WALANT for hand wound exploration in isolated conditions: Feasibility study.

INTRODUCTION: Military doctors usually deal with hand wound management. Their practice sometimes takes them far from any specialized surgical center. The WALANT could be a powerful tool for doctors operating in nuclear submarines or as part of special forces. This is a comparative, prospective and multicenter study. The hypothesis was that the management of hand wounds by military doctors specifically trained in WALANT and in the surgical exploration of hand wounds allowed a diagnosis as effective as in the FESUM center. PATIENTS AND METHODS: Military doctors, usually operating in isolated conditions, were trained at WALANT. Then, this method was used for the exploration of hand wounds in the emergency room, in a center outside FESUM. At the end, two different questionnaires were completed respectively by the patient and the operator. They aimed to assess various criteria such as the overall satisfaction of the patient and the operator, the level of pain felt or the ability of the operator to establish a precise lesion assessment. The results were compared with those obtained under the same conditions by hand surgeons in the FESUM centre. RESULTS: No significant difference was found between the two centers in terms of diagnostic capacity, satisfaction, comfort and perceived pain intensity. DISCUSSION: Under cover of prior training, the WALANT is effective for the exploration of hand wounds by submariner doctors and members of the special forces. Its use makes it possible to establish a precise injury report and this in material and human conditions approaching as closely as possible those of the armed forces on mission. The comfort of the patient remains preserved. CONCLUSION: The WALANT represents an effective tool for the exploration and lesion assessment of hand wounds outside the FESUM centre. Since emergency conditions are similar to those encountered in operational conditions, its use is also possible in situations specific to military doctors: nuclear submarines, special forces on mission. LEVEL OF EVIDENCE: III; comparative study, retrospective, multicentre.

Temporal trends in the management of metacarpal and phalangeal fractures in the 21st century: an analysis of Australian population-based data.

BACKGROUND: Fractures of the hand, specifically the metacarpals and phalanges, are a common injury. Whilst many of these fractures can be treated non-operatively, a number of advances have led to the increase in popularity of surgical intervention. The aim of this study was to assess and describe trends in management of phalangeal and metacarpal fractures in Australia over the last two decades. METHODS: A review was conducted of the Medicare Benefits Scheme (MBS), specifically querying the item numbers pertaining to the management of metacarpal and phalanx fractures. Data was recorded as the incidence per 100 000 patients. RESULTS: Overall, there was a statistically significant decrease in the incidence of closed reduction of metacarpal and phalanx fractures, with a converse statistically significant increase in open reduction internal fixation. CONCLUSION: This study demonstrates that over the last 20 years, there has been a decrease in closed reduction of intra- and extra-articular phalangeal and metacarpal fractures, with a converse but smaller increase in open reduction and fixation. These trends are likely multi-factorial in aetiology, and should be monitored to guide resource allocation and health provision in the future.

Low Infection Rate for Hand Fractures Managed with Surgical Fixation under Wide-Awake Local Anesthesia with No Tourniquet in Minor Surgery.

BACKGROUND: The purpose of this study was to review the rate and type of infectious complications after surgical fixation of hand fractures managed under wide-awake local anesthesia with no tourniquet (WALANT) in minor procedure rooms outside the main operating room. METHODS: A two-surgeon retrospective chart review was performed of patients who received surgical fixation of hand fractures under WALANT in minor surgery from March of 2014 to March of 2019. RESULTS A TOTAL OF: patients, with distal phalanx ( n = 16), middle phalanx ( n = 7), proximal phalanx ( n = 11), or metacarpal ( n = 26) fractures, were included in the study. The average patient age was 37 years, with a higher proportion of male patients (51:7). Two patients had two fractures each. Thirty of the 58 cases were already open fractures. Fixation was performed using either plates and screws (25 of 58) or nonburied Kirschner wires (31 of 58). Thirty-six percent of patients (21 of 58) were treated with prophylactic antibiotics. One patient developed postoperative cellulitis. The only case of osteomyelitis occurred in a patient with risk factors known to increase rates of infectious complications (open fracture, smoking history, and >24 hours from injury to treatment). No infectious complications occurred in those who sustained closed fractures. CONCLUSIONS: Although the minor surgery environment varies significantly from that of the main operating room, infection rates after surgical fixation of hand fractures using WALANT in this setting remain low (3.4 percent), with no documented infections in fractures that were referred closed and opened surgically for operative fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evaluation of burned hand function after enzymatic debridement.

