Hand stuff

[Aesculapius]

---

Members don't see this ad.

Hi all,
I'm a resident on my plastics/hand rotation. I go to a place where the common response from our attendings is "call hand" rather than do procedures ourselves. The plastic surgeon believes that we should do more ourselves. So, in your practice, I would like to know what you would do in the following scenarios (i.e., do you repair the following yourself, or do you temporize and refer for swift outpatient followup...):

1. Extensor tendon repair
2. Exploration of potential flexor tendon injury
3. Flexor tendon repair
4. Closed reduction of comminuted metacarpal or phalangeal fractures
5. Injection of steroid/anesthetic for suspected carpal tunnel syndrome
6. A 40 year old male comes in with a large wound to their radial wrist area that has been left alone for a week. They have not seen previous medical care for this injury. The area is now filled with black, necrotic appearing tissue and some potentially purulent drainage. You are unsure if there is tendon/muscular injury. The damage is limited to this area, and the patient does not appear otherwise toxic. What do you do?

 

[Apollyon]

Seriously?

1. Call hand
2. Call hand
3. Call hand
4. Call hand after "reduction" (although, if comminuted, I don't know what you are reducing, if it is just a bunch of pieces)
5. No
6. Huh? Call ortho, and see if they'll see that emergently. Might need vascular, too.

Extensor tendon injury repair is an EP skill (in zones IV, V, and VI). Flexor tendon repair is NOT, and flexor tendon injury requires a hand specialist.

Wray RC, Jr., Weeks PM. Treatment of partial tendon lacerations.
Hand
1980; 12(2):163 - 166.

Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand.
Am J Emerg Med
2001; 19(1):76 - 80.

 

[BJJVP]

Where I work, with the exception of #4&5, even the orthopedic surgeons wouldnt be comfortable with or willing to handle any of those scenarios.

 

[Daiphon]

Seriously?

1. Call hand
2. Call hand
3. Call hand
4. Call hand after "reduction" (although, if comminuted, I don't know what you are reducing, if it is just a bunch of pieces)
5. No
6. Huh? Call ortho, and see if they'll see that emergently. Might need vascular, too.

Extensor tendon injury repair is an EP skill (in zones IV, V, and VI). Flexor tendon repair is NOT, and flexor tendon injury requires a hand specialist.

Wray RC, Jr., Weeks PM. Treatment of partial tendon lacerations.
Hand
1980; 12(2):163 - 166.

Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand.
Am J Emerg Med
2001; 19(1):76 - 80.

+1

Sent from my DROID BIONIC using Tapatalk

 

[Aesculapius]

Thanks for the response Apollyon.

 

[Rendar5]

extensor tendon repairs are definitely described for EP's to repair. That said, I have never done those or been trained on those, and am not sure what Zone 4-6 are. Thus, splint and call hand. Not for me to take chances with someone's livelihood.

Hand stuff I will do prior to outpt referals? simple open phalanx fx's (though those are usually toes), initial felon drainage, nail repairs for complex lacs, very very straightforward abscesses, closed reduction of simple fractures, finger reductions (although the last one I dealt with had to go to a hand guy anyway, wouldn't hold a reduction secondary to some sorta tendon rupture).

 

[bougiecric]

I think the more relevant question is: who does hand need to see in the hospital vs. who can follow up in clinic?

In the community, you won't have the luxury of a hand resident coming to the ED. I'd argue the vast majority of these cases can seen in clinic.

 

[Arcan57]

I think the more relevant question is: who does hand need to see in the hospital vs. who can follow up in clinic?

In the community, you won't have the luxury of a hand resident coming to the ED. I'd argue the vast majority of these cases can seen in clinic.

With the exception of deep-space infections or flexor tenosynovitis, essentially anything can be loosely approximated, splinted, and have hand f/u outpt (revision amps, tendon repairs, metacarpal dislocations, etc). The point of rotating through plastics/hand is to realize that you'll never do those things again. I got a rain of crap poured down upon me for not repairing an extensor tendon lac over the 3rd metacarpal (when I couldn't even find the proximal portion of the tendon). One specialized hand tray, a nurse AND NP assisting, and 90 minutes later the orthopod had fixed it. I felt vaguely vindicated. Seriously, the key to hand is:have a doc that will f/u anything in an outpatient setting the next day, keep a tight relationship with them, and don't call them in for anything that doesn't require emergent microvascular repair. Of note, extraordinarily few surgeons do replants so find out if yours does prior to telling your patient that their finger can be sewn back on.

