Plastics

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====== Plastic Surgery Hand/Extremity Service ======

===== Service Pearls =====
==== Team Members ====
Attendings: Drs Matthew Iorio, Kia Washington, Mark Greyson, Tim Irwin\\
PA: Claire Law, Ben Nigg, Emily Walwood\\
Residents: This service is comprised of a Chief Resident and junior resident. There is no intern on this service. \\

==== Reps ====
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=====Boards Collection Photo Consent=====
{{ :medical_student:photo_consent.pdf |}}

==== Weekday Consults ====
  * The most junior resident on service is responsible for consults and service pagers. Amy and Ben (PA's) help to see consults when residents are in the operating room or occupied with other service/educational obligations. NB: Amy/Ben do have her own clinics and helps cover cases and clinic off-campus, so some days may not be immediately available to help.

==== Scheduling Follow-up Appointments ====
  * Consult patients should be added to the “Plastics Hand” shared Epic list upon receipt of the consult. 
  * If the patient will need a follow up appointment in the **Hand Clinic**, please make sure the ED puts in an order for “ambulatory referral to Hand Surgery” and specifies the attending who is on call that day. This is the same attending to whom your note should be routed. Send a staff message to: P SP AMC HAND SURGERY (pool) __and__ cc: Juli Peterson, the attending, Amy Kelso PA-C, Benjamin Nigg PA-C, etc.
  * If the patient will need a follow up appointment in the** Plastic Surgery Clinic**, please send a staff message to: P SP AMC PLASTIC SURGERY (pool) __and__ cc: the attending, Amy Kelso, Benjamin Nigg, Kristine Padiernos. 
  * If patient is an EXTREMITY patient (Greyson/Iorio) and discharging with WV in place, please cc "Stephanie Boyd" on follow up email so that she can help coordinate any home or follow up needs.

==== Clinic ====
  * Gordon: Monday afternoons, Wednesday mornings, and Friday afternoons. He writes his own notes
  * Iorio: Tuesday mornings and afternoons. Fast-paced. Amy and Ben are sometimes there to help.
  * Washington: Wednesday afternoons. She expects help.
  * Greyson: Wednesday mornings and afternoons. Uses his own smart phrases, make sure to familiarize yourself with them before going to clinic. 

==== Surgery ====
  * Gordon: Monday mornings, Wednesday afternoons and Friday mornings.
  * Iorio: Every Thursday. Mondays and Fridays may be hand cases or Plastics cases. Fast-paced. Have Preop orders and discharge orders in the night prior to facilitate turnover
  * Washington: Mondays are split between UCH and CCNSC. Operative days off campus are covered by Amy.

==== Consult Triage ====
Hand Triage

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==== Hand Therapy ====
  * Hand Therapy is an integral part of any successful hand surgery both pre and post-operatively
  * Below is a simple reference for hand therapy protocols and what the hand therapist will provide to our patients
  * Hand Therapy Guide{{ :medical_student:what_is_hand_therapy_-_resource_for_cu_residents_2.23.21.docx |}}


===== Postoperative Protocols =====

==== Flexor Tendon Repair - Early Active Motion Protocol ====


__Immediate Post-Operative Period:__

  * Immobilization for the first 3-5 days post-operatively in a surgical splint with the wrist in 10-30 degrees of extension, MPJ at 30 degrees flexion and IPJ in full extension.  
  * Patients are instructed to not move the fingers at all and to keep the hand elevated at all times in these early postoperative days to avoid bleeding into the wound.  Bleeding causes clotting, and clotting becomes scar.  Waiting 3 to 5 days before moving lets the swelling, work of flexion, and friction decrease to minimize the risk of rupture. Collagen formation does not start until day 3, so detrimental immediate movement is not necessary.

__3-5 Days Post-Op – 2 weeks Post-op:__

  * Placement into a forearm-based dorsal block splint with wrist in 10-30 degrees extension, MPJ in 30 degrees flexion and IPJ into full extension.
  * Edema control through elevation of the hand and gentle wrapping with Coban between exercises and at night
  * TAM measurement
  * Within the dorsal blocking splint, patients are taught the following 3 exercises at 25 repetitions every waking hour: (no tension, painful or forceful movement) “You can move it but you can’t use it” should be emphasized several times at each visit. 
  - Passive flexion of all digits as a “warm-up” before active flexion
  - Active IPJ extension with MP joint blocked in flexion to prevent interphalangeal joint flexion contractures
  - True active flexion up to 1/3 to 1/2 of a fist, initiating movement at the DIPJ (active hook fist)

