Plastics

Jeev's Common Hand Consults

• The in-house University intern covering the Plastic Surgery Service is always first call for Hand consults whenever there is a Plastic Surgery attending on call for Hand (approx. 15 days/month).
• The schedule identifying the days that Hand consults are covered by Plastics can found on AMION under the Plastics and Hand call schedules.
• Weekday daytime consults can be triaged directly to Kathryn Miller, PA-C.
• Evenings and weekends, or if Kathryn is not available, the intern should see the consult immediately, get the history, perform an exam, and then promptly contact the appropriate person for further instruction.
• On weekdays consults should be staffed with the Hand Fellow. On evenings and weekends consults should be staffed with the on call Fellow.
• 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 Fellow 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 or Dr. Iorio). This is the same attending to whom your note should be routed.
• Pearls for Common Calls

1. Always get a sensory/motor exam prior to local anesthesia
2. Discuss oral and IV pain control with ED
3. Know how to perform a digital block and a hematoma block
4. 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
• Arm Elevation Pillow from OR (blue foam pillow; need to send OR a patient sticker and go pick it up from the OR desk)

• Lacerations

1. Ask about the mechanism
2. Make sure tetanus is up to date
3. Give a dose of antibiotics
4. 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 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
• 22G 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)
• 2 sets of Lead, including thyroid shield, for the provider and the patient (tell ED to remind radiology tech to bring these, they often forget)
• 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

1. Determine the time and mechanism of the injury
2. Make sure tetanus is up to date
3. Give a dose of antibiotics
4. Determine the level relative to the next more proximal joint (DIP, PIP, MCP – i.e., “the amputation is just distal to the PIP joint”)
5. Make sure the part (if available) is wrapped in sterile gauze, placed in a bag, THEN placed in an ice bath
6. Do not delay contacting Plastics Fellow

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.