Management Of Hand Trauma Research Articles

The Hand KISS Protocol: Clinical Application of Smartphone in the Early Management of Hand Trauma

The Hand KISS Protocol: Clinical Application of Smartphone in the Early Management of Hand Trauma

Lessons From the Pandemic for Hand Surgery in Wales.

Aims In March 2020 the World Health Organisation (WHO) declared the COVID-19 virus a global pandemic. The United Kingdom's National Health Service (NHS) was placed under unprecedented pressure and hospitals were forced to adapt their working practices to continue offering world-leading healthcare. This project aims to highlight the lessons learnt within hand surgical departments throughout Wales. Using this knowledge, we can consider how these lessons can be implemented in both emergency and elective hand practice. Methods A qualitative questionnaire was distributed to hand consultants working across Health Boards within Wales during the pandemic. The questionnaire encompasses the impact of the pandemic on usual practices and what local departmental changes have been implemented in response to patient needs. Results Across the Welsh Health Boards, we received 12 of 19 consultant responses achieving a 63% response rate and captured data from five of seven (71%) major health boards. The questionnaire revealed that 100% of respondents changed their routine management of elective cases whilst 83% changed their management of hand trauma. 50% reported the need to issue updated management guidelines to junior doctors. The major highlighted lessons were the importance of a dedicated hand fracture clinic, coupled with a ring-fenced day-surgical unit (offering regional anaesthetic support) to manage trauma and elective patients independently from general trauma. Conclusion This qualitative research demonstrates that the pandemic drove the restructuring of many hand departments enabling us to find new, efficient ways of working. We must take these lessons forward to tackle the ever-growing waiting list, increased patient expectations and increasingly complex workloads.

Reduced Access to Acute Hand Care and Potential Role of Telemedicine in Tennessee During the COVID Pandemic.

Previous studies have identified that there is limited, although expanding, access to acute hand care in Tennessee. Because of the rapid changes that occurred in health delivery and access during the coronavirus disease pandemic, we reassessed access to acute hand care, with particular interest in the utilization of telemedicine to assess if this increased access. We surveyed Tennessee hospitals listed by the Tennessee Hospital Association on their management of hand trauma and availability of telemedicine programs. Census data including population demographics such as race, age, income, and county size were merged with the survey data. Descriptive analysis was performed comparing the 2021 cohort with the historic 2018 cohort and between counties that had hand care versus counties that had no hand care. Survey response rate was 71.4% (n = 80 of 112). Telemedicine was used in 80% of the hospitals for other specialties but was not used for hand care. Overall, counties that offered hand trauma care reduced from 60% to 26% from 2018 to 2021 ( P < 0.001). This change was associated with a significant reduction of acute hand care among counties that were classified micropolitan (from 56.3% to 6.7%, P < 0.01). Percentage of hand specialists on staff and 24/7 specialists availability remained low and were similar to the availability in 2018. There was a decrease of acute hand care access in Tennessee during the coronavirus disease pandemic despite widespread utilization of telemedicine for other specialty consults. Expansion of telemedicine in acute hand care, targeted to micropolitan areas, may help to reduce variability in access to care.

The Impact of COVID-19 on the Choice of Treatment for Hand Fractures: A Single-Centre Concordance Study.

Background: Management of hand trauma has evolved to incorporate assessment, treatment and rehabilitation of patients in a 'one-stop' clinic on initial presentation. Our aim was to evaluate the effect of coronavirus disease 2019 (COVID-19) on the choice of treatment for hand fractures using inter-rater agreement between surgeons. Methods: All patients with hand fractures during the COVID-19 lockdown from March to May 2020 were included in the study. Two experienced hand surgeons blinded to management and outcomes independently reviewed radiographic images and relevant clinical history to provide their opinion on optimal treatment. Weighted kappa analysis was performed to determine concordance and inter-rater agreement between the two surgeons and actual management. Results: The study included 82 patients (62 men and 20 women) with a mean age of 40.3 (SD 19.7). The injuries occurred most often at home following an accident (34%) or a fall (28%). Fractures involved the metacarpals in 29 patients and the distal phalanx in 22 patients. Thirty-five patients underwent surgery, whereas 47 were managed conservatively. Overall agreement between actual management and consultant A and consultant B was moderate (κ = 0.55, p < 0.0001 and κ = 0.63, p < 0.0001, respectively). Subgroup analysis showed a weak agreement between actual management of metacarpal fractures and consultant A and consultant B (κ = 0.22, p = 0.29 and κ = 0.47, p = 0.02, respectively). Inter-rater agreement was substantial for management of metacarpal fractures (κ = 0.73, p < 0.0001), but weak for distal phalanx fractures (κ = 0.29, p = 0.03). Conclusion: Our study has shown that overall management of hand fractures remained optimised throughout the pandemic. However, a lack of concordance was observed in the management of metacarpals. Level of Evidence: Level IV (Therapeutic).

