EVALUATION OF KNOWLEDGE OF EMERGENCY PHYSICIANS REGARDING ASSESSMENT AND INITIAL MANAGEMENT OF HAND INJURIES

1. Institute of Emergency Medicine, Peerless Hospital and B.K. Roy Research Centre, Kolkata-700094, India. 2. Clinical Director & Head of Department of Emergency Medicine, Peerless Hospital and B.K.Roy Research Centre. 3. Attending Consultant, Department of Emergency Medicine, Peerless Hospital & B.K. Roy Research Centre, Kolkata. 4. Associate Consultant, Department of Emergency Medicine, Peerless Hospital & B.K. Roy Research Centre, Kolkata. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 07 January 2020 Final Accepted: 10 February 2020 Published: March 2020 Introduction: We encounter acute traumatic injuries of the hand and wrist very often in the emergency department, ranging from simple soft tissue laceration to life threatening injuries.So for the optimum treatment of any serious hand injury depends upon early recognition and appropriate referral. This can only be achieved with a thorough understanding about the evaluation and management of hand injuries by the Emergency physicians. Aims and Objectives: To assess the knowledge on initial management of common hand injuries presenting to emergency department. To understand the importance of evaluation and management of hand injuries and for prompt referral and further expert management (surgical). Limitations of the Study: The study populations are being tested upon a confined set of questionnaire and it may not cover the entire range of questions. Physicians will be selected randomly, which may not represent ideal demographic scenario of physicians in our country. As some of the questionnaires are being distributed by e-mails, there is a high possibility of low response. Methodology: Over a 12-month period of all doctors working in the department of emergency and trauma care, working in the private and govt. sectors of the state of West Bengal, were asked to solve the questionnaire based on clinical scenarios of hand injuries which included evaluation of the same and the primary management .The clinical experience of these doctors varied from post graduate trainees to senior consultants in the field of emergency and trauma care. All replies were assessed by one individual. Results and Discussion: In our study we found that 25(16.7%) emergency physicians were ≤30 years old, 61(40.7%) emergency physicians were 31-40 years old and 64(42.7%) emergency physicians were 41-50 years old.43 (28.7%) emergency physicians were Female


Introduction:
We encounter acute traumatic injuries of the hand and wrist very often in the emergency department, ranging from simple soft tissue laceration to life threatening injuries.So for the optimum treatment of any serious hand injury depends upon early recognition and appropriate referral. This can only be achieved with a thorough understanding about the evaluation and management of hand injuries by the Emergency physicians. Aims and Objectives: To assess the knowledge on initial management of common hand injuries presenting to emergency department. To understand the importance of evaluation and management of hand injuries and for prompt referral and further expert management (surgical).

Limitations of the Study:
The study populations are being tested upon a confined set of questionnaire and it may not cover the entire range of questions. Physicians will be selected randomly, which may not represent ideal demographic scenario of physicians in our country. As some of the questionnaires are being distributed by e-mails, there is a high possibility of low response. Methodology: Over a 12-month period of all doctors working in the department of emergency and trauma care, working in the private and govt. sectors of the state of West Bengal, were asked to solve the questionnaire based on clinical scenarios of hand injuries which included evaluation of the same and the primary management .The clinical experience of these doctors varied from post graduate trainees to senior consultants in the field of emergency and trauma care. All replies were assessed by one individual. Results and Discussion: In our study we found that 25

Joint injury: Proximal interphalangeal joint:
Dislocation of the PIP joint most commonly results dorsally from hyperextension stress. An X-ray should be performed before and after the reduction to ensure proper reduction. However, most of these dislocations are already reduced before presentation. Treat fractures by splinting or as per the advice of the hand specialist. The volar plate and collateral ligaments will have been damaged if the joint is dislocated.
If after reduction: 1. joint dislocation with active movement, referral for repair is required. 2. joint hyperextension, treatment for volar plate avulsion fracture must be conducted. 3. there is no hyperextension, splint PIP joint in slight flexion for a few days followed by buddy taping. 19 Volar dislocations usually require referral for reduction. Failure of reduction need to be treated to prevent a boutonnière deformity (Figure).
Sideways force causes PIP joint collateral ligament sprain. If partially teared then treated with buddy taping for several days followed by early active exercise.

Distal interphalangeal joint:
Extensor tendon damage is associated with DIP joint injury. (See mallet finger deformity). Dislocations are less common and usually occur dorsally. 21 After reduction, splint the DIP joint in slight flexion for 2-3 weeks.

Metacarpophalangeal joint:
The MCP joint of thumb is most commonly injured. Sprain of the ulnar collateral ligament known as skiers thumb is more often seen in ball sports, occurs from forced abduction and hyperextension of the MCP joint. An X-ray is done before assessment of a UCL as any associated fracture is a contraindication to stress testing.
Stress the ulnar collateral ligament with the joint at 30 0 flexion and full extension. Complete rupture causes loss of end-feel and >10-20 degrees of deviation in both positions when compared to the other side. Pinch grip i.e. between thumb and index finger, will be painful and weak. There may be a painful lump on the ulnar side of the joint due to the ruptured ligament sitting outside the adductor aponeurosis (Stener lesion). 22 Complete rupture of the ligament which is unstable and requires surgical repair. Keeping the MCP joint in slight flexionpartial tears are immobilised with a splint for 6 weeks. Chronic forms of this injury are called gamekeeper"s thumb.
Injury to the radial collateral ligament is treated similarly. Complete rupture does not surgery. MCP joint dislocations usually require referral.

Tendon injuries:
In general, acute tendon injuries require surgical evaluation,exceptextensor tendon injuries.

