Management of Palmar Hand Lacerations

Initial Assessment and Imaging

The American College of Radiology recommends obtaining 3-view radiographs of the hand (posteroanterior, lateral, and oblique) as the initial imaging study to detect fractures, foreign bodies, or bone involvement, even in penetrating trauma 1, 3
Radiographs are essential in palmar wounds to identify fracture fragments that may require open reduction and internal fixation, particularly with suspected tendon injuries 1, 3
Examine for tendon injury by testing active range of motion of all digits—inability to flex suggests flexor tendon laceration requiring surgical repair 1

Irrigate the wound with high-pressure sterile saline or potable tap water to remove bacteria, foreign bodies, and blood clots—there is no evidence that antiseptic irrigation is superior to sterile saline or tap water 2, 4
Use copious irrigation volume (at least 200-500 mL depending on wound size) to mechanically remove contaminants and reduce bacterial load 2

Prescribe amoxicillin-clavulanate 625 mg orally three times daily for 5-7 days to prevent polymicrobial infection, as palmar wounds are at high risk for contamination 2
Do not use first-generation cephalosporins or clindamycin monotherapy as they lack adequate coverage for common pathogens in hand wounds 2

Verify tetanus immunization status immediately and administer 0.5 mL tetanus toxoid intramuscularly if the last dose was >10 years ago or status is unknown 2, 4

Elevate the hand during the first few days to reduce inflammation and promote healing 4
Cover the wound with antibiotic ointment (such as bacitracin) and a clean occlusive dressing to maintain a moist environment and prevent contamination 4

Schedule follow-up within 24 hours to assess for signs of infection including increasing pain, redness, swelling, warmth, purulent drainage, or fever 2, 4
Monitor specifically for deep space infections, flexor tenosynovitis (Kanavel's signs), and compartment syndrome in palmar wounds 2

Never suture palmar puncture wounds or heavily contaminated lacerations—this dramatically increases infection risk by trapping bacteria 2, 4
Do not miss flexor tendon injuries—test active flexion of all digits before wound closure 1
Do not overlook foreign bodies or fracture fragments on initial radiographs—these require removal 1, 3