Ambulatory Management of Bite Injuries to the Hand: A Safe and Cost-Effective Option.

Introduction Animal or human hand bites are a common presentation to the emergency department. If hand bites are not treated adequately, they can give rise to significant local and systemic complications, potentially leading to functional deficits that impact patients' lives. Traditionally, hand bites require hospital admission for the administration of intravenous antibiotics and, in some cases, surgical intervention. A combination of the increasing incidence, hospital admission rates, and in-patient bed pressures prompted a change in our bite management protocol and a move toward ambulatory management of bite injuries. We found this new protocol to be safe, efficient, and cost-effective with a scope for wider implementation. Aim The primary outcome is to assess the feasibility of safely managing hand bites on an outpatient basis, by reviewing the local data before and after the change in practice. The secondary outcome is to compare the financial implications of treating hand bites with an outpatient approach. Material and methods All first-presentation adult consultations referred to Trauma and Orthopaedics from the emergency department over a three-month snapshot period were reviewed in 2017. This was repeated after the implementation of the updated handbite guidelines in 2023. Initial admission documentation as well as operation notes and clinic follow-up letters were each reviewed retrospectively.  Results  In 2017, 36 patients were identified over three months. The average time to surgery was 1.19 days with an average inpatient stay of 2.36 days. There were two re-operations and follow-up of two cases of osteomyelitis.  In 2023, 63 patients were identified over three months. The average time to surgery was 1.03 days with an average inpatient stay of 0.56 days. Thirty-seven surgeries were performed for 33 patients with 32% (20/63) of patients admitted directly from the emergency department. There were no documented cases of osteomyelitis on follow-up. The cost per patient episode decreased by 40% from 2017 to 2023, without accounting for inflation. Conclusions With the implementation of the new departmental guidelines, there has been a reduced average inpatient stay and reduced time to surgery without an increase in documented osteomyelitis. There is also a significant decrease in the average patient cost. This data suggests that without compromising patient safety it is possible to cost-effectively manage hand bites without the need for long inpatient stays.  However, it is imperative that there is close patient follow-up as well as prompt time to surgery to ensure patient safety. Our findings suggest a need for further research to strengthen the evidence supporting our conclusions.

Early Discharge and Patient-Initiated Follow-Up in Hand Surgery: A New Norm Following Simple Hand Surgery?

AIMS: The demand for elective hand surgery has increased substantially over the last 10 years. With COVID-19 providing an added challenge of restrictions on face-to-face consultations, already overflowing follow-up clinics will be stressed further. Our aim is to assess the viability, effectiveness, and safety of an early discharge directly from the operating theatre following common hand surgery procedures with the safety net of open-access follow-up. METHODS: All eligible patients undergoing open-hand surgery under local anaesthesia between February 2019 and December 2020 were offered early discharge. Informed consent was obtained in the clinic, and they were counselled on rehabilitation immediately prior to surgery. Patients were given a custom-made "open-access business card" with clear post-operative instructions and hand exercises, along with information on how to get in touch to request clinic follow-up. A review was completed at a minimum of two months following surgery. Administrative support staff were briefed beforehand to minimise any delays in follow-up requests and either book patients who requested follow-up into a routine elective clinic or utilise ring-fenced emergency elective clinic slots depending on the patient's individual requirements. RESULTS: A total of 105 patients were included in this study, with an average age of 60 years. The average interval between surgery and review was 20 weeks. Eighty-nine patients had a successful early discharge, with 16 patients requesting clinic follow-up. The average time to follow up in the clinic was 35 weeks (range: four to 84 weeks). There were no complications that we were made aware of, and the most common reason for returning to the clinic was a new complaint, unrelated to the surgery. CONCLUSIONS: Although virtual follow-up is now well established in both the fracture and elective clinic settings, early discharge is largely uncharted water. Our pilot demonstrates that early discharge and patient-initiated follow-up for common elective hand surgical procedures under local anaesthesia are efficient, safe, and viable.

Unstable Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint: Volar Plate Fixation with or without Bone Graft.

BACKGROUND: To evaluate the treatment of severe dorsal fracture dislocation (DFD) injuries of the proximal interphalangeal joint (PIPJ) by open reduction, bone grafting and fixation with mini-hook plates. METHODS: Fourteen patients with extensive dorsal fracture dislocation of the PIPJ were operatively treated to reconstruct the fractured middle phalanx volar lip using a fabricated hook plate in conjunction with elevation and bone grafting of depressed articular fragments where present. RESULTS: Restoration of PIPJ articular anatomy and congruence by hook plate fixation permitted full-range mobilization of the joint during fracture healing, with an average arc of motion of 81° and an average loss of extension of 12.9° at a minimum of 6 months follow up. Hook plate treatment of PIPJ fracture dislocation restores articular anatomy and joint congruence at a single sitting and permits post-operative mobilization without the need for extension block splinting. CONCLUSIONS: Our results demonstrate a good range of motion following treatment, however hardware removal and tenolysis was necessary in 36% of cases.

The Effect of Distal Phalanx Bony Dimensions in Suture Anchor Fixations of Tendon Avulsion.