308 The Effect Of COVID-19 On Hand Trauma Management: A Single-Centre Correlation Study, Inter-Rater Agreement and Functional Outcomes

IntroductionManagement of hand trauma has evolved to incorporate assessment, treatment and rehabilitation of patients in a ‘one-stop’ clinic on initial presentation. Our aim was to evaluate the effect of COVID-19 on hand trauma management using inter-rater agreement between hand surgeons.MethodPatients with hand fractures were consecutively assessed from March to May 2020, with atleast 6-month follow-up outcomes. Two experienced hand surgeons blinded to management and outcomes independently reviewed radiographic images and clinical history to provide their opinion on optimal treatment. Weighted-kappa analysis was performed for concordance and inter-rater agreement between the two surgeons and actual management.Results268 patients were identified, 82 had fractures involving tubular bones of the hand. 62 were male and 20, female. Mean age was 40.3 (SD 19.7). Mechanism of injury was secondary to home-related injuries (34%) and falls (28%). Fractures involving the metacarpals (n = 24) and distal phalanx (n = 20) were most commonly seen. 35 patients underwent surgery whereas 47 were managed conservatively. Overall agreement between actual management and both consultant-1 and consultant-2 was moderate (κ = 0.55, p < 0.0001 and κ = 0.63, p < 0.0001, respectively). Subgroup analysis showed a weak agreement between actual management of metacarpal fractures and both consultant-1 and consultant-2 (κ = 0.22, p = 0.29 and κ = 0.47, p = 0.02, respectively). Inter-rater agreement was substantial for management of metacarpal fractures (κ = 0.73, p < 0.0001) whilst functional outcomes were comparable as reported by patients.ConclusionsOur study has shown that overall management of hand fractures remained optimized throughout the pandemic. However, lack of concordance was observed in the management of metacarpals through substantial inter-rater agreement but overall poor agreement.

377 Expanding the Use of Wide-Awake Local Anaesthesia Non-Tourniquet (WALANT) Technique in The Management of Hand Trauma Patients During the COVID 19 Pandemic

AimCOVID19 produced a unique challenge to the management of hand trauma. There was reduced theatre capacity and inpatient beds as staff and resources were lost to make way for the critically unwell1, however the burden of patients (albeit reduced) requiring emergency procedures remained2. During 1stUK peak we adopted a one-stop hand trauma clinic where patients were assessed by senior surgeons and immediately operated on under local anaesthesia with Adrenalin, a model mirrored by other units across the UK during this time3,4. Subsequent to surgery they were either seen on the same day for advice with a hand therapist or booked for immediate hand therapy follow up.MethodA retrospective review of 158 cases operated on over a 4-month COVID19 period compared to the same 4-month period 1 year previously. Indications for surgery and type of anaesthesia were recorded. Follow up and complication rates were reviewed for the COVID19 patients.ResultsThere were similarities in the demographic of patients across both cohorts and in mechanism of injury, with trauma the highest indication for surgery. The comparable data sets showed only 21% of patients treated used WALANT pre-COVID19 versus 100% of patient during COVID19.ConclusionsWALANT is a viable model by which to perform emergency hand trauma surgery in a low cost and low resource setting. Previously this model was not utilised to full effect in our hospital. The results demonstrate the adaptability of WALANT in an adverse and dynamic situation, such as COVID19, thus highlighting benefits to patient care and service provision.