Extensor tendonmallet finger:
Extensor digitorum injury at its distal insertion occurs when the joint is forced into flexion while being actively extended for eg. a ball hitting the outstretched finger. The patient may not present withtypical mallet finger injury deformity. Hence isolation of the DIP joint during resistance testing is to be done so that injury is not missed.
X-ray is to be done , as mallet finger can occur with an avulsion fracture. An avulsion fracture involving>30% of the articular surface or if there is joint subluxation, surgery is required. Otherwise, mallet finger deformity is managed conservatively.
Splint with the DIP joint in slight hyperextensionfor a minimum of 6 weeks. Crucial to maintain extension at all times, even when removing the splint for hygiene purposes. 9 Patients must be aware that failure to do this will result in permanent joint deformity. Although research 23 indicates similar outcomes for various splints, ready to use splints are only available in a small range of sizes, and custom made splinting may be required. Check for active pain free extension after six weeks and then begin intermittent splinting and active rehabilitation.
Mallet finger deformity can be successfully treated up to 3 months after the initial injury. 24,25 Extensor tendon -Boutonnière deformity Central slip of extensor digitorum is injured from a direct force to the PIP joint, or from the same mechanism of injury that causes mallet finger deformity. Initially presented as only pain with no deformity. Examine the injury with active finger extension showing the PIP joint will lag behind the DIP joint and full range can be lost.
Tenderness over the dorsal PIP joint may be present. Even suspicion of a subtle lag requires treatment. Failure to detect this injury results in the "boutonnière" (Figure) or "swan neck" deformity over time.
Surgery is required if there is associated intra-articular fracture of more than thirty percent. Splint the PIP joint in full extension while allowing DIP joint flexion for 6 weeks. Intermittent splinting and active rehabilitation is then required.
The rupture of the central slip of extensor digitorum from its insertion allows the lateral bands to migrate in a palmar direction. In turn, the middle phalanx is then pulled into flexion by FDS; the PIP joint herniates through the central slip tear

Flexor tendon injury:
Injury to the flexor digitorum profendus most commonly occurs at the fourth finger, as it is the weakest. Classically due to a grabbing incident, such as a missed tackle. After the injury fingerwould be in relative extension to the others, with inability to flex that finger. Order X-rays, as associated avulsion fracture is common. Immediate referral to a hand surgeon must be done as these injuries are irreparable after 10 days.

Lacerations:
Management of lacerated injury to the hand require exclusion of damage to underlying structures. Before the infiltration of local anaesthetic, examination of movement and sensation must be done. Careful wound exploration can then take place. If the mechanism of injury suggests a fracture, an X-ray should be performed.
Excruciating pain with active movements and against resistance is suspicious for tendon injury. If unsure about tendon integrity, re-evaluate in two to three days. Compound fracture, tendon or nerve injury warrants surgical repair.
Simple lacerations should be given copious lavage and irrigated then sutured loosely to allow ooze. Although normal saline is traditional, there is evidence to suggest 15 that drinking-quality tap water is a viable option. Delayed closure can be done in wounds that present after 6 hours of injury. Antibiotics should be prescribed as per antibiotic guidelines 26 and tetanus toxoid administered as necessary.

Bites:
Bites with fracture requires surgery referral for surgical washout along with oral antibiotics or parenteral antibiotics depending upon the severity. A bite wound should not be primarily closed. It should undergo copious lavage, treated with antibiotics ,tetanus cover and review. 26, 27 For human bitesconsider the patient"s hepatitis B status and if the wound is clean in 3 days, then it can be loosely suture but ongoing review should be continue.

Nail bed injuries:
Nail bed injuries are commonly sustained as a result of high-force crush from a car or home doorsor high-speed lacerationfrom band saws. Fingernails originate from the germinal matrix, and injury to germinal matrix can result in permanent nail deformity. When assessing fingertip injuries, it is important to note the size and level of the defect, analyse the nail bed for significant injury, as well as the presence or absence of exposed bone.

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Incomplete avulsion of the nail plate through the eponychia surface is one of the commonest injuries dealt by the emergency physicians in emergency department amongst nail injuries as the proximal nail plate lies on top of the eponychia surface. This even signify laceration of the underlying nail matrix and, possibly, fracture of the distal phalanx. In this case, the nail plate is removed and the underlying nail bed is sutured with a fine absorbable suture (level III evidence). 28 The original nail plate is then washed and replaced as a "free nail plate splint." In 2 to 4 months, a newly grown nail will push this out.

Fingertip amputations:
Fingertip amputations are classified according to the level of amputation with respect to the distal phalanx.
Principles of managing fingertip amputations areto provide effective and durable coverage, to preserve the finger length and sensation,pain management and donor-site morbidity. 29 In the absence of exposed bone, healing occurs by secondary intention for defects less than 1 cm in size. All wounds should be thoroughly irrigated and debrided of non-vitalized tissue to avoid infection .Haemostasis should be obtained; local direct pressure is often sufficient.
The bone is trimmed proximally with a bone rongeuras the bone might protrude beyond the soft tissue wound margin followed by daily dressing until the soft tissues contract over the next3 weeks, covering the bone and reepithelializing the wound. The techniques for obtaining soft tissue coverageinclude V-Y advancement flaps, crossfinger flaps, and pedicled flaps. 29,30 These procedures need to be managed by hand surgeons.
Fingertip open wounds, undergoing daily dressing are extremely painful. After the initial debridement and exploration under a metacarpal or digital block, the open wound is dressed with a single layer of petrolatum gauze, followed by a saline compress and dry gauze under all aseptic precautions. After 48 to 72 hours, the external dressing is soaked first in normal saline and removed, leaving the underlying petrolatum gauze in place, allowing alleviation of pain during future dressings and alsofacilitates epithelialization of the wound. After the first dressing change, the patient is instructed to bathe the finger in warm salt or magnesium sulphate baths daily for 1 to 2 minutes and then to dress the wound with dry gauze to minimize the bacterial count on the wound and prevent infection. The small wound epithelializes under the petrolatum gauze dressing, lifting it off approximately after 2 weeks. Hand injuries are often grouped by anatomical location. For instance the mechanism of injury should be a cue for the emergency clinician to consider specific diagnoses like a fall on outstretched hand "FOOSH" should prompt consideration of scaphoid fracture, scapholunate instability, lunate dislocation, and peri lunate dislocation. A motor vehicle crash with rapid deceleration while holding the steering wheel or a FOOSH injury while holding an object like ski pole or a bottle should prompt consideration of gamekeeper"s thumb. The most common injuries to the hand are lacerations (49.8%), fractures (15.3%), strains/sprains (8.4%), and contusions/abrasions (8%). 31

Differential Diagnosis:
Time critical limb-threatening injuries, high morbidity injuries, and diagnoses detected solely by examination like gamekeeper"s thumb, deserve emphasis in patients presenting with acute hand injuries. Diligence is required in the trauma patient presenting with multisystem trauma or distracting injury (e.g. open tibia-fibula fracture), as this scenario may lead to search-satisfying error (that is the tendency to call off the diagnostic search once something is found). 32 278 Emergency Department Evaluation: Triage and Stabilization: Initial Emergency triage, bed utilization, and care should follow standard practices for the undifferentiated trauma patient (example: Advanced Trauma Life Support or emergency clinician discretion). Certain injuries warrants immediate placement of the patient in an intensive care area to address lifeor limb-threatening injuries. In instances of significant bleeding where there is anticipation of the need for disposition to the operating room, parenteral pain medications, or intravascular volume resuscitation, intravenous access should be obtained and the patient should remain NPO (nil per oral). Haemorrhage control, splinting, and parenteral analgesia should be undertaken as needed.

