Understanding Hand Surgery
1. History Taking
History taking L H Tan, V. Rajaratnam COMFORT AND ANALGESIA Ensure that the patient is as comfortable as possible and that adequate analgesia has been given even before the history -taking and full evaluation. Patient’s concerns: • What effect will his injury have on his/her everyday life, both immediately and in the long term, and • What treatment options are available? You must also be aware that the patient requires sufficient information, assurance and confidence to be in the surgeon’s hands. HISTORY The following information must be obtained in any hand injury patients: 1. Name 2. Gender 3. Age 4. Dominant-hand 5. Occupation 6. Hobbies/recreational activities 7. Smoker / non-smoker Other general points in history: The patient’s current health status, past medical history, previous anaesthetic experiences, bleeding disorders, current medications, allergies, tetanus immunisation status and time of last meal should all be recorded. Date, time and type of injury It can potentially have medico-legal implications. The time of injury should be noted as certain injuries require urgent management and should be treated as soon as they are recognized; in order of urgency: 1. Uncontrolled haemorrhage secondary to vascular injury 2. Complicated fracture or dislocation compromising major vascular injury or producing doubtful viability 3. Compartment syndrome 4. Macro-replantation, that is when the amputated part contains significant muscle bulk 5. Hydrofluoric acid burns 6. Pressure gas injuries If left untreated, the hand will undergo certain changes, which will influence its eventual recovery of function: • Necrosis and contractures may result from vessel occlusion secondary to unstable fractures. (Due to irreversible permanent intimal changes or irreversible ischemia in the area of blood supply) • Contamination of the tissue causing infection. • Progressive edema, leading to: a) Compartment syndrome b) Joint contracture c) Friability of tissues, which may complicate tendon, nerve, and vessel repairs d) Difficulty in skin closure, to the point of compromising skin circulation Place of injury • Home • Work • Outdoor Mode of injury • Accident • RTA (Are there other injuries which may take precedence?) • Self-inflicted (Is the patient likely to re-injure / be non-compliant?) • Assault Mechanism of injury 1. What happened to your hand? 2. Which part of your hand is injured? 3. How was it injured? • Roller • Punch Pressure • Saw • Laceration • Penetrating • Blunt • Pressure gun • Gunshot wound • Others e.g. lawn mower Roller injuries • Does it have a roller? Roller injuries commonly produce avulsion flaps, whereby the distal part may not be viable and hence amputation would be the only treatment option. • What is the size of the gap? If the gap is small, distal crush may be so severe that revascularisation may not be successful. • What are the rollers surfaced with? • What normally passes through the rollers? There may be some foreign bodies in the wound which may or may not cause increased risk of wound contamination and will therefore Fig: Extensive roller injury to hand and forearm Fig: Punch press injury need adequate irrigation in A&E or a formal washout and debridement in theatre. • Are they hot? The viability may be compromised by burns or heat from the friction of rollers, especially the ones that do not have an automatic release or arrest. • Do they have an automatic release mechanism? • How quickly were they stopped once your hand was caught? As prolong pressure necrosis can result. Punch pressure • What is (roughly) the area and shape of the punch press? • What is the narrowest space in which your hand was compressed? Depending on what the punch pressure produces, it can inflict moderate to severe injuries. A large area of injury can cause comminuted fractures, carpal disruption and soft tissue injuries. In a smaller area of injury, division of tendons and nerves at two levels is more likely compared to roller injuries. • How long was your hand under the punch? Again bear in mind that blood vessels may be compromised causing significant necrosis. Saw Saw (esp. electrically driven circular saw) injuries from carpentry/DIY accidents is very common. • What kind of saw? e.g. Circular saw or high speed metal saw • What were you cutting? (a) (b) (c) Fig: a) Laceration caused by a saw injury. (b) Laceration caused by a sharp instrument (c) Avulsion injury of thumb This will give you an idea of risks of contamination or possibilities of foreign bodies. • What’s the set on the blade (amount of deflection in the saw’s teeth from a straight line) A high speed metal saw with a narrow set will approximate to a knife cut. On the other hand a wide set saw avulses as well as cutting, producing damage distant from the skin wound. This would make re-vascularisation and replantation difficult. Laceration • Show me the position of your hand when it slipped on the knife? The relationship of the distal cut end of the long flexor tendons of the fingers to the wound skin varies according to the posture of the hand at the time of injury. The distal tendon ends may be at the wound itself when the