Question for hand surgeons

[Apollyon]

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Since hand surgery can be approached from General, Ortho, and Plastics, I am putting this up in the "General" forum.

Need advice/opinions from hand surgeons.

A few weeks ago, had a patient that had an open fracture of the small finger on her dominant hand (right). Smoker. Wound was about 8 hours old. Her finger had gotten caught in the lanyard of the flagpole at 6am (so the weight of the flag brought the line down, with her finger in it).

Finger was inline, but there was a 270 degree laceration, with an island of tissue on the radial side. Xray shows a comminuted fracture of the proximal phalanx. 2 point was greater than 10mm on the ulnar side.

Now, teaching for me was "fracture with overlying laceration is open". When I talked on the telephone with the hand surgeon, he said that "it might just be a fracture with an overlying laceration, and not necessarily an open fracture". I internally marveled at this statement, but did not argue. I had not had sufficient time to really examine the wound yet (as it seemed straightforwardly "Hand surgical"). He said that it might just be to close the wound primarily, and to follow up in the office. I then ended the telephone call, and went and further examined the wound. My first entry into it had the sound of crepitus, as the forceps rubbed against the bone end, which clearly confirmed to me the open nature of this fracture.

So, to summarize: lac that goes 3/4 of the way around the finger, with the side of the finger without the skin bridge having the digital nerve out. With a radiographically proven comminuted fracture, would you (as a hand surgeon) ever tell the EM doc to close the wound primarily, and have the patient follow up? (This was a Friday afternoon at 2pm.)

(Because of the digital nerve being out, the Hand Sx grudgingly took the patient in transfer.)

 

[Black Surgeon]

I can't answer your question, but according to some of the hand guys at my school, "General surgery is no longer an accepted path for a hand fellowship and there are only about one or two hand programs that still take general surgery residents" . Thus you may be barking up the wrong tree. Try getting an answer in the plastics or ortho forum.

 

[maxheadroom]

Couple of points from the Hand Surgery side . . .

1. I find your consultant's approach to be acceptable and similar to what I will do out in private practice, with the caveat that the EM doc irrigate the hell out of the lac, close primarily, splint, and send home on antibiosis.

2. EM docs largely don't seem to understand that finger fractures with associated lacerations are not the same as open tib/fibs or open femurs. These can be managed in the acute setting by the EM physician with my above protocol.

3. The bigger issue is the continuing decline in the number of physicians who will actually take Hand call. This is due to a mix of declining reimbursement and the increasing burden of call, especially in places where insurance mixes are lousy, meaning that we're coming to the hospital to take care of someone who can't pay. This has reached a crisis point in some fairly large communities where there simply are no Hand docs who take call anymore. In order to make call more palatable, several larger groups have taught their referring EM docs how to appropriately stabilize the patient's injury until the next day or two when the Hand surgeon can see them in the office.

4. Hand surgery is primarily the domain of Plastics and Ortho. While General Surgeons can do a Hand fellowship, there aren't many out there that are interested in taking a General surgeon.

 

[Apollyon]

See, but you miss my point just a bit. First, is there a difference between a fracture and a laceration vs an open fracture?

And I am not averse to the lavage and close the open fracture - I had an open thumb that the hand doc asked me to close at 1am one night, after I was down to single coverage, and I did - and it locked down my ED for 1 1/2 hours.

And, to educate me - the digital nerve could wait until Monday, from Friday morning injury? I mean, this finger was just hanging off - index finger on the dominant hand, with only the soft tissues holding it on.

And, from where I came in South Carolina, there was a robust hand service that would see ANY patient in the office, as long as you called them - no matter what time of day or night. They were polite, professional, accomodating, not condescending, and very reasonable. It didn't have to be broken for them to see it - I even sent a guy to them for a wound check after a combination scything and lacerating cut from a carpet knife, and they were happy to see him.

All of those docs (6 in total) were ortho --> hand. However, where I am now, there is a guy that is GSX --> hand. I know that they're not prevalent, but they still exist. And, even at Duke, there were plastics attendings that were on for hand call - that didn't do hands. I had to scratch my head at that.

 

[maxheadroom]

See, but you miss my point just a bit. First, is there a difference between a fracture and a laceration vs an open fracture?

And I am not averse to the lavage and close the open fracture - I had an open thumb that the hand doc asked me to close at 1am one night, after I was down to single coverage, and I did - and it locked down my ED for 1 1/2 hours.

And, to educate me - the digital nerve could wait until Monday, from Friday morning injury? I mean, this finger was just hanging off - index finger on the dominant hand, with only the soft tissues holding it on.