Hand burns are common injuries that can result in long-term impairment of hand function. Enzymatic debridement (ED) prevents damage to the viable dermis due to the procedure's selectivity and has become an option for obtaining an accurate depth assessment and enabling wound re-epithelialization with less skin graft use. We conducted a prospective study from July 2015 to July 2018, which enrolled patients with deep partial-thickness hand burns and treated them with ED using bromelain. After a specified period, we assessed the patients' hand function, using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHOQ) to assess their disabilities and activities of daily life, respectively. We assessed the hand joint range of motion using a goniometer and assessed scar quality with the Vancouver Scar Scale (VSS). We analyzed 72 patients with 90 burned hands at 3 months and, at the final assessment, 69 patients with 86 burned hands. Fire was the most common cause of the burns. Bromelain allowed for early debridement (73.6% during the first 24 h). At the 3-month evaluation, the mean DASH and MHOQ scores were 2.35 and 97.9%, respectively, with a high inverse correlation between the 2 types of scores (Spearman's rho, -0.78; p < .001). The mean wrist flexion and extension were 85.7 and 80°, respectively, the mean metacarpophalangeal flexion was 88.3°, the proximal interphalangeal (PIP) flexion was 112.9°, and the thumb opposition was 77°. The mean VSS score was 2.87. At the final evaluation, with a minimum follow-up of 391 days, the mean DASH and MHOQ scores were 0.18 and 99.71%, respectively. ED with bromelain in deep partial-thickness hand burns resulted in normal values at 3 months and at over 1 year of follow-up, with complete restoration of function and quality of life and good scar results.

[Treatment of acute injuries of the hand]. / Tipps und Tricks in der Behandlung offener Handverletzungen in der Notfallpraxis.

Treatment of acute injuries of the hand Abstract. Injuries to the hand are a common presentation in primary care units. When accurately assessed, many open injuries may be handled in the emergency department without referral to a hand surgery specialist. We would like to give some recommendations on how to treat the most frequent injuries like lesions to the nail and nailbed, fingertip amputation as well as burns, infections and bites. But first, we highlight the different methods of local anesthesia and discuss the use of a tourniquet or vasoconstriction with adrenalin - WALANT - instead.

Wide-Awake Surgical Management of Hand Fractures: Technical Pearls and Advanced Rehabilitation.

Most unstable metacarpal and phalangeal fractures for which operative treatment is indicated can be reduced and stabilized with either open or closed techniques using local anesthetic with epinephrine instead of intravenous sedation or general anesthesia. With the patient wide-awake during surgery, the hand can be taken through active range of motion to assess fracture stability. In this article, the authors review the rationale and technique for wide-awake, local anesthesia, no tourniquet surgery in the treatment of phalangeal and metacarpal fractures and impart pearls to optimize the patient experience and illustrate common fixation techniques using percutaneous Kirschner wires. The intraoperative assessment of fracture stability permits an accelerated, protected-range-of-motion protocol that minimizes postoperative stiffness and facilitates expedient recovery.

[Enzymatic débridement as a treatment option for deep dermal burns of the hand]. / Enzymatisches Débridement als Therapieoption bei tiefdermalen Verbrennungen der Hand.

Burns and thermal injuries from other causes often affect exposed body regions such as the hands. Besides aesthetic aspects, deep dermal burns of the skin are often critical from a functional point of view, especially for important subcutaneous structures. This article reports the course of two patients who received enzymatic debridement with bromelain-based salve as a treatment for deep grade burns of the hands.

Performing Hand Surgery Under Local Anesthesia Without a Tourniquet in China.

In China, wide-awake surgeries are increasingly used by surgeons in a growing number of hospitals for hand and upper extremity surgeries. Experience suggests that wide-awake surgery is safe, economical, and patient-friendly, optimizing hospital resource allocation and increasing efficiency. This article discusses which procedures are most suitable, variations in procedures, departmental impacts, and future direction.

Cost analysis of percutaneous fixation of hand fractures in the main operating room versus the ambulatory setting.