1549 Patient Perception on Hand Trauma Management Through a Plastic Surgery Trauma Clinic

Abstract Aim We assessed patient perceptions of hand trauma management through a plastic surgery trauma clinic. We also assessed effects of educating patients about outcomes of their condition on their desire to have prompt surgery. Method A prospective survey review was conducted at our plastic surgery trauma clinic. Patients included were those referred due to simple hand trauma. Any patients needing urgent admissions were excluded. An anonymous survey assessing patient perceptions before and after education about delay in surgery was distributed. Results Of 100 patients, there were mixed expectations regarding trauma clinic; 38% (n = 38) expect an operation, 32% (n = 32) expect no operation and 30% (n = 30) expect either option. 90% (n = 90) expect surgery within a week (50% n = 50) or within a day (40% n = 40); 10% expect it (n = 10) within a few weeks. After educating patients about no negative effects on their condition from surgical delay, 43% (n = 17) fewer patients desired surgery within a day, and 8% (n = 3) fewer patients desired surgery within a week. 190% (n = 19) more patients were willing to have surgery within a few weeks. 79% (n = 79) would rather come back at a guaranteed surgical slot than stay in hospital until a slot is available. 72% (n = 72) considered knowledge about long-term outcomes associated with surgical delay to influence their decision more than anaesthetic type (12% n = 12) and personal circumstances (16% n = 16). Conclusions If appropriate patients are assured that their condition will not be affected by surgical delay, fewer patients may stay in hospital with financial benefits of reduced bed occupancy and reduced covid risks.

1394 Operation Notes Performa: The Way to Optimise Hand Trauma Service

Abstract Aim To assess the effect of the introduction of British Society for Surgery of the Hand (BSSH) guided operation note Performa on the hand trauma service in St. George’s University Hospitals. Method First cycle was done in October 2019. This included retrospective evaluation of accuracy of documentation for closed hand fracture audit. Reassessment was done in September 2020 after introduction of surgical Performa guided by the latest BSSH guidelines. Results 27 patients have been included in the first cycle compared with 81 patients in the second cycle. While 82% of first cycle patients underwent operation, only 40% of second cycle patients were treated surgically. Overall documentation has improved by a mean of 40% in all parameters. This includes documentation of discussion of shared decision making regarding conservative and surgical management, documentation of level of competency of the operating surgeon and mobilisation advice given to patients before their first appointment with a hand therapist. This led to improvement in overall patient outcome including rate of infection falling from 14% to 1% and reoperation rate from 23% to 1%. Conclusions Op notes Performa is a useful tool in the armamentarium of hand trauma management. It helps junior trainees to memorise critical information to document especially in the ones usually missed like detailed post-operative advice.

Relevance of antibiotic prophylaxis in the management of surgical emergency open hand trauma

Surgical site infection after emergency hand surgery can cause considerable morbidity and, in the most severe forms, even toxic shock syndrome. Postoperative antibiotic prophylaxis aims to reduce the number of surgical site infections. However, excessive use of antibiotics induces side-effects for patients and antibiotic resistance for society. Contrary to other orthopedic sites, there is no consensus on postoperative antibiotic prophylaxis in open hand trauma beyond analogic reasoning with no proven scientific validity. Our hypothesis was that absence of postoperative antibiotic prophylaxis after open hand trauma surgery does not affect the rate of surgical site infections. A prospective cohort study included 405 patients, operated on in the emergency hand trauma unit without intra- or post-operative antibiotic prophylaxis. Patients were followed up in consultation at 7, 14 and 30 days. Surgical site infection was defined by need for surgery for detersion and flattening, followed by curative antibiotic therapy. The surgical site infection rate was 2.22%. Four patients were lost to follow-up and counted as surgical site infection as originally planned in the worst-case analysis. There were five surgical revisions followed by antibiotic therapy. These results do not differ from those reported in the literature, and thus confirm our hypothesis that postoperative antibiotic prophylaxis is not indicated in open hand trauma management.

AB071. SOH21AS091. The impact of coronavirus disease 2019 (COVID-19) on the management of hand fractures: a concordance study through inter-rater reliability

Background: The current global pandemic due to coronavirus disease 2019 (COVID-19) is generating significant burden on health services. As a result, management of hand trauma has evolved to incorporate assessment, treatment and rehabilitation of patients in a ‘one-stop’ clinic on initial presentation. Whilst it is early to qualitatively assess the impact of these changes, we must evaluate the potential effect of COVID-19 on surgical management of patients with hand fractures. Our aim was to determine interrater agreement between hand surgeons and concordance of hand fracture management during the COVID-19 period

Strategies in reconfiguration of hand injuries management during COVID-19 pandemic

During the COVID-19 pandemic there has been a re-organisation of care provided by the Trauma and Orthopaedic services in the United Kingdom. The National Health Service England (NHSE) speciality guide forms the primary responses to this pandemic, whilst British Society for the Surgery of Hand (BSSH) provides sub-specialty guidance on management of hand trauma. The orthopaedic community’s responsibility of providing a continuity of care for patients has to be balanced with measures to reduce risk of viral transmission (e.g. reduce face to face consultations) and also protect ion of both the patients and staff.We highlight the strategies applied whilst reconfiguration of hand injury management following publication of COVID-19 British Society for the Surgery of Hand and Indian Orthopaedic Association (IOA) guidelines.