 

[Xerxes1729]

One thing I've seen thrown out is putting a suture with a long tail through the free ends of a severed tenon, particularly a flexor, so the surgeon can find it more easily if/when it retracts. Would you guys do this if the surgeon requested it? Obviously then they'd know the suture was in there.

 

[Apollyon]

Thanks for the response Apollyon.

As I reread my response, I am sorry if I sounded prickly. The point was that, if the hand guy thinks you should be doing these in the ED, well, you shouldn't.

What a hand guy told me was, if there is ONE thing - at all - that he would ask, it is for a good washout. That is as good as you can do, but, if you can't get it done, call them for the OR.

 

[RustedFox]

This stuff is aggravating for me in particular, as it seems that there is no "hand guy" within 3-4 hours, as they've all "stopped doing that". Thus, I'm frequently left to tell the patient that they're going to lose a digit... or no, I'm not going to just "sew it up right now", or.... whatever.

Seriously, if the sub-SUB-specialist refuses to do it.... what makes me want to be a hero and do it myself? All the while, tick-tock, tick-tock, tick-tock.

I dont' even do LPs anymore (unless they're turbo-easy). Call radiology and do it under flouro; even if just to get them out of the department for a bit and keep those beds clear. Before anyone says "b-b-bbut ALL lumbar puncutures are EASY!".... keep in mind that my patient population is overwhelmingly obese people over the age of 68 with all sorts of fun kyphoscoliosis. No landmarks. Might as well just give me a blindfold.

 

[Aesculapius]

Oh, one other thing: for small fingertip amputations (<1 cm, no bone exposed, no fracture, no proximal nailbed/lunula involvement), what do you typically do?

 

[Rendar5]

bacitracin, Cover w/ gelfoam or chopped up surgicell stop the bleeding, and have them return if it gets infected.

 

[Arcan57]

bacitracin, Cover w/ gelfoam or chopped up surgicell stop the bleeding, and have them return if it gets infected.

Add in referral to hand (which will refuse to see them because of insurance despite telling you over the phone they will) and this is my management also.

 

[Rendar5]

Add in referral to hand (which will refuse to see them because of insurance despite telling you over the phone they will) and this is my management also.

Hey Arcan, out of curiousity, since I haven't had a fingertip amp w/ bone exposure since I left my ivory tower where it was easy to get hand consults, do you get them to come in to Ronjour those same day or refer them for next day f/u?

 

[bougiecric]

Hey Arcan, out of curiousity, since I haven't had a fingertip amp w/ bone exposure since I left my ivory tower where it was easy to get hand consults, do you get them to come in to Ronjour those same day or refer them for next day f/u?

These get sent out to clinic as well, with antibiotics. I actually managed to get our hand surgeon to see one in the ED, during the day. Even then, he said dress it and send it to clinic -- not emergent.

Like Arcan said, this is because the majority of these are uninsured, and they'll ultimately be denied a clinic appointment.

This actually makes me feel dirty... almost to the point that I've considered learning to ronjour and close myself. But that's impossible to do in a busy community ED. At times I've resorted to "implying" that they might want to make the two hour drive to the academic center ER. They have no options otherwise.

 

[Arcan57]

Hey Arcan, out of curiousity, since I haven't had a fingertip amp w/ bone exposure since I left my ivory tower where it was easy to get hand consults, do you get them to come in to Ronjour those same day or refer them for next day f/u?

Same as bougiecric, antibiotic ointment, xeroform and splint w/ outpt referral. The literature seems to back them up on the infection end of things, it's just tough to make the patient buy into the plan and your PG is going to be 0 if the plastics doc reneges on their word over the phone (wish that wasn't personal experience).

For bougiecric, Ronjouring the bone is not even vaguely practical in a community setting and while not difficult it is time consuming, especially making sure you've removed all the synovium. I'll offer our plastics guys the option of doing it in-house the next day with a 23-hr obs for our unresourced, sometimes they take me up on it.

 

[Zanegray]

Same as bougiecric, antibiotic ointment, xeroform and splint w/ outpt referral. The literature seems to back them up on the infection end of things, it's just tough to make the patient buy into the plan and your PG is going to be 0 if the plastics doc reneges on their word over the phone (wish that wasn't personal experience).

For bougiecric, Ronjouring the bone is not even vaguely practical in a community setting and while not difficult it is time consuming, especially making sure you've removed all the synovium. I'll offer our plastics guys the option of doing it in-house the next day with a 23-hr obs for our unresourced, sometimes they take me up on it.

