What's your practice with these lacs?

[erdoc00]

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Lacerations to the skin directly overlying tendons (i.e. on the hand or foot) but without visualized evidence of tendon injury and no deficit with active ROM or against resistance: How exhaustive do you get in exploring the wound to directly visualize for any tendon injury? Are most of you suturing these and then letting them go with instructions to return should they develop any deficits? Or is there a role to splint and have them follow-up with ortho in 2 days to get a re-examination if you can't definitely exclude a tendon laceration (i.e. can't visualize the tendon, possibly some pain with resistance testing, etc.)?

Lacerations of the fingertip that extend partially into the nail: In situations where the nail remains attached to the underlying nail bed without any detachment (i.e. such as a saw), are most of you performing a nail removal and nail bed repair or is it also acceptable to suture the skin around the nail and then dermabond over the approximated nail? I find that it takes me much longer to perform a nail removal and bed repair-- probably at least 30 minutes longer-- and I'm not sure if this provides a much better outcome. According to my orthopods, they recommend removing the nail and performing a direct bed repair. In residency, though, the ortho residents often times would use dermabond to repair these. I haven't been able to find any great literature, though.

Deep/long lacs to the arm or leg: For long/deep lacerations that sometimes extend to the underlying muscle +/- evidence of muscle laceration, what is your preferred repair strategy? Is it acceptable to suture the fascia and sub-q and then staple the remaining skin? If there is evidence of minor muscle-belly laceration without ROM deficit, do you place them in a splint to follow-up with ortho or leave them unsplinted and have them go home without restriction and provide them with return instructions? When I've discussed these cases with my orthopods, they have told me to repair the skin and then let them return to normal duty without any restriction and no need for ortho follow-up.

The reason I'm asking about these is I'm trying to be more efficient managing these injuries and I think I'm "overthinking" these cases, slowing me down. Any feedback or advice on how to be quicker is appreciated. Thanks in advance.

 

[dotcb]

1. Visualize the wound throughout ROM in a bloodless field (finger tourniquet). No visualized injury - repair the lac. If you're concerned you're missing something, splint them and arrange follow up.

2. In my center (county trauma center) we would at least discuss these with our hand service (plastics/ortho). They would inevitably want to see the patient, remove the nail, and repair the lac. If I was in a community center, I'd either do what they do, or do the minimum (repair visible lac), splint, and refer to a hand clinic

3. Do a layered closure of the laceration, no staples. That's it.

 

[Daiphon]

Lacerations to the skin directly overlying tendons (i.e. on the hand or foot) but without visualized evidence of tendon injury and no deficit with active ROM or against resistance: How exhaustive do you get in exploring the wound to directly visualize for any tendon injury? Are most of you suturing these and then letting them go with instructions to return should they develop any deficits? Or is there a role to splint and have them follow-up with ortho in 2 days to get a re-examination if you can't definitely exclude a tendon laceration (i.e. can't visualize the tendon, possibly some pain with resistance testing, etc.)?

The way I look at it is this: my job is to investigate for obvious injury. If I don't see one, and if ROM is wnl with patient being NVI, I repair. However, I send all my patients out with hand lacs with 2 instructions - 1) RTER in 2 days for wound check (which is another chance to reexamine for function), and 2) followup with our ortho/hand person on call. If I don't see anything obvious, then I don't necessarily call ortho/hand before discharge; if I do, then it's a figure of eight and a phone call.

Lacerations of the fingertip that extend partially into the nail: In situations where the nail remains attached to the underlying nail bed without any detachment (i.e. such as a saw), are most of you performing a nail removal and nail bed repair or is it also acceptable to suture the skin around the nail and then dermabond over the approximated nail? I find that it takes me much longer to perform a nail removal and bed repair-- probably at least 30 minutes longer-- and I'm not sure if this provides a much better outcome. According to my orthopods, they recommend removing the nail and performing a direct bed repair. In residency, though, the ortho residents often times would use dermabond to repair these. I haven't been able to find any great literature, though.