History:
Hand trauma needs a focused history which stratifies the differential diagnosis and possible complications likejoint violation, tendon injury, retained foreign body,high pressure injection injury, infection, tetanus, rabies, and compartment syndrome. Rapid identification of limb-threatening and high-morbidity injuries must be done. Any information that may change the patient"s ultimate disposition or alter management should be gathered, such as in cases of a suicide attempt or suspicion of child abuse. If the patient is unable to offer a reliable history aswith a child, or if the patient has an altered mental status, an attempt should be made to obtain information from an alternative source, such as from parents or care giver.
A detailed description of the mechanism of injury and the symptoms should be sought, including asking whether the injury was from blunt force, penetrating force, FOOSH, closed fist, or high-pressure injection. The patient or witness should also be asked about the time of onset, pain, location, range of motion, functional impairment, exacerbating/relieving factors, weakness, numbness, tingling, and discoloration. 32 In certain situations such as amputation, additional data are critical, including the method of storage of the body part and ischemic time. Knowledge of dominant hand, occupation, and hobbies are significant in surgical decision making in specific patient populations (example: for a professional musician).
Medical history should include baseline functional status, disability, prior injury, immunosuppression like diabetes mellitus, asplenia, bleeding disorders, current medications, allergies, peripheral vascular disease, rheumatoid arthritis,smoking, and past surgical history. 32

Physical Examination:
A standardized hand examination is very important in every patient presenting with hand injury in emergency department. Some clinical circumstancesdemand additional focused examination. Examination should always begin with inspection and comparison with the unaffected hand for swelling, discoloration, bleeding, misalignment, amputation, and asymmetry. Palpation of the wrist joint, anatomical snuffbox, scapholunate joint, wounds, deformity, metacarpal bones, and metacarpophalangeal (MCP) joint, proximal interphalangeal (PIP) joint, and distal interphalangeal (DIP) joint in all digits should be performed. Passive and active range of motion of all joints is performed at the wrist and at the metacarpophalangeal, proximal and distal interphalangeal joints, looking for evidence of limited range of motion, crepitus, and tenderness. Valgus and Varus stress should be applied to the metacarpophalangeal, proximal and distal interphalangeal joints, and thumb joints to assess for ligamentous instability.

Assessing Motor And Nerve Function:
The motor components of the radial, median, and ulnar nerves are assessed with resistance to active thumb extension, thumb opposition, and thumb adduction, respectively.Weakness in the adductor pollicis brevis muscle shows the presence of Froment"s sign positive due to ulnar nerve palsyresults in flexion of the thumb interphalangeal joint due to compensatory action of the flexor pollicis brevis, which is innervated by the median nerve. The motor and sensory function of the radial, median, and ulnar nerves may be rapidly assessed with a set of simple manoeuvres. Sensation with light touch at the dorsal aspect of the thumb carpometacarpal joint, second digit pulp, and fifth digit pulp, is assessed to evaluate the sensory components of the radial, median, and ulnar nerves respectively.

Assessing Tendon Function:
Extensor tendon examination is performed with the hand immobilized on a flat surface, with resistance against extension at the MCP, PIP, and DIP joints. The flexor system of digits 2 through 5 consists of flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and the flexor tendon sheaths. The flexor pollicis longus 279 (FPL) is the major flexor tendon of the thumb. The FDP inserts into the volar aspect of the distal phalanx. The FDS runs superficial to the FDP and inserts into the volar aspect of the middle phalanx. Hand flexor tendons are assessed individually. To assess the Flexor digitorum profundus, hold the PIP in extension and the patient flexes at the DIP joint. FDS is assessed by immobilizing the other digits in extension while the patient flexes the non-immobilized digit. In open wounds, where tendon is exposed direct visualization up to the base of the wound is required.

Assessing Vascular Function:
Vascular examination should identify gross injuries of the dual blood supply of the hand and examine for any evidence of impaired perfusion. Bright-red pulsatile bleeding; expanding hematoma; a cold, pulseless extremity; a palpable thrill; or an audible bruit are the hard signs of arterial injury.Impaired capillary refill and pallor are the soft signs of arterial injury. Capillary refill and pulse oximetry have limited diagnostic utility. 33,34,35 The Allen test was originally devised to identify patients with a single radial artery supply of the hand.The Allen test is performed in suspected ulnar artery injury proximal to the wrist,.The hand is elevated 30 degrees in a clenched position and pressure is applied over the radial and ulnar arteries for 5 to 6 seconds. When the hand is unclenched and ulnar artery pressure is released, colour should return to the hand. If the pallor is persistent, it raises the suspicion of abnormal ulnar artery patency.
Diagnostic studies: Laboratory Studies: Complete Blood Count: CBC has limited diagnostic utility in isolated hand trauma, particularly in the absence of significant bleeding or suspected coagulopathy. The platelet count may be useful in suspected coagulopathy or thrombocytopenia. 36

Coagulation Studies:
Coagulation studies (prothrombin time, international normalized ratio, activated partial thromboplastin time) are generally not indicated in acute hand trauma except with significant bleeding or suspected coagulopathy (example: warfarin use, family history, or liver disease).

Imaging Studies:
Unlike in suspected ankle or cervical spine fractures, there are no prospectively validated clinical decision rules to omit imaging studies in low-risk patients with acute hand injury. In suspected fracture or joint injury, the initial imaging modality is plain radiography with anterior-posterior and lateral views, and consideration of an oblique view for overlapping bones. 37 Hand radiographs should be evaluated for adequacy of views, bony alignment, and individual bone morphology. In the posterior-anterior view of a normal hand, the middle metacarpal axis and radius axis should line up with one another, and the ulnar styloid should project laterally from the distal ulna. In the PA view of the wrist, the carpal bones form 2 arches and 3 distinct smooth arcs which is known as Gilula arcs. Irregularities in these smooth arcs suggestive of ligamentous instability or fracture. Spacing between carpal bones should be limited to 2 mm.The middle metacarpal axis forms a line through the capitate, lunate, and radius in the lateral view X-ray of the wrist. Scapholunate angle is formed by the longitudinal axis between the scaphoid and the lunate, normally measures 30° to 60°. Abnormal shapes of individual bones may signify pathology such as signet ring sign, pie-inthe-sky sign, spilled teacup sign, jumbled carpus.

