple compression successful? If not-- refer.
• Severe or pulsatile bleeding – send to Emergency Dept.
• Any associated compromise of blood supply or nerve function?
• Blood supply: Check capillary refill
• Nerve function: Check sensation and movement distal to the injury

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Capillary Refill

33 yo female: wrist laceration.

Repaired in the Emergency Dept.

https://theswiftinstitute.com/wrist-nerve-compression/

14 days after surgery

32 days after surgery

8 months after surgery

Bleeding Control

• A basic skill of first aid and one of the few actions with which a first aid provider can critically influence outcome.

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This Photo by Unknown Author is licensed under CC BY-SA-NC

Bleeding Control

• Direct Pressure
• Best controlled by applying pressure until bleeding stops.
• Amount of pressure applied and the time the pressure is held are the most important factors affecting successful control of bleeding.
• The pressure must be firm and maintained for a long time.
• If bleeding continues, do not remove the gauze; add more gauze on top and apply more pressure.

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• Lehmann KG, et al. Am Heart J. 1999;138(part 1):1118 –1125.
• Koreny M, et al. JAMA. 2004;291:350 –357.
• Mlekusch W, et al. J Endovasc Ther. 2006;13:23–31.
• Upponi SS, et al. Eur J Radiol. 2007;61: 332–334.
• Simon A, et al. Am J Crit Care. 1998;7:308 –313.
• Walker SB, et al. Int J Nurs Pract. 2001;7:366 –375.
• Yadav JS, et al. Am J Cardiol. 2003;91:1463–1466, A1466.

After Bleeding Control--- Next Step?

Wound Irrigation

https://www.aliem.com/trick-trade-diy-squirt-bottle-wound-irrigation/

Wound Irrigation

• Cleaning the wound (First wash your hands)
• Reduces bacteria and promotes healing.
• Gentle irrigation and soap (fragrance free) and potable tap water.
• Soaking the wound is not a substitute for mechanical cleaning.
• Careful with antiseptics: alcohol, hydrogen peroxide, iodine, etc.
• Can damage normal tissue.

• Rodeheaver GT, Ratliff CR (2018) Wound cleansing, wound irrigation, wound disinfection. In: Krasner DL, van Rijswijk L (eds.) Chronic Wound Care: The Essentials e-Book. HMP: Malvern, PA:47–62.
• Weir D, Swanson T (2019) Ten top tips: wound cleansing. Wounds International 10(4): 8-11.

Wound Irrigation

• Wound: Most common complication is infection.
• Severe infection seen in 2.5% of wounds sutured in the Emerg Dept.
• Wound irrigation: Best intervention to reduce infection.

• Rutherford WH, Spence RA. Infection in wounds sutured in the accident and emergency department. Ann Emerg Med. 1980 Jul;9(7):350-2. 
• Edlich RF, Rodeheaver GT, Morgan RF, Berman DE, Thacker JG. Principles of emergency wound management. Ann Emerg Med. 1988 Dec;17(12):1284-302.

Wound Irrigation

• Optimal pressure for irrigation is 5 to 8 psi.
• Achieved by using a 19-gauge needle with a 35-mL syringe or
• Place the wound under a running faucet.

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• Moscati RM, et al. Wound irrigation with tap water. Acad Emerg Med. 1998; 5(11): 1076-1080.
• Singer AJ, et al. Pres­sure dynamics of various irrigation techniques commonly used in the emergency department. Ann Emerg Med. 1994; 24(1): 36-40.

This Photo by Unknown Author is licensed under CC BY

Tap Water and Gloves

• Tap water vs. sterile saline: No significant difference in the risk of infection.
• Use of clean nonsterile examination gloves, vs sterile gloves during wound repair has little to no impact on rate of wound infection.

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Tap Water

• Dumville JC, et al. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2013;3:CD003949.
• Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;2:CD003861.
• Moscati RM, et al. A multi-center comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007;14(5):404-409.
• Ernst AA, et al. Warmed versus room temperature saline for laceration irrigation: a randomized clinical trial. South Med J. 2003;96(5):436-439.