Leave the nail in - it's a better protector of the nailbed and epinychial fold.

Deep/long lacs to the arm or leg: For long/deep lacerations that sometimes extend to the underlying muscle +/- evidence of muscle laceration, what is your preferred repair strategy? Is it acceptable to suture the fascia and sub-q and then staple the remaining skin? If there is evidence of minor muscle-belly laceration without ROM deficit, do you place them in a splint to follow-up with ortho or leave them unsplinted and have them go home without restriction and provide them with return instructions? When I've discussed these cases with my orthopods, they have told me to repair the skin and then let them return to normal duty without any restriction and no need for ortho follow-up.

If there's muscle involvement, then you need to ROM and strength test them. No deficits and minor injury, then I'd close fascia and otherwise approach as a deep laceration. Any motor deficit or severe laceration = superficial closure + splint + ortho f/u for definitive repair once swelling decreases and can be fixed.

Cheers!
-d

 

[Rendar5]

1. ROM through bloodless field + intact str = A-OK. can't do that? splint and refer.
2. depend on the damage. simple nonjagged laceration? stithces ot it and leave nail on to protect wound and keep it together. jagged lac and unusre how muhc nailbed is involved? remove nail and repair bed and replace nail. only had to do taht once in the last 5 years.
3. I suture muscle layers and suture skin. if ithere's significant muscle damage and debridement required and concern for compartment syndrome (e.g. top half of a glass bottle buried in anterior tibil compartment)? I close approximately, splint/crutch whatever's involved, and have f/u in ortho's office next day or have ortho see in ED.

 

[Groove]

1. I'm paranoid with the hand injuries. I have extremely low threshold to call whoever is on and arrange very close f/u. I've had two cases already this year where I thought the pt had no tendon injury but ended up with a dx of partial tendon lac and was repaired. If a guy has any relatively complex hand laceration overlying tendons, I almost always either speak with the on call surgeon or arrange very close f/u at the office. The reality is that I find very few patients who will tell me convincingly that they have "no pain" when I'm stressing the tendon. If you're testing fxn in a bloodless field, it's going to interfere with their report of pain during the testing. Even with good fxn... if they have pain, they could have a partial lac which is what happened in both of these cases. One I suspected, but the other... I did not. Both had equivocal pain but good function. From my point of view, I just can't afford to send a guy home without adequate f/u if a partial lac is anywhere on my radar. If he suffers any loss of function that gets dx 2/2 tendon injury, I don't see how I can defend myself adequately in court. So, in short... I either 1) call the surgeon or 2) arrange close f/u with almost any lac where I have any remote suspicion of tendon injury. I never dispo someone with return to ED for re-check without referring them to hand surgeon at the same time.

2) Depends. Rare for me to deal with... I'd probably remove nail, repair, replace... I'd have a really hard time finding time to do this though in my shop. They would be sitting there for a long time. It more than likely would end up a partial repair and referral for next day hand vs apologies for their wait, etc.., meal trays and asking if they would mind waiting until I could take the time to repair.

3) Multi-layer closure, sutures, no staples. All would get referral to ortho. If I had any concerns whatsoever, I would not hesitate at all to call the surgeon.

 

[erdoc00]

Thanks for the replies. I, too, have a low threshold with injuries overlying tendons. I've also been criticized by the surgeons for calling them at times regarding some of these injuries, so it's nice to know that it's not necessarily as inappropriate as they seem to indicate.

 

[Daiphon]

Thanks for the replies. I, too, have a low threshold with injuries overlying tendons. I've also been criticized by the surgeons for calling them at times regarding some of these injuries, so it's nice to know that it's not necessarily as inappropriate as they seem to indicate.

Keep in mind that what they feel is annoying & "inappropriate" is, to an EP, the right thing to do. They don't see or know about 95% of hand injuries we definitively treat, so they have an inherent sample bias.

-d