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Home , Hand injury, Orthopedic surgery

Combined Orthopedic and Plastic Manager (Revised 06.05.20)

Statement Regarding Contacting the Consult Team . This guide is intended to streamline consultations and facilitate time to disposition in the Emergency Department. If an injury pattern or guideline is unclear, the EM should not hesitate to contact the on-call team to discuss a potential consultation. Call the attending on call directly if there are any communication issues.

Expectations of Hand Surgery Consult Team . For ‘Consult’: The on-call team will evaluate the patient in the ED within the timeframe outlined by the consult type (E.g. STAT, ASAP, Routine). . When appropriate a phone consult can be completed by agreement of EM and Hand providers. The on- call hand team will (1) discuss the injury with the EM Physician, (2) review pertinent images/photos, (3) provide treatment guidance over the phone, (4) write a note in eStar with recommendations, and (5) place follow-up order for the patient. . For ‘Referral’: Communication with the on-call team is not mandatory, and the EM physician will place a clinic follow-up order as recommended by the Hand Injury Manager.

General Guidelines Regarding Hand . All consults should have hand 3 view x-ray prior to placing consult. . Important history includes age, sex, handedness, occupation, mechanism of injury, time of injury, and smoking status. . Exam should include neurovascular assessment as this determines urgency in all cases. . All open injuries require appropriate antibiotics (ASAP), followed by washout, closure, and splinting. . Provide antibiotics for contaminated injuries and open fractures (3 days). . Update tetanus, diphtheria, and pertussis in contaminated injuries.

General Discharge Follow Up Instructions . Lacerations: Takedown dressing after 48 hours and allow soap/water to wash over twice a day. . Fractures: Leave splint in place, no weight bearing, and elevate extremity at all times. . Pain control: Fives days of acetaminophen, NSAID, Gabapentin, and two days of Tramadol (or Oxycodone) . Referral: On-call attending contact information and follow-up timing should be provided to patient.

Condition Characteristics Consult Type Recommendations Digit Fractures Consult is indicated for open fractures Thumb Nondisplaced Referral (3-5 days) Thumb Spica

Intra-articular, Consult Hand Reduce Comminuted, Displaced, Thumb Spica Dislocated RCL/UCL tear or avulsion Referral (3-5 days) Thumb Spica (Skier’s thumb) Digits 2-5 Nondisplaced Referral (3-5 days) Intrinsic plus splint No intra- articular involvement Displaced Consult Hand Reduce Angulated > 30 degrees Intrinsic Plus Splint Shortening Ulnar Gutter for RF or SF fractures Intraarticular Carpal Fracture Low threshold for CT scan hand/wrist for occult fractures Scaphoid Any Consult Hand Thumb Spica

Lunate Fracture Consult Hand Intrinsic Plus Splint

Dislocation Consult Hand Watch for median compression Reduction, Intrinsic Plus Splint Surgery likely indicated All Others Any Consult Hand Intrinsic Plus Splint Wrist and Forearm Factures Distal and ulnar fractures Consult Hand Reduce If other extremity Sugar-tong splint injuries Consult Orthopedic Surgery Mid and proximal radius and/or ulnar Consult Orthopedic Reduce fractures Surgery Sugar-tong splint Includes Galeazzi, Monteggia Fractures Small Dislocations Interphalangeal joint Reduce Self-reduced Referral (3-5 days) Digit splint Reduced after single attempt Referral (3-5 days) Unreducible after single attempt Consult Hand Metacarpophalangeal joint Consult Hand Reduce Digit splint

Traumatic Amputations Consult Hand Document time of X-ray hand & amputated digit Wrap digit(s) in wet cold towel/bag Replant versus revision amputation Soft dressing Auto-amputations (e.g. dry gangrene) Consult Hand If no acute , BID betadine paint application. Leave open to air Nail Bed Injuries Nail bed injuries (often associated Consult Hand Repair of sterile matrix with 6-0 FAST or with distal phalanx fractures) dermabond. Digit splint Subungual Acute (< 48 Consult Hand Trephination or remove nail hours, > 50% of nail, & painful) Soft dressing Delayed presentation of subungual Consult Hand Observe versus trephination versus hematoma (> 48 hours, painless) remove nail. Soft dressing Lacerations/ Injuries Open flexor or extensor tendon Consult Hand Flexor injuries: Extension Block Splint injuries Extensor injuries: Intrinsic Plus Splint Closed tendon injuries (e.g., mallet Consult Hand Digit splint finger) Obtain cultures when possible Simple cellulitis (hand, wrist, forearm Consult Hand Oral vs IV Antibiotics

Simple abscess (hand, wrist, forearm Consult Hand , PO antibiotics Daily soaks, Dressing +/- splint Paronychia or Felon Consult Hand Incision & drainage PO antibiotics, Soft dressing Flexor Tenosynovitis Consult Hand Incision and drainage of sheath Cardinal Signs (fusiform swelling, pain IV antibiotics on passive extension, tenderness over Admission for surgery or IV antibiotics flexor sheath, flexed digit) Human Bites (clenched fist injury) Consult Hand Incision and drainage. Likely admission Examine hand with fully flexed for surgery or IV antibiotics Septic Consult Hand Aspiration (send fluid for gram stain, Pain/ limited movement of affect joint an/aerobic culture, fungal, crystals, cell count). Intrinsic Plus Splint/ Elevation Necrotizing fasciitis Consult Hand Emergent surgical

Shooter’s Abscess Consult Hand Incision and Drainage

High Pressure injections Consult Hand Emergent surgical debridement/decompression Animal Bites Dog bites Consult Hand Irrigate and leave open or loosely Ascertain rabies vaccination approximate Empiric Augmentin Cat Bites Consult Hand Irrigate and leave open Ascertain rabies vaccination Empiric Augmentin Snake Bites Consult Hand Strict extremity elevation Expect necrosis/allow for full declaration Brown Recluse Spider Bites Consult Hand Refer to protocol Expect necrosis/allow for full declaration Clinical suspicion of compartment Consult Hand Emergent surgical decompression syndrome Lacerations Simple Lacerations (easily Referral (3-5 days) Washout. Close with interrupted 4-0 reapproximates, isolated) chromic sutures Complex lacerations (loss of soft Consult Hand Irrigate, close or pack, splint as tissue, associated injuries) appropriate IV Infiltration Hand & upper extremity IV infiltration Consult Hand Isolated soft-tissue Consult Burn

Burn with associated fracture/tendon Consult Burn and Debridement by Burn injury Consult Hand Fixation/splinting by Hand Surgery Ischemia Atraumatic acute limb ischemia Consult Vascular Surgery to consult Hand Surgery Must obtain Doppler US and CTA if appropriate Raynaud’s Disease Consult to refer (1-2 weeks) to Hand and/or Medicine Surgery for possible Botox or Sympathectomy