And, from where I came in South Carolina, there was a robust hand service that would see ANY patient in the office, as long as you called them - no matter what time of day or night. They were polite, professional, accomodating, not condescending, and very reasonable. It didn't have to be broken for them to see it - I even sent a guy to them for a wound check after a combination scything and lacerating cut from a carpet knife, and they were happy to see him.

All of those docs (6 in total) were ortho --> hand. However, where I am now, there is a guy that is GSX --> hand. I know that they're not prevalent, but they still exist. And, even at Duke, there were plastics attendings that were on for hand call - that didn't do hands. I had to scratch my head at that.

1. There is no rush on repairing the nerve. I like to get to them within a week, just to keep the wound fresh enough so I'm not digging through lots of half-formed scar. Remember, it takes months and months to get sensation back after a nerve injury, so the difference between fixing it Friday night and the following Tuesday is negligible.

2. It sounds like you had a nice deal in SC. When you have a large group practice like that, you can afford to be more responsive to the ED because you're on call Q6 instead of Q3 or worse. This is becoming a bigger and bigger problem as Hand surgeons drop coverage at hospitals and work more and more at Surgicenters. Almost everything that we do electively is outpatient, so why should we subject ourselves to Hand call at the local hospital?

3. I really don't believe that there's a difference between an "open fracture" and a "fracture with associated laceration" in the hand. I think the majority of Hand surgeons would agree. Once you get into the wrist and distal radius, the normal conventions apply again.

4. Go to page 6 on the following link to read about a round table that was held at last year's AAHS meething in regards to the increasing problems of getting coverage for hand trauma call.
http://www.handsurgery.org/pdf/HSQ_09-3_vF.PDF

 

[Apollyon]

Thanks for that. I had to laugh when the first thing I see is a picture of Scott Levin. He is (or was, as I'm not up to speed) unique at Duke, as he was Ortho residency and Plastics fellowship trained; otherwise, it was one side (Ortho resident) or the other (Plastics fellow), and rarely the twain met.

My ortho and hand training at Duke was lacking, and not for a lack of trying. I learned a lot more on the job. I take out fish hooks (even though a general ortho guy came in to a community ED in SC to do that for a colleague). I do hand lacs. I do not go fishing for bullets, BBs, or glass, if I can't get it right there (I tried to get a dog's tooth out of a forearm, and that was a debacle, and he went to the OR - the Ortho told me "You would never have gotten it" - hindsight). I did not receive adequate training in felons - I am NOT putting a fish mouth incision on the index finger of a person's dominant hand.

Maybe it's because I haven't developed a working relationship with the guys here in HI yet, because I know that the first thing to put the consultant's mind at ease is "I don't need you to see this patient right now - I just need some advice, and the pt can follow up in the office", but, if I say "I can't do this", or "it's beyond me", the round table discussion seemed to support that.

Perhaps it is because of coverage difficulties here in HI that the first hand guy was how he was (had a forearm with a tendon lac that another hand guy here was more than gracious enough to accept), but, as all politics is local, there's a general surg/hand guy out where I am that will take our stuff (more than usual) because, when he was new out here and didn't have a job, my boss gave him one until he built up his practice - which he didn't have to do.

 

[maxheadroom]

Levin's now Chair of Ortho at Penn. He is an interesting man. I'm just glad that I've never had to work for him -- he's never struck me as someone whom I would enjoy.

When it comes to felons, they're pretty easy. Don't do the fishmouth. Just make a longitudinal incision right where it's coming to a point and then stick a clamp under the skin and break up the dermal appendages that make all of the mini-compartments in the pulp. Irrigate copiously with peroxide and leave in a wick. Have the patient pull the wick in around 12 hours and start soaking it TID in half strength peroxide.

 

[Apollyon]

Thank you. At my standalone ED, the stuff we DON'T send out is remarkable. I shall add this to the list!!

 

[maxheadroom]

Fly me in and I'll do a couple of days of Hand surgery teaching for all of your colleagues! 😀

 

[Apollyon]

Hey, we have Atkinson out here, and he's chill.

But I'll talk to the boss...we fill a very special niche here, so it could happen.

 

[maxheadroom]

Heck, if y'all know of someone out there who wants to hire a Hand surgeon, I'm their boy. I'm pretty sure that I could get used to that.

 

[Apollyon]

Reimbursement for ortho and hand are VERY poor in Hawai'i - that's one thing that drives people away.

But I did my first felon today! I called the hand guy and told him I was talking with people on the mainland. He said soapy water (no peroxide) and no wick - especially no iodoform. I had asked about the peroxide, and he said that there were all sorts of different opinions on it.