...if its not the weekend.

 

[zinjanthropus]

Seriously?

1. Call hand
2. Call hand
3. Call hand
4. Call hand after "reduction" (although, if comminuted, I don't know what you are reducing, if it is just a bunch of pieces)
5. No
6. Huh? Call ortho, and see if they'll see that emergently. Might need vascular, too.

Extensor tendon injury repair is an EP skill (in zones IV, V, and VI). Flexor tendon repair is NOT, and flexor tendon injury requires a hand specialist.

Wray RC, Jr., Weeks PM. Treatment of partial tendon lacerations.
Hand
1980; 12(2):163 - 166.

Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand.
Am J Emerg Med
2001; 19(1):76 - 80.

👍 +1

 

[MediCane2006]

Plastics fellow at a (very) hand-heavy academic center here, just wanted to chime in. It's quite interesting to get the ED perspective on this stuff, especially from the community folks who sound like they are dealing with limited or nonexistent specialist follow up for a lot of these injuries.

To the OP, I would say that with exception of the fracture reduction, I would not expect an ED physician to deal with any of those situations. Hell I wouldn't even undertake a tendon repair in the ED, and I have the benefit of loupes and having done many repairs. Thorough washout and approximation of the skin is what I would ask the ED doc to perform (and document a good hand exam).... No "tagging" the tendon ends or anything like that. And unless it's a superficial, well-demarcated dorsal abscess, I'd also defer abscess drainage to the hand folks.

I find the discussion on completion amputations particularly interesting, as in my opinion it's one of the easiest/quickest procedures we as hand docs do in the ED. Digital block, washout, snip down the bone with a small rongeur, trim the skin edges, and close with a few stitches ( I do a couple PDS's in the deep layer and a Prolene in the skin). 20-30 minutes, max (the key being a sharp rongeur and some good light).

For those physicians who find them to be too time consuming to do in the ED setting, do you really find they take longer than, for example, suturing complex lacerations? I can see how you'd be stuck between a rock and a hard place if you can't get people good follow up.....must be incredibly frustrating....

 

[dchristismi]

Thanks for the input MediCane...
There's technically a guy in my town who does hand... If you have insurance, and are lucky. He doesn't take call, though. Amputations are something that most of us cringe at. I have never done one.

We end up transferring pretty much all of the above, though. None of my orthos will touch hand stuff. Hell, I have orthos that transfer stuff that seems pretty bread-and-butter ortho, for that matter.

And to be perfectly honest, my PAs and ARNPs are excellent at repairing complex lacerations. I generally don't have the luxury to spend 20-30 min doing a procedure UNLESS is a life-threatening situation. Or I just feel like staying late to fix whatever it is. Now, if it's a really complex lac (think degloving, little-kid-facial-dog-mauling, etc) we don't have plastics coverage, and that gets transferred as well.

 

[gro2001]

Plastics fellow at a (very) hand-heavy academic center here, just wanted to chime in. It's quite interesting to get the ED perspective on this stuff, especially from the community folks who sound like they are dealing with limited or nonexistent specialist follow up for a lot of these injuries.

To the OP, I would say that with exception of the fracture reduction, I would not expect an ED physician to deal with any of those situations. Hell I wouldn't even undertake a tendon repair in the ED, and I have the benefit of loupes and having done many repairs. Thorough washout and approximation of the skin is what I would ask the ED doc to perform (and document a good hand exam).... No "tagging" the tendon ends or anything like that. And unless it's a superficial, well-demarcated dorsal abscess, I'd also defer abscess drainage to the hand folks.

I find the discussion on completion amputations particularly interesting, as in my opinion it's one of the easiest/quickest procedures we as hand docs do in the ED. Digital block, washout, snip down the bone with a small rongeur, trim the skin edges, and close with a few stitches ( I do a couple PDS's in the deep layer and a Prolene in the skin). 20-30 minutes, max (the key being a sharp rongeur and some good light).

For those physicians who find them to be too time consuming to do in the ED setting, do you really find they take longer than, for example, suturing complex lacerations? I can see how you'd be stuck between a rock and a hard place if you can't get people good follow up.....must be incredibly frustrating....

Thanks for contributing! It's very interesting to hear your (and other specialists) perspective on this. It's very appreciated!