BACKGROUND: The terminal phalanx of the fingers carries the attachment of the Flexor Digitorum Profundus (FDP) on the volar surface and the extensor on the dorsal surface. Avulsion of these tendons has traditionally been repaired with pull-through sutures. Recently, bone anchor sutures have been found to be of comparable biomechanical strength but with the added advantage of technical ease and fewer complications. However, the dimensions of the bone, at the site of insertion of the anchors, have never been studied. METHODS: Following some cases of penetration of the dorsal cortex by the anchors, we measured the antero-posterior dimensions of the terminal phalanx in 251 digits from plain radiographs and compared these with the dimensions of the commonly used bone anchors. We also compared male and female digits. RESULTS: The anchors were oversized in 76% of index, 78% of ring and 100% of little fingers in the female population and in 49%, 44% and 97% of index, ring and little fingers respectively in the male population. CONCLUSIONS: This analysis of bone dimensions can be a useful guide to surgeons in choosing the appropriate implant for flexor tendon avulsions.

Non-union of the trapezium: rare consequence of a rare injury.

Fractures of the trapezium are rare and easily missed. As these injuries are often imperceptible on plain radiographs, diagnosis in the ED setting is challenging. We report a case of an isolated fracture of the trapezium which was picked up as a non-union 5 months after the injury following persistence of symptoms.

Iatrogenic Injuries of the Palmar Branch of the Median Nerve Following Volar Plate Fixation of the Distal Radius.

BACKGROUND: Our aims were to identify iatrogenous injuries to the palmar branch of the median nerve sustained during volar plate fixation of the distal radius, make the clinician aware of this relatively uncommon complication of distal radius fixation, to emphasise common threads in symptomatology and to propose an algorithm for evaluation and management. METHODS: Retrospectively interrogating our database over a 5 year period, the case records, neurophysiology records, operative records, therapy records were reviewed. The data was analysed with regard to the grade of surgeon performing the procedure, the site of injury, complexity of the fracture, delay to surgery, implant choice and outcome of the treatment. Variations in nerve anatomy were documented during revision surgery and common themes in symptomatology and clinical presentation were identified. RESULTS: Seven patients with an iatrogenic injury involving the palmar branch of the median nerve associated with volar plate fixation of the distal radius were assessed. The male: female ratio was 1:6 and the mean age of patients was 47.8 years (33-74 years). The initial operative fixation was undertaken by a consultant orthopaedic surgeon at a mean of 7.8 (1-17) days from injury. The mean time from fracture fixation surgery to referral to the peripheral nerve injury service was 8.9 (2-36) months. Six patients presented with pain on attempted wrist extension. Five patients had parasthesia, hyperaesthesia or dysaesthesia in the distribution of the PCBMN. Anaesthesia or hypoaesthesia was present in three patients. Two patients presented with symptoms of complex regional pain syndrome (CRPS) Type 2. CONCLUSIONS: Revising relevant anatomy and possible variations as well as careful placements of retractors in the region of the median nerve could bring down these injuries. We propose an algorithm for their management.

An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation.

Traumatic knee dislocation is a complex ligamentous injury that may be associated with simultaneous vascular and neurological injury.Although orthopaedic surgeons may consider CPN exploration at the time of ligament reconstruction, there is no standardised approach to the management of this complex and debilitating complication.This review focusses on published evidence of the outcomes of common peroneal nerve (CPN) injuries associated with knee dislocation, and proposes an algorithm for the management. Cite this article: Deepak Samson, Chye Yew Ng, Dominic Power. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2016;1:362-367. DOI: 10.1302/2058-5241.160012.

The Adipofascial Radial Artery Perforator Flap: A Versatile Reconstructive Option in Upper Limb Surgery.

BACKGROUND: Flaps have been used in upper limb surgery for varied indications including coverage of soft tissue defects, interposition and to provide a pliable bed for gliding structures among others. METHODS: We report our use of the radial artery perforator based adipofascial flap in nine patients, five with rigid radioulnar synostosis, three with recalcitrant carpal tunnel syndrome and one with a soft tissue defect. RESULTS: All our patients with radioulnar synostosis regained good functional rotations of the forearm with no recurrence at follow up. The patients with recalcitrant carpal tunnel also had resolution of symptoms with no recurrence. The flap healed well in all the patients. CONCLUSIONS: We propose this flap as a viable, versatile reconstructive option for the hand and upper limb.

Adipofascial radial artery perforator flap interposition to treat post-traumatic radioulnar synostosis in a patient with head injury.

We report this 47-year-old man who presented with polytrauma following a fall from a roof in March 2011. He sustained a head injury and a complex, comminuted forearm fracture. He underwent an open reduction and internal fixation of the fracture at the time of injury, but later developed a rigid type 2 diaphyseal radioulnar synostosis, with loss of forearm rotation. Synostosis excision and a radial artery perforator-based adipofascial interposition flap to prevent recurrence has resulted in a good functional outcome and no recurrence at 2.5 years follow-up.

Perilunate dislocation in an asymptomatic SNAC wrist: an uncommon presentation requiring a scaphoidectomy and four corner fusion.

This report describes a 53-year-old man who presented, following a motocross injury, with a Mayfield stage 1 perilunate dislocation through a pre-existing asymptomatic scaphoid non-union with a degenerative midcarpal joint. A salvage reconstruction with scaphoid excision and four corner midcarpal arthrodesis resulted in a satisfactory outcome. Follow-up at 6 years demonstrated no instability and no further progression of the osteoarthritis.