Well, the pus in that finger was the stinkiest I've smelled in a long time! And, on recognition, it may have just been one hell of a paronychia, instead of a felon. Still, irrigated with 600mL, clinda and Bactrim, and the guy said he will follow up with the hand sx. (As the guy was left hand dominant, then stroked, so now is R hand, and it was on the ring finger R, I was a little nervous, but also that's why he'll follow - if he loses this hand, he's out completely.)

God's honest truth, had I not had this thread, I would have sent this guy downtown. Mahalo!

Oh, and I did talk to the boss, saying I had a guy from the mainland that could come and do a hand inservice, but first dibs would go to our hand guy in our area.

 

[maxheadroom]

Glad to be of assistance. I like peroxide, but it does beat up the skin a bit. Warm soapy water works well, too. Pretty much anything should work -- the big thing is to soak it and wash out the cavity pretty well.

 

[chael]

I don't know..if I heard that there was a circumferential lac 270 degrees around the digit and that there was evidence one of the nerves was out, I'd have to assume at least one of the arteries was out too. If the lac was proximal to the DIP, we'd probably explore the guy in my program (plastics). If the finger was really only hanging on by a narrow skin bridge, then its a partial amputation and needs to be discussed whether completion amp or replant is appropriate.

I agree though that a simple lac overlying a finger fracture could be irrigated and closed and return for follow up.

 

[maxheadroom]

That's the difference between the real world and residency world. Out in private practice you'll want to have an EM doc who can give you an accurate description so you can figure out if you have to go see this or if it can come to clinic.

So what if one of the digital arteries is out? I'm not going to fix it if the finger is pink. In residency you lose sight of the fact that there are a whole lot of things that you take care of in the ED because it's convenient for your faculty. When you're on your own, you learn that there is a narrow range of things that absolutely have to be done at night.

Good luck in residency.

 

[Winged Scapula]

That's the difference between the real world and residency world. Out in private practice you'll want to have an EM doc who can give you an accurate description so you can figure out if you have to go see this or if it can come to clinic.

So what if one of the digital arteries is out? I'm not going to fix it if the finger is pink. In residency you lose sight of the fact that there are a whole lot of things that you take care of in the ED because it's convenient for your faculty. When you're on your own, you learn that there is a narrow range of things that absolutely have to be done at night.

Good luck in residency.

QFT.

Its amazing how patients survive in the real world without residents or even in house surgeons.

And I NEVER get called anymore with a 2:00 am, "I was just looking through this patient's chart and I see she takes an MVI regularly but you didn't write for it, would you like me to take a verbal for a daily vitamin?"

 

[maxheadroom]

QFT.

Its amazing how patients survive in the real world without residents or even in house surgeons.

And I NEVER get called anymore with a 2:00 am, "I was just looking through this patient's chart and I see she takes an MVI regularly but you didn't write for it, would you like me to take a verbal for a daily vitamin?"

Heck, at the place where I'm in fellowship getting a nurse to take a verbal order is nearly impossible. Painful. Fortunately, the residents deal with most of that stuff.

 

[Winged Scapula]

Heck, at the place where I'm in fellowship getting a nurse to take a verbal order is nearly impossible. Painful. Fortunately, the residents deal with most of that stuff.

True. Wasn't there some JCAHO (or some other governing body) which tried to crack down on verbal orders? I recall having signs during residency that verbal orders would not be taken except for stat ICU orders.

Of course, once we got the EMR and residents could log in from home/call room, nurses who knew that wouldn't take a verbal and would make you sign in and order it.

But yes, usually as a Chief or the fellow you were saved from those phone calls anyway. My problem now in PP is NOT getting called. It is very frustrating to round in the morning to find patients not having their diet advanced (even when they were asking) or being in pain or being nauseated and I didn't know about it. I have returned to my former micromanagement ways and calling before I go to bed to sort these things out.🙁

 

[maxheadroom]

But yes, usually as a Chief or the fellow you were saved from those phone calls anyway.

It's pretty rare that I get one of those calls. The thing that drives me nuts is the culture of the institution -- nurses won't do a thing to help out a trainee. I can't get a nurse to take a T.O. on just about anything. They won't do dressing changes. These things don't affect me very often -- the residents handle all of that stuff. Compared to the place where I did my residency, it's ridiculous.

 

[kirurg]

I used to get so upset at the nurses at my hospital. They only give meds and take vitals (expcept temperatures- that's the aid's job). Recently I found out that the hospital's insurance doesn't cover them to change dressings/draw blood/put in IVs/do EKGs. The CEO/CMO wants to make sure he gets his fat Christmas bonus, buys the cheapest RN malpractice coverage, and lets the housestaff suffer.