Computed Tomograph:
Computed tomography (CT) is infrequently required in the ED. CT is more sensitive and specific than plain radiography to identify fractures. 38 The ACR supports CT imaging when clinical suspicion of occult fracture persists despite normal radiographs or when it is requested for surgical planning. Non-emergent CT imagingas in the case of suspected metacarpal fracture despite normal radiographs may be obtained in the outpatient setting.

Magnetic Resonance:
Imaging Magnetic resonance imaging (MRI) is very infrequently indicated in acute injuries of the hand in the ED. Although controversial, the ACR considers MRI as a diagnostic option for suspected scaphoid fracture with normal radiographs versus splinting, repeat examination, and radiographs at 10 to 14 days. 38,39,40 Nonemergent MRI in acute hand injury such as occult scaphoid fracture, gamekeeper's thumb may be obtained in the outpatient setting.

Ultrasonography:
Several studies have shown that ultrasound imaging is a useful diagnostic imaging tool for acute hand injuries. [41][42][43] Wu et al prospectively studied 34 patients with suspected tendon injury , 17 of whom had digit or hand injuries, comparing the diagnostic accuracy of emergency physician-performed bedside ultrasound versus physical examination. The authors reported equal sensitivities (100%); however, the specificity of ultrasound was superior to physical examination (95% vs 76%). 41 with appropriate training, emergency physician-performed bedside musculoskeletal ultrasound is a useful diagnostic tool.
Altman RS et al 44 (1987) found that failure to develop a proper routine for complete examination and documentation of the injured hand may result in the inability to make the proper diagnosis. Less than optimal treatment may result. The end result is unnecessary loss of function and, frequently, medical-legalliabilities.Initial ED management of acute hand is reviewed: Early recognition of surgical emergencies, proper initial treatment of tendon and nerve and arterial injuries, splinting, ,providing tetanus cover, parenteral or oral antibiotics and record keeping are emphasized.
Cheung K et al 45 (2013) found that to review the initial management of common traumatic hand injuries seen by primary care physicians. Recent clinical evidence and literature identified through MEDLINE electronic database searches was reviewed. For areas with little evidence, expert opinion was used to supplement recommendations. Primary care physicians while routinely managing the patients with acute traumatic hand injuries shouldreview the assessment, diagnosis, and initial management of common traumatic hand injuries. The presentation and management of burn injuries of hand, high pressure injection injuries,nail bed injuries, fingertip amputations, mallet fingers, hand fractures, tendon lacerations, bite injuries, and infectious tenosynovitis will also be discussed. The management of traumatic hand injuries are reduction and immobilization of fractures, post-reduction x-ray scans, obtaining soft tissue coverage, preventing and treating infection by oral or parenteral antibiotics depending upon the extent of trauma and ensuring tetanus prophylaxis. Accurate initialassessment and management of traumatic hand injuries is very essential to prevent any kinds of substantial long-term morbidity in generally otherwise healthy population. All critical injuries requiring expert opinion by hand surgeon, should be promptly referred .
Ghiya MN et al 46 (2017) found that despite having a dedicated Plastic Surgery Unit, emergency physicians (EPs) manage many of the acute, traumatic hand injuries. The management of pain is often neglected in a busy ED. To provide a clinical description of hand injuries with aetiology and mechanism; and describe the trends of ED management, including analgesia and tetanus prophylaxis. Records of 80 patients with hand injuries were reviewed. SPSS version 18 was used for statistical analysis. Wilcoxon signed rank test, and Pearson Chi-square test were used to compare left with right-hand injuries and validate associations, respectively. The mean age of the patients was 27.41 years with a median delay in presentation was 2 h. The predominant mode of injury was occupational injury (74%).Most patients (59 of the 86) received intravenous analgesia; while 6 of the patients received local anaesthesia and 24 patients received no analgesia at all. A majority of patients (56) received tetanus toxoid prophylaxis, while only four patients (4.6%) also received tetanus immunoglobulin intramuscular. Most patients (71%) were admitted, while only a small number of patients (14%) were discharged from the ED. With proper training and sensitization towards the need and technique of anaesthesia, particularly local anaesthesia the quality of patient care would be improved. Several guidelines and periodic review of the charts would help to overcome poor adherence to tetanus prophylaxis. With proper training through rotations to the Plastic Surgery Unit, hand injuries could be managed in a better and systematic approach.
Bowen WT et al 47 (2014) found that although injuries of the hand are infrequently life-threatening,they are common in the emergency department and are associatedwith significant patient morbidity and medicolegal risk for physicians. Examination of patients with acute hand injury begins with a focused history and physical examination. In most of the cases,a diagnosis is achieved clinically or with plain radiographs and some patients would require straightforward management The emergencyclinician should be capable of rapidly identifying the limb-threatening injuries, obtainingcritical clinical information, navigate diagnostic uncertainty, andfacilitate specialist consultation, when required. This review emphasises on the clinical evaluation and management of high-morbidityhand injuries in the context of the current evidence.
Alphonsus CK et al 48 (2011) found that mangling hand injuries are high energy complex conditions that are challenging to manage. Most of them requires careful planning and meticulous execution of treatment. A clear set of anatomical and functional goals are necessary as it guides the planning. The first surgery is crucialand it ensures 281 good vascularity to the salvaged tissue, prevent infection and achieve bony stabilization. Re-look surgery and definitive reconstruction can then follow. Post-operative therapy is an important component of treatment. Inspite of best efforts, outcomes are variable in these devastating injuries. Secondary procedures and provision of prostheses undoubtedly improves the patient's body image and limb function.
Chung KC et al 49 (2011) found that although reconstruction is often the primary choice of surgeons following an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over belowknee amputation. This studyaims to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Hand surgeons, physical medicine physicians and patients with lower extremity trauma completed a web-based standard gamble utility survey to generate quality-adjusted life years. Out of whichphysicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and alsofavoured reconstruction over amputation, but with a larger gain of 5.54 QALYs. This study highlights the necessity of realistic discussion of outcomes, regardless of management methods.
Wieschhoff GG et al 50 (2016) found that traumatic finger injuries account for a substantial number of emergency visits every year. Imaging helps in diagnosis and in management of these injuries. Many injuries can be managed conservatively, invasive interventions are sometimes required to prevent complications and loss of function. The soft-tissue anatomy of the hand is very complicated and due to this very often accurate diagnosis of finger injuries can often be difficult.The Radiologists must have a thorough knowledge of finger anatomy, the wide array of injury patterns that can occur, the characteristic imaging findings of different finger injuries, and the most appropriate treatment options for each type of injury. This would be very helpful for the treating physician .In this article the intricate anatomy of the hand is explained in detail as it relates to common finger injuries. This studyalsothrows some light on the various imaging findings of a range of injuries, optimal imaging modalities and imaging parameters for the diagnosis of different injury types, and addresses management implications for the patient and the orthopaedic surgeon. With this knowledge, radiologists will be able to recommend the most appropriate imaging studies, make accurate diagnoses, convey clinically relevant imaging findings to the referring physician, and suggest appropriate follow-up examinations there by improving patient care and outcomes. Online supplemental material is available for this article.
Jha S et al 51 (2014) found that bite wounds are a common form of hand injury with the potential to lead to severe local and systemic sequelae and permanent functional impairment. Bite wounds can be injuries resulting from the bites of various animals like dogs, cats and even humans and these are the most widely discussed and reported in the literature. The bite wounds are severely contaminated with aggressive pathogens and because of the anatomical vulnerability of structures within the hand,such injuries become fatal if early recognition and treatment is not provided. The bite injuries are managed with irrigation and antibiotics, and woundsinvolving deep structures require formal surgical exploration and washout. The consequences of such injuries can be disastrous.
Pilling T et al 52 (2016) found that numerous studies internationally highlight the devastating effects of fireworkrelated injuries and the costs involved in treating these injuries. This study was done to profile the firework-injured hand and to review the management from a surgical and rehabilitation perspective. A retrospective audit was conducted on patients with firework injuries between 2009 and 2014 (n = 65) in two hospitals in KwaZulu-Natal (KZN), South Africa. The thumb, index and middle fingers were predominantly affected at the level of the distal phalanges and distal interphalangeal joints resulting in amputation due to severe soft tissue injury and resultant fractures. Both medical and surgical interventions were performed within the first three to six hours post-injury involved washout, cleaning, debridement and suturing. was The predominant course of action was formalisation of amputation.The authors concluded that the firework-injured hand should be managed according to the resultant diagnosis, be it an amputation, fracture, or soft tissue injury.
Goldwyn RM et al 53 (1974) found that it was important to provide the surgeon with a basic approach to the management of acute hand injuries founded on the biology of tissue repair and regeneration. The result of a hand injury and the operation done depends on the technique and the biological processes.
Griffin M et al 55 (2012) found that flexor tendon injuries still remain a challenging condition to manage to ensure optimal outcome for the patient. Kirchmayr in 1917, described the first flexor tendon repair. Primary surgical repair often results in better functional outcome compared to secondary repair or tendon graft surgery. This literature 282 demonstrates that successful repair of flexor tendon injury requires minimal gapping at the repair site or interference with tendon vascularity, secured suture knots, smooth junction of tendon end and having sufficient strength for healing.This review aims to discuss the results of studies demonstrating the current knowledge regarding the optimal approach for flexor tendon repair. There has been an extensive debate in field of hand surgery regarding postoperative rehabilitation for flexor tendon repair surgery. It was supporting active mobilisation protocols but further study in this area is needed to find the protocol, which achieves function and gliding but avoids rupture of the tendons. Complications that commonly occur post surgery are adhesion formation, tendon rupture and stiffness of the joints. This study has also discussed the appropriate management of these difficulties post surgery.
Vitale E et al 56 (2019) found that hand injuries after high-pressure injection are a medical emergency. This types of injuries frequently seen in industrial workers while cleaning, painting, and lubrication, and may have devastating consequences, leading to eventual amputation and poor functional outcomes. The study has attempted in investigatingthe evolution, management, and outcome of such injuries which often go unattended. Medical records were collected from occupational medicine units and hand surgery units in order to spot the high-pressure gear accident cases. Records were analysed by dividing the subjects into two groups: those treated within 6 h and after 6 h of the trauma. A follow-up was carried out at least 1 year after treatment; the post-treatment outcomes were assessed. Of the 71 (100%) subjects, 26 (37%) were treated ≤6 h and 45 (63%) >6 h. A total of 28% (n = 20) underwent amputation. In 61% of cases, accidents had occurred in the iron and steel sector. High viscosity materials with a delayed treatment beyond six hours led to compartmental syndrome and following amputation. In this type of injury early management is crucial for better outcome.This study contributes to providing guidelines to occupational physicians in order to best manage this type of emergency.

