Purpose: Hand injuries rank as the second most common category in A& E medicolegal claims. Accurate diagnosis and treatment is essential, with a high index of suspicion and low threshold for exploration. The first clinical examination for tendon and nerve injuries is crucial for prioritisation in a busy unit and surgical/anaesthetic planning.

Method: St Andrew’s being a tertiary level hand unit in the United Kindgom, has a significant throughput of trauma (head to feet) with 10–15 cases daily. Most patients are reviewed in the daily consultant/senior trainee–lead trauma clinic, with entries recorded on a computerised trauma database. We analysed the pattern of tendon and nerve injuries and accuracy of pre-operative assessment compared to operative findings. The database for a 12-month period was reviewed. After exclusions, 1670 sequential cases of adults with below-elbow, soft tissue injuries and complete clinical/operative notes were included. There were 1573 structures potentially injured in 823 digits, including 994 named tendons and 568 nerves. Knife and glass injuries predominated and 89% were operated on within 24 hours of assessment.

Results: Anatomical accuracy was greater than 98% for both tendons and nerves. Border nerves (index radial and little finger ulnar) were particularly at risk. Assessment of severity (nil, partial or total) was accurate in 60 % overall – 58% for nerves and 62% for tendons. Highest error rates(excluding true negatives) were same in all the digits. Zonewise, high error rates were encountered in flexors and nerves at wrist, while for the extensors it was at E6. On analysis of tendons individually, high false positives were encountered with FDS and FDP among the flexors.

Conclusion: This findings support our practice of low threshold for exploration. Distribution and accuracy by structure and zone are discussed, with recommendations for diagnostically difficult regions. Knowledge of potential pitfalls may prevent inappropriate choices of anaesthetic and aids prioritisation.