Gloves

• Xia Y, et al. Infection rates of wound repairs during Mohs micrographic surgery using sterile versus nonsterile gloves: a prospective randomized pilot study. Dermatol Surg. 2011;37(5): 651-656.
• Heal C, et al. Comparing non-sterile to sterile gloves for minor surgery: a prospective randomized controlled non-inferiority trial. Med J Aust. 2015; 202(1): 27-31.
• Perelman VS, et al. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004; 43(3): 362-370.
• Creamer J, et al. Sterile gloves: do they make a difference? Am J Surg. 2012; 204(6): 976-979.

Wound Foreign Body (FB)

• Any remaining foreign bodies or dead tissue? If yes—refer.
• Metallic FB are inert (except those that oxidize- cause a tissue reaction)
• Organic FB must be removed in their entirety.
• X rays can detect
• Metal except aluminum
• Glass seen in 95% if > 2mm in size
• Wood seen 15% of time (decreases after 48 hrs because of fluid absorption).
• Ultrasound can detect nonradiodense FB 1 X 2 mm or larger.

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Wounds- Primary Closure Time

• Clean wounds with no signs of infection closed within 6-12 hrs.
• Suturing delayed up to 18 hrs (depends on initial treatment).
• Wounds with an extensive vascular supply (head, face) may be closed 24 hours from the time of injury.
• Bite wounds: Because of the high risk of infection are typically left open unless they are on the face and are potentially disfiguring.

• Berk WA, et al. Evaluation of the ‘golden period’ for wound repair: 204 cases from a Third World emergency department. Ann Emerg Med. 1988;17(5):496-500.
• Eliya-Masamba MC, Banda GW. Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury. Cochrane Database Syst Rev. 2013;10:CD008574.
• Fleisher GR. The management of bite wounds. N Engl J Med. 1999;340(2):138-140.

Dressings

• Uncomplicated lacerations of face and scalp often left open
• Regular application of petrolatum-based antibacterial ointment to maintain a moist environment.
• Dressings
• Protection from contamination
• Nonadherent and porous (passage of exudate)
• Moist environment
• Partial immobilization

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Wound Care Supplies ---- What to buy?

Company First Aid Kit�What Does OSHA Require?

OSHA 2006 document: https://www.osha.gov/sites/default/files/publications/OSHA3317first-aid.pdf

First Aid Kit- OSHA Requirements

• OSHA does not mandate specific contents for first aid kits.
• Requires that adequate supplies be readily available in workplaces. 
• Tailored to the specific hazards and risks in the work setting. 
• Essential items: adhesive bandages, gauze pads, gauze roller bandages, triangular bandages, wound cleaning solutions, scissors, tweezers, adhesive tape, latex gloves, and resuscitation equipment.
• Directions for requesting emergency assistance.

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OSHA 29 CFR 1910.151

Eyewash stations

https://www.osha.gov/sites/default/files/publications/OSHA3818.pdf

Antiseptic Precautions

• Allergy
• Open Wounds: Strong antiseptics like hydrogen peroxide or iodine can damage tissues and delay healing.

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Bednarek RS, Nassereddin A, Ramsey ML. Skin Antiseptics. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

Local examples at one point in time (2025).

Topical antiseptics (Betadine and Hibiclens) are useful for reducing bacterial counts on intact skin in preparation for surgery.

Antiseptics have been shown to be toxic to healing tissue and should not be used on open wounds.

Local examples at one point in time- 2025.

Cases

• Contusion
• Laceration
• Injection

Hand Pain after Using a Torque Tool

Kerwyn Bornell. Introduction to Torque Tool & Safety Basics. Hytorc Bolting Institute.

Reaction arm pinch hazard

• Pinch point is created on the active front side between the torque wrench reaction arm and the reaction surface.
• An area where technicians may get their hand caught during normal operations.

Hand Pain after using an Industrial Torque Tool

This Photo by Unknown Author is licensed under CC BY-SA-NC

X-rays and other diagnostic procedures

• Not considered medical treatment.
• Do not make a case recordable.
• OSHA defines medical treatment as the management and care of a patient to combat a disease or disorder.
• Does not include visits for:
• Observation and counseling
• Diagnostic procedures
• First aid

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Per section 1904.7(b)(5)(i)(B)- General recording criteria.