Methodology:-
Over a 12-month period of all doctorsworking in the department of emergency and trauma care, working in the private and govt. sectors of the state of West Bengal, were asked to solve the questionnaire based on clinical scenarios of hand injuries which included evaluation of the same and the primary management . The clinical experience of these doctors varied from post graduate trainees to senior consultants in the field of emergency and trauma care. All replies were assessed by one individual.

Study Design:
The study was a prospective, multi-centric, observational, questionnaire-based study. For the purpose of this thesis, a descriptive correlational analytical survey was used, in which a qualitative approach was undertaken to determine the answers of above mentioned research questions. According to Cormack (2000), this research approach wasallow a large collection of empirical evidence through a series of steps according to a pre-specified plan of action. Essentially, descriptive and correlational are classed as non-experimental research methods and in a survey; its purpose is to observe, describe, and document aspects of a situation as it naturally occurs and to describe the interrelationship or association between variables.

Study population:
Study Sample: For the purpose of this proposal, data was collected, from all participants fulfilling the inclusion criteria. The expected sample size that was recruited for this study is calculated with the help of "Raosoft" sample Size calculation. The following data were entered: Population Size: 250 Confidence Level: 99% Margin of Error: 5% Response of Distribution: 50% The sample size required for this survey was calculated as 152, rounded to 150 with the following formula: Sample size n and margin of error E are given by, x = z(c/100)^2 r(100 − r) n = Nx/((N − n) E^2 + x) E = sqrt[(N − n)x/n(N − 1)] Where N is the population size, r is the fraction of responses that you are interested in, and z(c/100) is the critical value for the confidence level c.