__2-4 Weeks Post-Op:__

  * Dorsal block splint is shortened to a hand-based Manchester orthosis
  * Continue use of Coban between exercises and at night
  * Scar massage as needed
  * TAM measurement
  * Patients are instructed to complete the exercises below at 25 repetitions every waking hour:
  - Continue passive flexion of all digits,
  - Continue active IPJ extension with MP blocked in flexion,
  - Continue true active flexion ½ to full active fisting and up to 45 degrees of wrist extension, working toward full active fisting by 6 weeks post-op 
  - Add active synergistic exercises in the Manchester orthosis
__
4-6 Weeks Post-op:__

  * Continue use of hand-based Manchester orthosis
  * Continue use of Coban between exercises and at night
  * Scar massage as needed
  * TAM measurement
  * Continue the following at 25 repetitions every waking hour:
  - Passive flexion of all digits,
  - Active IPJ extension with MP blocked in flexion
  - Active flexion ½ to full active fisting and up to 45 degree of wrist extension, working toward full fisting by 6 weeks post-op
  - Active synergistic exercises in the Manchester orthosis

__6 Weeks Post-Op:__

  * Manchester short orthosis is discontinued
  * Scar management as needed
  * TAM measurement
  * Patients can start to use the hand for light activity
  * Start palm-based or digit extension splinting at night if needed to correct IPJ flexion contracture
  * Relative motion flexion orthosis during daytime activity may be used to regain active flexion
  * Relative motion extension orthosis may be used to address PIP flexion contracture

__8 Weeks Post-op:__

  * TAM measurement 
  * May begin strengthening

====Mallet Finger Protocol - For Hand OT====

I have created a smart phrase for a referral to Hand Therapy for Mallet fingers.  To make it simple, just type Mallet and then insert it in your referral.    (full name is Malletprotocol).\\

Our protocol is to apply quikcast material with the DIP in hyperextension. We follow up in 5-7 days to recheck as edema reduces pretty quickly and the cast becomes loose.\\

We will reapply and follow up every 10-14 days for skin checks, compliancy and integrity of the cast. \\

At 6 weeks of immobilization for bony mallets, it is helpful to have a return MD visit for xray to ensure that AROM is appropriate at that time.  If it is, we begin with gradual AROM of 25 degrees, increasing this weekly.  We use dynamic tape under the cast and during AROM ther ex to limit ext lag, or sudden flexion and to assist in Active extension in the early weeks of AROM.\\

For tendon lacerations, we begin the same AROM protocol at 8 weeks.\\

Patients are followed up weekly for AROM advancement and to assess for lag.  They wean out of their splints gradually beginning the second week of AROM.  They wean out of night splints around 4-6 weeks after beginning AROM.\\

Those of us therapists who have used this protocol (dynamic tape and quikcast, with weekly follow up) have found a much better return to full use with very minimal lag.  I think this is because we follow up fairly frequently and can modify use of the uninvolved fingers, e.g., if patients report they are still forcefully gripping, or that the splint doesn’t fit as well as when first provided. \\

These splints tend to stay on well, control edema during the initial healing process and are more streamlined than the typical plastic splints.\\

There are exceptions:  Extreme ecchymosis, edema or open wounds, etc, we will continue to use plastic splinting until the finger can tolerate the quikcast.\\


===== Resources for Cross-Cover Interns =====

The in-house University intern covering the Plastic Surgery Service on nights, weekends, and holidays is always first call for Hand consults whenever there is a Plastic Surgery attending on call for Hand (approx. 4 weekdays/month and 3 weekends/month.).
  * The schedule identifying the days that Hand consults are covered by Plastics can found on AMION under the Plastics and Hand call schedules.
  * The intern should see the consult immediately, get the history, perform an exam, and then promptly contact the on call Plastics resident for further instruction.
  * If for some reason the intern has not been able to reach anyone, the intern should contact the on call attending directly, rather than sit on an unstaffed consult.
  * It’s always better for the on call resident to be notified of a consult sooner rather than later.
  * Consult patients should be added to the “Plastics Hand” shared Epic list upon receipt of the consult. (If you do not have access to this list, ask one of the residents to add you.) If the patient will need a follow up appointment in the Hand Clinic, please make sure the ED puts in an order for “ambulatory referral to Hand Surgery” and specifies the attending who is on call that day (Dr. Gordon, Dr. Iorio, or Dr. Washington). This is the same attending to whom your note should be routed.
  * After a consult is completed and discharged from the Emergency Room, add the patient to the “For Hand Clinic Follow-up” shared Epic list and send a staff message to: P SP AMC HAND SURGERY (pool) and cc: the attending, Amy Kelso PA-C, Janessa Denman RN, and Dan Rodgers, ATC. \\