finger is extended. If the finger was fully flexed then the distal tendon ends will be as far removed (proximally) from the skin laceration. This would be important for surgeon when carrying out primary tendon repair. Penetrating • Show me how it happened? Penetrating injuries of the hand carry the same sinister implication as penetrating injuries to the abdomen or neck. An unimpressive wound may hide a remarkable amount of damage to deep structures. • In what direction was it pointing? The damage to deep structures in stab wounds may be remote from the skin wound. • What stuck into your hand? Short puncture lacerations over the knuckles should raise suspicion as they are most likely inflicted by the human teeth, even though the patient may deny it. This injury is prone to infection, which can be more resistant than infections related to dog bite injuries. Immediate copious irrigation can significantly decrease this risk. Hence exploration and washout in theatre is essential. Broad spectrum antibiotics are essential in the management of human and dog bite injuries. For example, intravenous co-amoxiclav and flucloxacillin for human bite wounds and intravenous co-amoxiclav for dog bite wounds. Pressure gun Penetrating gun injuries need to be treated with urgency depending on what agent has been injected. The most common substances are paint, grease, hydraulic fluid or molten plastic. Patients may not have pain immediately. They should have immediate exploration and removal of all foreign material. If not immediate, may result in infection, gangrene and amputation. The long term outcome includes fibrosis, and discharging sinuses from granulomas which can cripple the hand Gunshot 1. Type of gun? 2. Range and calibre? High-energy injury is associated with comminution, bone loss, significant skin defects and a high incidence of vascular and nerve injury. Low-energy wounds, however, often present as a foreign body in the tissues. Blunt injury Blunt injury including falls. Very heavy falls on an outstretched hand are commonly associated with supracondylar fractures in children, carpal injuries in young and middle aged adults and Colles fractures in the elderly. 1. What height did you fall from? 2. Did you have to stop what you were doing? Patients may be able to continue doing what they were doing with the initial sustained hair line fracture, which can subsequently progress into a complete fracture following further insult, thus causing severe pain and not allowing them to continue. Previous injury Previous injury to the part, primary treatment and subsequent progress and therapy may be relevant. Other relevant points in history include: Current health status/ Relevant past medical history Apart form obtaining associated injuries, a brief general medical history should be obtained. This is to elicit any cardio-respiratory problems, which may influence the choice of anaesthesia. Psychiatric disorder Psychiatric disorders which may severely limit postoperative co-operation. Medication / Allergies Some medication may interfere with adequate healing. Uncontrolled diabetes, certain skin conditions, and steroid intake are associated with increase sepsis rate. Drug allergies should always be recorded. Social history Patient’s occupation is very important in choosing the appropriate operation procedure. This is especially important in reconstructive surgery, which aims to restore maximum function to the hand and to do that in the shortest time. For instance, a self employed manual worker would want to get back to work as soon as possible, therefore a long lengthy rehabilitation period is unsuitable for patient’s needs. 1. What exactly do you do? 2. How long have you been doing that kind of work with the current employer? 3. Are you self-employed or is your employer holding your job? 4. Do you hope to go back to the same job? 5. Are you the only person working at home? 6. How many people are you supporting? Smoking is also well known to affect tissue healing and a high alcohol abuser may indicate a non-compliant patient. Recreational • Do you play any musical instruments? E.g. Guitar, piano, violin TAKING REFERRALS FOR REPLANTATION When taking a referral for replantation, the following questions and statements should be presented to the caller. (Also see Chapter 13) 1. What is your name, that of your facility and the contact number? 2. How did the amputation happen? 3. Are there any injuries else where in the body? 4. How old is the patient and is he generally healthy? 5. Does the patient smoke? 6. Is that limb otherwise intact? 7. How about the x-ray? 8. How will you prepare the limb for transport? With respect to the amputated part: 1. Are there other injuries? 2. When you wash off the wound, are there structures dangling from the part? 3. Tell me about the xray of the part? 4. How will you transport it? 5. Is there a good/fair/poor chance of replantation? 6. We will be glad to see the patient but please emphasize to him/her and the family that the decision to try replantation can only be made here and, of course success cannot be guaranteed. 7. How will patient be transported? 8. Can you give me an estimated time of arrival?