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Inclusion Criteria: All doctors who deals with trauma patients and working as a resident or a consultant in the Dept. of emergency and trauma care.

Exclusion Criteria:
Doctors who specialized in the field of orthopaedics and/or plastic surgery Dept.

Study Sample:
A sample plan is an important feature of a qualitative research. According to one of the crucial task in designing a research project is to decide on the number and characteristics of the respondent who was invited to take part in the study.
According to quantitative research the larger the sample the more representative of the population it is likely to be. For the purpose of this proposal, data was collected, from all participants fulfilling the inclusion criteria.

The Survey:
The author proposes to carry out a mixed methodology of data collection using one-to-one interviews and electronic survey using the Web-based software Survey Monkey (http://www.surveymonkey. com), which was allow secure, anonymous distribution of the questionnaire via the Internet. An e-mail message containing the aims and objectives of the study with a link to the survey was distributed through an email to the Emergency physicians all over India.
After initial e-mailing, two reminders were sent out approximately every 3 weeks to physicians who had not responded to the survey. There is no incentive for participation and physicians who do not want to take part in the study they do not have to, and that the non-participation was have no bearing on their professional careers since questionnaires are anonymous.

Ethical consideration:
Ethics refer to the rights and protection of subjects and according to Cormack, there are ethical considerations at every stage of a research process, including the choice of topic to research. A written explanation of the nature of the study was given to the participants alongside the questionnaire. Participants can make an informed decision whether to enter into the study, by the informed consent form (Appendix I). No names were attached to the questionnaires, which were allow for participant anonymity. Confidentiality of data gathered from participants was respected at all times. This research proposal was submitted to the Research Ethics Committee of Peerless Hospital & B. K. Research Center, Kolkata for scrutiny and was undertaken if approval is granted.

Anticipated benefits:
Emergency physicians deal daily withthe hand injuries,Emergency physicians must rapidly identify limb-threatening injuries, obtain critical clinical information, navigate diagnostic uncertainty, and facilitate specialist consultation, when required.This study was help us in the following ways; 1. No studies to assess the magnitude of the problem amongst doctors in India have been so far. 2. Improvement in the quality of knowledge and awareness. 3. Improvement in the quality of care was provided to the patients.

Statistical Analysis:
For statistical analysis data were entered into a Microsoft excel spreadsheet and sent to the statistician. He then analyzed by SPSS (version 25.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism version 5.Data had been summarized as meanand standard deviation for numerical variables and count and percentages for categorical variables.
Z-test (Standard Normal Deviate) was used to test the significant difference of proportions. p-value ≤ 0.05 was considered for statisticalsignificance.      48 32.0%

Result and Analysis:-
Amputated part wrapped in moist gauze placed in bag with ice (c) 39 26.0% Amputated part kept in a bag, that bag placed into a second bag containing ice (d) 43 28.7% Total 150 100.0% Correct option: (b) 20(13.3%) emergency physicians answered Amputated part placed in a bag with Iceland water, 48(32.0%) emergency physicians answered Amputated part wrapped in moist gauze in bag, then placed into a second bag containing ice, 39(26.0%) emergency physicians answeredAmputated part wrapped in moist gauze placed in bag with ice , 43(28.7%) emergency physicians answered Amputated part kept in a bag, that bag placed into a second bag containing ice. The value of z is 0.628. The value of p is .5287. The result is not significant at p < .05.

Q2: Which of the following is the correct method of physical examination of the median nerve in the hand?
Q2:Which of the following is the correct method of physical examination of the median nerve in the hand?

Frequency Percent
Light touch second fingertip; resistance against thumb adduction (b) 20 13.3% Light touch second fingertip; resistance against thumb opposition (c) 121 80.7% Light touch dorsal aspect thumb carpal metacarpal joint; resistance against wrist extension (d) 9 6.0% Total 150 100.0% Correct answer option (c) 13.3%emergency physicians had answered Light touch second fingertip; resistance against thumb adduction, 80.7% emergency physicians had answered Light touch second fingertip; resistance against thumb opposition and 6.0% emergency physicians had answered Light touch dorsal aspect thumb carpal metacarpal joint; resistance against wrist extension.0% emergency physicians answered Light touch fifth fingertip; resistance against finger abduction.The value of z is 11.6835. The value of p is < .00001. The result is significant at p < .05. Figure 5:-Pie chart depicts13.3%emergency physicians had answered Light touch second fingertip; resistance against thumb adduction, 80.7% emergency physicians had answered Light touch second fingertip; resistance against thumb opposition and 6.0% emergency physicians had answered Light touch dorsal aspect thumb carpal metacarpal joint; resistance against wrist extension.0% emergency physicians answered Light touch fifth fingertip; resistance against finger abduction.The value of z is 11.6835. The value of p is < .00001. The result is significant at p < .05.

Q3: Proximal tourniquet placement is the recommended method of haemorrhage control in persistent haemorrhagefrom a radial artery injury despite direct pressureand limb elevation. True or False?
: Proximal tourniquet placement is the recommended method of haemorrhage control in persistent haemorrhage from a radial artery injury despite direct pressure and limb elevation?

Q4: Which of the following regarding high-pressure injection injury is FALSE?
Q4: Which of the following regarding high-pressure injection injury is FALSE? Frequency Percent Early high-pressure injection injury often appears clinically innocuous (a) 13 8.7% The injected material tracks along the neurovascular bundles along the path of least resistance. (b) 30 20.0% These injuries are associated with a high rate of infection, necrosis, and considerable amputation risk.(c) 32 21.3% All patients should receive intravenous antibiotics and immediate hand surgery consultation for operating room wound exploration and admission. (d) 52 34.7% Pain management with ice compression, digital nerve block, and local infiltration of anaesthetic drugs(e) 23 15.3% .0% Correct answer option (g) Figure 10:-Pie chart depicts110.7% emergency physicians had answered Test flexion of the wrist against resistance, 4.0% emergency physicians had answered Test flexion of the fifth finger against resistance, 4.0% emergency physicians had answered Test Abduction of the Index finger against resistance, 29.3% emergency physicians had answered Test flexion of the fifth finger against resistance and Test Abduction of the Index finger against resistance, 10.7% emergency physicians had answered check for clawing of the 4th and 5thfingers and 41.3% emergency physicians had answeredTest Abduction of the index finger against resistanceAll of the above tests.0% emergency physicians had answered The value of z is 2.1741. The value of p is .03. The result is significant at p < .05.