**Pearls for Common Calls**
  - Always get a sensory/motor exam prior to local anesthesia
  - Discuss oral and IV pain control with ED
  - Know how to perform a digital block and a hematoma block\\

==== Infections ====
  * Obtain a detailed history (including rapidity of onset and progression)
  * Examine for fluctuance
  * Give a dose of antibiotics (Get culture first if possible and if necrotizing soft tissue infection is not suspected)
  * Supplies needed for I&D:
  *- //1% lidocaine with epi//
  *- //ED I&D kit//
  *- //Culture swabs//
  *- //¼ inch Penrose drain//
  *- //1L of NS irrigation with 60cc syringe and luer lock irrigation shield attachment//
  *- //Bucket//\\
==== Lacerations ====

  * Ask about the mechanism
  * Make sure tetanus is up to date
  * Give a dose of IV antibiotics
  * Is there a tendon injury? //Determine this by asking the patient to open and close their hand – do the fingers all move normally?//\\ 
  * Is there a digital nerve injury? //Determine this by performing a sensory exam on the radial and ulnar border of EACH finger to test the radial and ulnar digital nerves to each finger.//\\
  * Is there an arterial/nerve injury at the wrist? //Perform a complete sensory and motor exam for the ulnar/radial/median nerves.//\\ 
  * Does the hand appear ischemic? Was there mention of arterial bleeding in the history?\\
  * Supplies needed for repair:
  *— //1% lidocaine with epinephrine//\\
  *- //Betadine//\\
  *- //Gauze//\\
  *- //1L of NS irrigation with 60cc syringe and luer lock irrigation shield attachment//\\
  *- //Bucket//\\
  *- //5-0 nylon sutures//\\
  *- //3-0 Supramid or Fiberwire from OR if extensor tendon is involved//\\
  *- //Suture tray: Hemastat, Needle Driver, Forceps, Scissors (Plastics Minor Set from OR is ideal)//\\
  *- //Xeroform, 2 inch Kling wrap, Kerlix, Coban//\\
==== Hand/Wrist Fractures/Dislocations ====

  *For distal radius fractures: Determine if there is an acute carpal tunnel syndrome, meaning, is there numbness in the distribution of the median nerve (thumb, index, long, and radial border of the ring finger)?
  *Discuss with ED their ability/availability to perform conscious sedation if needed
  *Supplies needed for fracture/dislocation reductions:
  *- //1% lidocaine with epi//\\
  *- //10cc syringe//\\
  *- //18G needle//\\
  *- //27G needle//\\
  *- //Alcohol swabs and Gauze//\\
  *- //Finger traps and IV pole from ED//\\
  *- //4 liters of IVF in bags and surgical netting (for traction weight)//\\
  *- //Mini C-arm (have the ED call the radiology tech to bring it)//\\
  *- //Cast cart for cast padding, 4 inch plaster, and 4 inch ACE or Bias//\\
  *- //Scissors//\\
  *- //1L of NS irrigation with 60cc syringe, luer lock irrigation shield attachment, & bucket if open fracture//\\
  *- //Arm Elevation Pillow from OR (blue foam pillow; need to send OR a patient sticker and go pick it up from the OR desk)//\\
==== Amputations ====

  *Determine the time and mechanism of the injury
  *Make sure tetanus is up to date
  *Give a dose of antibiotics
  *Determine the level relative to the next more proximal joint (DIP, PIP, MCP – i.e., “the amputation is just distal to the PIP joint”)
  * Make sure the part (if available) is wrapped in sterile gauze, placed in a bag, THEN placed in an ice bath
  * Have ED perform XRays of both the hand and the amputated finger
  * Do not delay contacting Plastics Fellow
  * Replants are only done at Denver Health (NOT UCH). If at UCH, will likely perform a revision amputation. Supplies needed are similar to laceration repair above. Get a Minor Hand Tray from the OR for the appropriate surgical instruments.


=====Common Hand Consults=====

{{ resident:common_hand_consults.pptx |Jeev's Common Hand Consults}}