Though I think it will take YOU '20-30 minutes max' to complete an amputation though. I think for most ER docs it will take that amount of time just to figure out where the rongeur is hidden in the department/find the keys to the charge RN closet. Plus for anyone who probably has done very few of these (especially compared to a plastic surgeon) it would take longer, maybe require watching a refresher video. And after it's done you can say "see me in clinic on Tuesday", we have to get you on the phone to arrange it and that's additional time too. I can't imagine it taking less that 45 minutes start to finish for most ER docs. Even if it did only take 20-30 minutes, that's 1-1.5 patients they could have seen in the meanwhile.

 

[RustedFox]

A third "thanks for the input" post from me, too.

I would love, LOVE, love to do more stuff like this, but the bottom line from "management" is simply:

"Why are these people waiting for more than 15 minutes ?!"

... and now, a question back atcha. Why is it that 'hand' is disappearing from the subspecialty sphere? The refrain that I frequently hear from the orthos is "we won't do that anymore".

 

[KiloAxe]

What I have found that is confusing with fingertip amputations is the variation in practice amongst some of our hang folks. I have yet to get a clear understanding of when the fingertip shoukd be saved versus completing the amp. ive seen some distal phalanx gone to OR for fixation etc and others completely chooped off. my thought is if it is the thumb or a kid, hand surgery should at least consider saving it. thoughts? I tend to agree with medicane that to ronguer bone back and close is actually a relatively quick procedure. Often times there is nothing to close d/t poor skin coverage and I ronguer the bone to smooth out the edges, dress it, and let close by secondary intention. The important thing is to remove all of germinal matrix to prevent nail formation.

 

[Arcan57]

A third "thanks for the input" post from me, too.

I would love, LOVE, love to do more stuff like this, but the bottom line from "management" is simply:

"Why are these people waiting for more than 15 minutes ?!"

... and now, a question back atcha. Why is it that 'hand' is disappearing from the subspecialty sphere? The refrain that I frequently hear from the orthos is "we won't do that anymore".

Emergent hand call features high risk patients with potentialing disabling injuries. They tend to have higher rates of being unresourced and often have comordities (substance abuse, smoking) that contribute to poor wound healing. It's close to a perfect storm of things that make you not want to be responsible for a patient's outcome. So ortho avoids getting credentialed for hand cases (they still need the hospital for hip cases which are cash cows).

Additionally, the lucrative hand (carpal tunnel, etc.) tends to be non-emergent and outpt in nature so their is relatively little need for a hand surgeon to be tied down at a hospital when they can collect the facility fees from their outpt surgery center without the medicolegal hassle of taking call. Thus plastics call tends to be either heavily subsidized or non-existent.

 

[MediCane2006]

Gotcha. (fair point by groh, btw, the inaccessibility of equipment inthe ED is why I keep a peel-packed rongeur in my car's glove compartment).

The uninsured hand patients - and hand call in general - are problematic even at our big academic center (where we have ortho AND plastics to share hand call). As Arcan said, the injuries are often potentially HUGELY disabling (especially in the blue collar or illegal patient cohort that depend on their hands to make a livelihood) and even when they make it to surgery the patients usually don't have the means or motivation to complete the rehab protocols. I can only imagine what its like in non-academic places that dont have reliable coverage. It's always humbling to be reminded of what you guys are facing out in the community. Keep fighting the good fight 🙂

To the poster who asked why hand is disappearing from subspecialty practice - its a good question. I think one of the factors is that plastic surgeons just don't want to deal with the patient population, not to mention the extensive follow up and rehab these folks often need. Also, as is true with many surgical specialties, the breadth and complexity of the field is expanding as technological innovations occur, and it becomes harder and harder for the community plastic surgeons to keep up with the latest standards of care and literature.

Most of the plastics/hand surgeons I work with either do mostly hand, or practice fairly out-of-date hand surgery.

 

[Rendar5]

A third "thanks for the input" post from me, too.

I would love, LOVE, love to do more stuff like this, but the bottom line from "management" is simply:

"Why are these people waiting for more than 15 minutes ?!"

... and now, a question back atcha. Why is it that 'hand' is disappearing from the subspecialty sphere? The refrain that I frequently hear from the orthos is "we won't do that anymore".

I too love complex lacs, but never learned to Ronjeur bone so won't touch those fingertip amps if I can help.. I count myself lucky, there are a few hand guys in the area, and a couple of them are super friendly and don't care about insurance issues for ED patients. Majority of cases are office referal. I rarely have to use general plastics though, and don't really know the ones in my area. Parents in my hospital never ever ever request plastics repair their kids. I've even had a few facial lacs that I offered to call plastics for patients because they'd likely do a better job, but still have the patient insist I do the repair myself.