43.3% emergency physicians had prioritised as per below Order
A. Thorough irrigation and debridement, B. Prophylaxis for tetanus (and rabies if warranted) must be initiated, C. Wounds should be left open and cleansed frequently to minimise bacterial load, D. Prophylactic antibiotics (In patients with compromised immune systems, such as those with asplenism, underlying hepatic disease, or diabetes mellitus, to prevent potentially life-threatening infections.) The value of z is 0.5855. The value of p is .5552. The result is not significant at p < .05.
Q12: A five-year-old average sized patient presents with a laceration to the finger. Which of the following statements is True regarding anaesthetic choice for this patient? Q12: A five-year-old average sized patient presents with a laceration to the finger. Which of the following statements is True regarding anaesthetic choice for this patient?

Frequency Percent
A digital block is the preferred anaesthetic choice(a) 88 58.7% When giving lidocaine with epinephrine, the maximum safe dose Is lower than when giving lidocaine without epinephrine. (b) 29 19.3% Lidocaine with epinephrine has been definitely shown to cause digit ischemia when applied to the finger. (c) 33

22.0%
Total 150 100.0% Correct answer option (a) Figure 14:-Pie chart depicts 58.7% emergency physicians had answered digital block is the preferred anaesthetic choice. 19.3% emergency physicians had answered when giving lidocaine with epinephrine, the maximum safe dose Is lower than when giving lidocaine without epinephrine and 22.0% emergency physicians had answeredLidocaine with epinephrine has been definitely shown to cause digit ischemia when applied to the finger.The value of z is 6.473. The value of p is < .00001. The result is significant at p < .05. 17.3% In patients with persistent pain from an injury to hand, Computed tomography, scintigraphy or MRI may be used to identify an occult fracture (b) 13 8.7% In occult fractures of radius, scaphoid bone,or the hook of the hamate bone, MRI may allow early evaluation of avascular necrosis (c) 21 14.0% All of the above (d) 90 60.0% Total 150 100.0% Correct answer option (d) answered persistent pain from an injury to hand, Computed tomography, scintigraphy or MRI may be used to identify an occult fracture, 21(14.0%) emergency physicians had answered In occult fractures of radius , scaphoid bone ,or the hook of the hamate bone , MRI may allow early evaluation of avascular necrosis and 90(60.0%) emergency physicians had answered all of the above mentioned as correct. The value of z is 7.5876. The value of p is < .00001. The result is significant at p < .05.  44 (1987) found that initial ED management of acute hand injury needs prompt recognition of surgical emergencies which may be initially innocuous, proper initial treatment of tendon and nerve injuries, splinting, and record keeping.
Bowen WT et al 47 (2014) found that care of patients with acute hand injury begins with a focused history and physical examination. In most cases, a diagnosis is achieved clinically or with plain radiographs. Some of the patientspresenting to emergency department with hand injuries may require straightforward treatment, andin others the emergency clinician must rapidly identify limb-threatening injuries, obtain critical clinical information, navigate diagnostic uncertainty, and facilitate specialist consultation, when required.
Wieschhoff GG et al 50 (2016) this article explains the intricate anatomy of the hand as it relates to common finger injuries, illustrates the imaging diagnosis, presents optimal imaging modalities and imaging parameters for the diagnosis of different injury types, and addresses which findings have important management implications for the orthopaedic surgeon. This would guide thephysicians to recommend the most appropriate imaging studies, to make accurate diagnoses, convey clinically relevant imaging findings to the referring physician, and suggest appropriate follow-up examinations there by improving patient care and outcomes.
Pilling T et al 52 (2016) found that Hand Injury Severity Scores indicated a large percentage of cases within the severe category. According to the study, any interventions whether it is medical or surgical occurred within the first three to six hours post-injury and involved washout, cleaning, debridement and suturing. The predominant course of action was formalisation of amputation. Rehabilitation had a marked advantage over assessment and hand therapyand they ensured functional outcomes. Managing the symptoms of oedema, pain and stiffness, in amputation, fracture, or soft tissue injuries has a major impact on hand function outcomes.

In Amputation:
Our study found that in the question regarding Amputation, 48(32.0%) emergency physicians had rightly answered and 102(68.0%) emergency physicians had answered wrong. This difference was statistically significant (p<0.0001).

Nerve Examination:
Question regarding the correct method of physical examination of the median nerve in the hand was, correctly answeredby 121(80.7%)emergencyphysicians and 29 (19.3%) emergency physicians had wrongly answered. Correct answer was significantly higher than wrong answer (p<0.0001).
Question on the Test procedure of motor function and integrity of the ulnar nerve was, correctly answered by62(41.3%)physiciansand 88 (58.6%) emergency physicians had wrongly answered. This difference was statistically significant (p=0.0027).
GOLDWYN RM et al 53 (1974) found that the first section of Management of Acute Hand Injuries presents in detail the response to trauma of skin, cartilage, tendon, bone, and nerve.

Haemorrhage Control:
It was found that questions ofHaemorrhage Control, was correctly answered by 103(68.7%)emergency physicians and 47(31.3%) emergency physicians had wrongly answered. Correct answer was significantly higher than wrong answer (p<0.0001).

High Pressure Injection Injury:
Regarding question on High-pressure injection injury, only23(15.3%)emergency physicians had answered right and 127 (84.7%) emergency physicians had answered wrongly. Wrong answer was significantly higher than correct answer (p<0.0001).Question on choosing the trauma which are limb threateningor having very high morbidity, only 28(18.7%)emergency physicians had correctly answered and 122 (81.3%) emergency physicians had answered wrongly. Wrong answer was significantly higher than correct answer (p<0.0001).

Fight Bites:
Question on the most common site of a fight bite wound, was answered correctly by87(58.0%) emergency physiciansand 63(42.0%) emergency physicians had wrongly answered. Correct answer was significantly higher than wrong answer (p=0.0056). Question on Arranging in order priority wise the treatment protocol for Bite injuries, 303 was correctly answered by 65(43.3%) emergency physiciansand wrongly answered by and 85 (56.7%) emergency physicians. Wrong answer was significantly higher than correct answer (p=0.0208). ). Wrong answer was significantly higher than correct answer.