A Novel Telemedicine System for Care of Statewide Hand Trauma.

Background: Telemedicine is an evolving tool to increase patients' access to subspecialty care. Since 2014, Arkansas has been utilizing telemedicine in the evaluation of patients with hand injuries. The purpose of this study is to assess the effect of this novel telemedicine system for the management of hand trauma on patient transfer. Methods: We reviewed data from the first year of the telemedicine program (2014) and compared it to data from the year prior (2013). Data collection from both years included number of hand consults and need for transfer. From the 2014 data, we also recorded the use of telemedicine, type of transfer, distance of transfer, and time to disposition. Results: During 2013 (pre-telemedicine), there were 263 hand traumas identified. In all, 191 (73%) injuries required transfer to a higher level of care, while 72 (23%) were managed locally. In the first year of the telemedicine program (2014), a total of 331 hand injuries were identified. A total of 298 (90%) resulted in telemedicine consultation with 65% (195) utilizing video encounters. After telemedicine consultation, local management was recommended for 164 injuries (55%) while transfer was recommended for 134 (45%). Using telemedicine, there was a significant decrease in the percentage of transfer for hand injuries (P < .001). Conclusions: The telemedicine program was well utilized and provided patients throughout the state with continuous access to fellowship trained hand surgeons including regions where hand subspecialty care is not available. The program resulted in a significant decrease in the number of hospital transfers for the management of acute hand trauma.

Establishing a paediatric hand trauma management pathway: A closed loop multi-centre audit

Establishing a paediatric hand trauma management pathway: A closed loop multi-centre audit

Hand trauma: A prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements

Hand injuries are common, contributing up to 30% of accident and emergency (A&E) attendances. The aim of this study was to prospectively analyse the pathological demographics of hand injuries in a level 1 trauma centre with a Hand Trauma Unit and direct A&E links, and compare clinical and intra-operative findings. The null hypothesis was that there would be no differences between clinical and intra-operative findings (100% diagnostic concordance). Data were prospectively collected for referrals during 2012. Referral diagnosis, additional pathologies found on clinical assessment and intra-operative findings were documented on a live database accessible from both the Hand Unit and associated operating theatres. Odds ratios were calculated using SAS. Injuries (1526) were identified in 1308 patients included in the study. Diagnostic concordance between Hand Unit clinical examination and intra-operative findings was 92.5%±2.85% (mean±SEM); this was lower for flexor tendon injuries (56.3%) because a greater number of additional pathologies were found intra-operatively (2.25±0.10). This 'trend' was noted across multiple referral pathologies including phalangeal fractures (1.28±0.02; 82.9%), lacerations (1.33±0.04; 79.1%), extensor tendon injuries (1.30±0.05; 87.8%) and dislocations (1.18±0.05; 87.8%). Odds ratio analysis indicated a relationship between primary referral diagnoses that were more or less likely to be associated with additional injuries (p<0.05); referral diagnoses of flexor tendon injuries and lacerations were most likely to be associated with additional injuries. As hand injuries are a common presentation to A&E departments, greater emphasis should be placed on training clinicians in the management of hand trauma. Our findings, coupled with the presented relevant literature reports, lead us to advocate that A&E departments should move towards a system wherein links to specialist hand trauma services are in place; we hereby present useful data for hospitals implementing such services.

Adherence behavior in an acute pediatric hand trauma population: A pilot study of parental report of adherence levels and influencing factors

IntroductionDescriptive and cross-sectional study. Purpose of the StudyThe hand is a common site of injury in children; however, little is known regarding adherence to hand trauma management in this population. PurposeThis pilot study aimed to describe adherence to plaster slab immobilization, advice regarding return to sport, appointment attendance, and the factors influencing nonadherence. MethodForty-seven parents of children with hand trauma completed an online questionnaire reporting their child's adherence to the initial medical management. ResultsParents reported that 34% (16 of 47) of children were adherent to all aspects of management. Nonadherence with plaster slab immobilization was reported by 38% (18 of 47), and 45% (21 of 47) reported nonadherence with advice regarding return to sport. Hygiene, discomfort, and restriction were the most common reasons for plaster removal. Belief that sport would not cause harm and social factors influenced return to sport against medical advice. ConclusionNonadherence behavior is commonly reported in children with acute hand trauma. Level of evidence4.