Laceration

20 yo male with left-hand laceration. Initial repair

8 days after repair

Tissue Adhesive

• Best for small, superficial lacerations
• Used on larger wounds where subcutaneous sutures are placed
• Used to replace sutures that are 5-0 or smaller in diameter
• Provides a flexible water-resistant protective coating
• Saves time during wound repair
• Eliminates the need for suture removal

https://www.shopwoundcare.com/p-ethicon-dermabond-topical-skin-adhesive.html

Tissue Adhesive- Contraindications

• Contaminated wounds
• Bites, punctures or crush wounds
• Jagged or stellate lacerations
• High-moisture areas: axillae, perineum, mucosal surfaces
• Hands, feet, and joints (unless kept dry and immobilized)

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• Quinn J, et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA. 1997;277:1527-30.
• Singer AJ, et al. Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs. standard wound closure techniques for laceration repair. Acad Emerg Med. 1998;5:94-9.
• Bruns TB, et al. A new tissue adhesive for laceration repair in children. J Pediatr. 1998;132:1067-70.
• Bruns, TB and Worthington JM. Using Tissue Adhesive for Wound Repair: A Practical Guide to Dermabond. Am Fam Physician. 2000;61(5):1383-1388.

Tissue Adhesive Care Instructions

• Do not to scratch or pick at the film.
• No bandage is necessary. 
• If the incision is covered-- less likely to pick or scratch the film. 
• Do not apply any ointments, lotions, creams, or tape over adhesive.
• Do not need to clean the incision with soap or water. 
• If adhesive gets wet, gently blot the incision dry with a soft towel. 
• Do not soak or scrub the incision. 

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Wound Taping- Steri Strips

• Tapes maintained in place as long as sutures would be left in place
• Tape should not be washed or moistened
• Never wrap in a circumferential manner

Steri Strips- Guidelines

• Wound with straight edges: Shallow cuts with straight edges. 
• Bleeding light and manageable? Don’t use Steri-Strips if the cut is still bleeding after 5 mins.
• In areas with minimal movement. Steri-strips may not work well on joints or other areas where it may have trouble staying in place.

https://www.healthline.com/health/steri-strips#how-to-apply

Wound Strength

• Epithelialization (sealing) by 48 hours
• Tensile strength 20% of full by 3 weeks
• Tensile strength 60% of full by 4 months
• Tensile strength never exceeds 80% of normal
• Mature scar forms by 6 to 12 months

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https://washnit.com/when-do-you-need-an-industrial-pressure-washer/

High Pressure Injection Injuries

• Initial injury may appear mild, but injury progresses rapidly!!!
• First phase: Mechanical impact of injection: pressure-induced neurovascular compromise, edema, and compartment syndrome.
• Damage to ligaments, tendons, nerves and blood vessels.
• Second phase: Inflammation and chemical interaction.
• Third phase: Infection due to direct bacterial inoculation.

Sirio CA, et al. High-pressure injection injuries of the hand. A review. Am Surg. 1989 Dec;55(12):714-8. 

High Pressure Injection Injuries- Materials

• Turpentine and organic solvents: Extremely cytotoxic-- poor prognosis.
• Oil-based paints: More inflammatory than water-soluble acrylic-based paints.
• Grease and wax: Do not create a robust inflammatory response but are engulfed by granulation tissue to form chronic granulomas surrounding the substance.
• Air and water injections: Minimal inflammatory response, are absorbed over time, and usually bypass the inflammatory phase of the injury.

• Rimmer MG, et al. J Hand Surg Br. 1993 Oct;18(5):654-5. 
• Green SM. Injection injuries of the hand. Bull Hosp Jt Dis Orthop Inst. 1981;41:48-58. 

High Pressure Injection Injuries- Prognosis

• Dependent on the following factors:
• Time to debridement
• Material injected (SDS sheet)
• Extent and location of soft tissue injury
• Magnitude of pressure the device released

Occupational Hand Injuries --- Summary

• Common occupational injuries.
• Account for significant workers compensation claims and cost.
• Initial management can greatly affect the prognosis.
• Clinicians should be aware of the indications for surgical consultations regarding wound evaluation and management.

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The End

“A man who works with his hands is a laborer;

a man the works with his hands and brain is a craftsman;

but a man the works with his hands and his brain and his heart is an artist.”

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---Louis Nizer