Tendon Injury:
Our study showed that in question regarding appropriate splint for mallet finger, 97(64.7%) emergency physicians had answered correctly and 53 (35.3%) emergency physicians had answered wrongly. This difference was statistically significant and Correct answer was significantly higher than wrong answer (p<0.0001). the True or False question stating Diagnosis of Jersey finger is made by physical examination with evidence of DIP swelling, Volar DIP tenderness, and impaired DIP flexion, 132(88.0%) emergency physicians had answered True which was correct and 18 (12.0%) emergency physicians had answered False which was wrong.It was statistically significant (p<0.0001). Regarding question on Mallet finger, 86(57.3%) emergency physicianshad answered correctly but 64 (42.7%) emergency physicians answered wrongly. This difference was statistically significant (p=0.01108).
Cheung K et al 45 (2013)This study propagated a message that primary care physicians must follow proper assessment and management of traumatic hand injuries and it is essential to prevent substantial long-term morbidity in this generally otherwise healthy population. This study also showed that early recognition of injuries that require urgent or emergent referral to a hand surgeon is critical.

Fractures and Dislocation:
Present study showed that in question related to the best method to reduce a Bennett fracture, 102(68.0%) emergency physicians had correctly answered and 48 (32.0%) emergency physicians had wrongly answered. This difference was statistically significant (p<0.0001). In the question based on the management of DIP, PIP, MCP dislocation, 106(70.7%) emergency physicians had answered Reduce, splint, and refer to hand surgeon which was the right management and 44 (29.3%) emergency physicians had wrongly answered. This difference was statistically significant (p<0.0001).
Jha S et al 51 (2014) found that Bite wounds may be contaminated with aggressive pathogens and the anatomical vulnerability of structures within the hand means that without early recognition and treatment with irrigation and antibiotics, alongside a low index of suspicion for deep structural involvement requiring formal surgical exploration and washout, the consequences of such injuries can be disastrous.

Burns:
For the question on the management of burn injury of hand, 117(78.0%) emergency physicians had answered correctly and 33 (22.0%) emergency physicians had incorrectly answered. This difference was statistically significant (p<0.0001).

Anaesthesia:
For the question on anaesthesia, to choose the correct statement regarding the anaesthetic choice for the patient where a five-year-old average sized patient presents with a laceration to the finger,88(58.7%) emergency physicians had answered correctly and 62 (41.3%) emergency physicians had wrongly answered.This difference was statistically significant (p=0.0027).
Ghiya MN et al 46 (2017) found that proper training and sensitization towards the need and technique of anaesthesia (particularly local anaesthesia) would improve the quality of patient care. Printed guidelines and periodic review of the charts would help to overcome poor adherence to tetanus prophylaxis. Hand injuries could be managed better by the EP, with training through rotations to the Plastic Surgery Unit.

Radiology:
Forthe question on Radiology90(60.0%) emergency physicians had right answered and 60 (40.0%) emergency physicians had wrong answered. This difference was statistically significant (p=0.0005). Overall in our study, 10(6.7%) emergency physicians gave 100% correct answers, 35(23.3%) emergency physicians gave 50% correct answers and 105(70.0%) emergency physicians had below 50% correct answers. Hence this study showed significant knowledge deficit in assessment and management of hand injuries amongst Emergency Physicians.

Conclusion and Summary:-
The human hands play a pivotal role in our daily lives within our family, work, and recreational environments. Best patient care and clinical decision-making in the Emergency Department regarding hand injuries undoubtedly depends upon the anatomical knowledge, history taking, physical examination, rapidly identifying limb-threatening injuries, obtaining critical clinical information, navigating diagnostic uncertainty, facilitating specialist consultation, and recognition of the limitations of imaging modalities.
In our study , we included the commonest hand injuries presenting to emergency and prepared a questionnaire and distributed to all the emergency physicians in West Bengal both govt. and private sector, personally and via emails , to assess the knowledge of emergency physicians regarding initial management of hand injuries presenting to emergency department.
It was found that most of the emergency physicians had correctly answered the questions on the Haemorrhage Control, Fight Bites, Burns, Nerve Examination, Fractures, Tendon Injury, Radiology and local anaesthesia.
Our study showed that there was significant knowledge deficit in the areas of amputation as in the mode of transportation of an amputated part. Emergency physicians were opting options which were wrong and those modes of transportation of amputated part would lead to nonviability of the tissue.
We also found that most of the emergency physicians had wrongly answered the questions based on Nail bed Injury and HighPressure Injection Injury. Many of the emergency physicians were not thorough about nail trephination and its significance, and were unknown about the recent studies done on the nail bed injuries. Most of the emergency physicians were in favour of performing nail trephination alone rather than nail plate removal in emergency and hand surgeon consultation, hence possibility of delay in immediate referral to hand specialist.
Our study also showed that the knowledge of emergency physiciansregarding some injuries like scapholunate dissociation showed significant knowledge deficit.
Study also showed a narrow difference in the opinion regarding prioritisation of treatment protocol for bite injuries. Emergency physicians had also found to have a confined knowledge regarding triaging of acute hand injuries (Limb-threatening or very high morbidity, High morbidity if missed or if diagnosis is delayed and Moderate morbidity if missed).

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In our study we have come across few areas of acute hand trauma , where the emergency physicians needed more training as in to identify the innocuous or hidden emergencies example high pressure injection injury which needed emergency referral to hand surgeon, we also found some lacunae in areas of amputation and nail bed injuries in which the emergency physicians needed updates from the recent studies done.
We can ensure quality practice of emergency physicians in Emergency Department as in promptly identifying and initiating emergent hand referral if demandedfor all acute hand injuries,and also fill the lacunae of these knowledge deficits by the following actions: 1. Appropriate workshops on the acute hand injuries for the ED physicians, should be designed and conducted at regular intervals. 2. Ensure more clinical experience in Plastic surgery, Orthopaedics and Vascular surgery during Emergency medicine training. 3. Conducting Journal clubs in every hospital and updating the emergency physicians about the recent advances in acute hand injuries. 4. Conduct similar surveys on larger scales with questionnaires on hand injuries. 5. Poster presentations on initial management and assessment of hand injuries.

Limitations of the Study:
In spite of every sincere effort my study has lacunae. The notable short comings of this study are: 1. The study populations are being tested upon a confined set of questionnaire and it may not cover the entire range of questions. 2. Physicians will be selected randomly, which may not represent ideal demographic scenario of physicians in our country. 3. As some of the questionnaires are being distributed by e-mails, there is a high possibility of low response.