An Educational Intervention to Improve Splinting of Common Hand Injuries

BackgroundHand trauma is a top presenting complaint to hospital emergency departments (EDs) and can become costly if not treated effectively. The cornerstone for initial management of the traumatized hand is application of a splint. Improving splinting practice could potentially produce tangible benefits in terms of quality of care and costs to society. ObjectivesWe sought to determine the following: 1) whether the present standard of ED splinting was appropriate and 2) whether a strategically planned educational intervention could improve the existing care. MethodsWe used a pre- and postprospective educational intervention study design. In the preintervention phase, patients referred to our hand clinic were assessed for injury and splint type. Splinting appropriateness was evaluated according to a predetermined hand surgeons' expert consensus. Next, an educational intervention was targeted at all ED staff at our institution. Postintervention, all patients were again evaluated for splint appropriateness. A follow-up evaluation was performed at 1 year to see the long-term effects of the intervention. ResultsThe most common mechanism of injury of referred patients was falling (35%), and the most frequent injury was metacarpal fracture (40%). Splint appropriateness increased significantly postintervention from 49% to 69% (p = 0.048). At follow-up after 1 year, splinting appropriateness was 70% (p = 0.041). ConclusionAppropriate hand splinting practice is essential for hand trauma management. Our results show that an educational intervention can successfully improve splinting practice. This quality of care initiative was low-cost and demonstrated persistence at 1 year of follow-up.

Are online learning modules an effective way to deliver hand trauma management continuing medical education to emergency physicians?

The enormity of modern medical knowledge and the rapidity of change have created increased need for ongoing or continuing medical education (CME) for physicians. Online CME is attractive for its availability at any time and any place, low cost and potentially increased effectiveness compared with traditional face-to-face delivery. To determine whether online CME modules are an effective method for delivering plastic surgery CME to primary care physicians. A needs assessment survey was conducted among all emergency and family physicians in Nova Scotia. Results indicated that this type of program was appealing, and that hand trauma related topics were most desired for CME. 7 Lesson Builder (SoftChalk LLC, www.softchalk.com) was used to construct a multimedia e-learning module that was distributed along with a pretest, post-test and feedback questionnaire. Quantitative (pre- and post-test scores) and qualitative (feedback responses) data were analyzed. The 32 participants who completed the study indicated that it was a positive and enjoyable experience, and that there was a need for more resources like this. Compared with pretest scores, there was a significant gain in knowledge following completion of the module (P=0.001). The present study demonstrated that an e-learning format is attractive for this population and effective in increasing knowledge. This positive outcome will lead to development of additional modules.

Are online learning modules an effective way to deliver hand trauma management continuing medical education to emergency physicians?

Are online learning modules an effective way to deliver hand trauma management continuing medical education to emergency physicians?

Epidemiology of Upper Extremity Replantation Surgery in the United States

Replantation remains an important technique in the management of hand trauma. Given the resources necessary for a successful replantation program, regionalization of replantation care may ultimately be required. The purposes of this study were to analyze the geographic distribution of upper extremity replant procedures, analyze factors of patients undergoing replantation, and characterize the facilities performing these procedures. We performed a cohort study using the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2001, 2004, and 2007. Patients with an upper extremity amputation were defined, and a subgroup of patients undergoing replantation was delineated. We analyzed patient demographics and injury characteristics and characteristics of treating facilities. A total of 9,407 patients were treated for upper extremity amputation, 1,361 of whom underwent replantation. Mean age of patients undergoing replantation was 36 years (range, 0-86 y), compared with 44 years (range, 0-104 y) in patients not undergoing replantation. Hospital charges (P < .001) and length of stay (P < .001) were significantly higher for patients with replantations versus those without replantations. Patients treated at teaching facilities were more likely to undergo replantation than those at a non-teaching facility (19% replantation rate at teaching hospitals vs 7% at non-teaching). Large hospitals and urban hospitals were more likely to perform replantation. Self-pay, Medicare, and Medicaid patients all had lower replantation rates than patients with other payer status. Patients who undergo replantation are younger, incur higher hospital charges, and have longer hospital stays compared with patients who do not undergo replantation. Treatment at large, urban, and teaching facilities is associated with higher replantation rates. Payer status appears to have some bearing on replantation rates. Further studies are needed to better elucidate the relationship between patient and injury characteristics, treatment location, and outcomes, to adequately distribute the finite resources for replantation. Economic and Decision Analysis IV.

A new committee dedicated to understanding and helping hand trauma management in Europe: The FESSH Hand Trauma Committee

A new committee dedicated to understanding and helping hand trauma management in Europe: The FESSH Hand Trauma Committee