PURPOSE: To date, there have been no studies identifying the cost differential for performing closed reduction internal fixation (CRIF) of hand fractures in the operating room (OR) versus an ambulatory setting. Our goal was to analyse the cost and efficiency of performing CRIF in these two settings and to investigate current practice trends in Canada. METHODS: A detailed analysis of the costs involved both directly and indirectly in the CRIF of a hand fracture was conducted. Hospital records were used to calculate efficiency. A survey was distributed to practicing plastic surgeons across Canada regarding their current practice of managing hand fractures. RESULTS: In an eight-hour surgical block we are able to perform five CRIF in the OR versus eight in an ambulatory setting. The costs of performing a CRIF in the OR under local anaesthetic, not including surgeon compensation, is $461.27 Canadian (CAD) compared to $115.59 CAD in the ambulatory setting, a 299% increase. The use of a regional block increases the cost to $665.49 CAD, a 476% increase. The main barrier to performing CRIFs in an outpatient setting is the absence of equipment necessary to perform these cases effectively, based on survey results. CONCLUSION: The use of the OR for CRIF of hand fractures is associated with a significant increase in cost and hospital resources with decreased efficiency. For appropriately selected hand fractures, CRIF in an ambulatory setting is less costly and more efficient compared to the OR and resources should be allocated to facilitate CRIF in this setting.

Effects of lubricant and autologous bone marrow stromal cell augmentation on immobilized flexor tendon repairs.

The purpose of the study was to test a novel treatment that carbodiimide-derivatized-hyaluronic acid-lubricin (cd-HA-lubricin) combined cell-based therapy in an immobilized flexor tendon repair in a canine model. Seventy-eight flexor tendons from 39 dogs were transected. One tendon was treated with cd-HA-lubricin plus an interpositional graft of 8 × 10(5) BMSCs and GDF-5. The other tendon was repaired without treatment. After 21 day of immobilization, 19 dogs were sacrificed; the remaining 20 dogs underwent a 21-day rehabilitation protocol before euthanasia. The work of flexion, tendon gliding resistance, and adhesion score in treated tendons were significantly less than the untreated tendons (p < 0.05). The failure strength of the untreated tendons was higher than the treated tendons at 21 and 42 days (p < 0.05). However, there is no significant difference in stiffness between two groups at day 42. Histologic analysis of treated tendons showed a smooth surface and viable transplanted cells 42 days after the repair, whereas untreated tendons showed severe adhesion formation around the repair site. The combination of lubricant and cell treatment resulted in significantly improved digit function, reduced adhesion formation. This novel treatment can address the unmet needs of patients who are unable to commence an early mobilization protocol after flexor tendon repair.

Selective Nerve Block Combined With Tumescent Anesthesia.

PURPOSE: To evaluate the effect of selective nerve blocks before tumescent anesthesia on the pain and anxiety levels of patients. METHODS: A prospective study was performed with 80 patients. Forty consecutive patients received tumescent anesthesia, and 40 consecutive patients received selective nerve blocks followed by tumescent anesthesia. Patients filled out a questionnaire regarding their preoperative, intraoperative, and postoperative pain and anxiety levels. The results of the questionnaire were evaluated with an independent samples t test. RESULTS: The 2 study groups showed similar distribution in age, sex, and diagnosis. No complications related to tumescent anesthesia or nerve blocks were observed. The group that received tumescent anesthesia with selective nerve blocks reported lower pain scores in anesthesia injections than the group that received tumescent anesthesia alone. The intraoperative and postoperative pain and anxiety levels between the groups were not different. CONCLUSION: Tumescent anesthesia combined with selective nerve blocks in hand surgery decreased the pain associated with injections and increased patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Humane Surgical Positioning During Minor Limb Surgeries Under Local Anesthesia in Young Children.

Injured children are in pain, anxious, scared, and intimidated by the emergency room environment and parents often compound this anxiety by their own fears. During minor surgical procedures, a child held in the "humane position" by the parent is helpful. The child is positioned on the parent's lap so that the affected extremity is drawn out and placed on the side of the parent. The surgeon and instruments are positioned behind the parent's back out of the child's and parent's field of vision especially if the wound is bleeding actively. Physical intimacy with the parent is capitalized upon; this makes the child feel secure, comfortable, relaxed, and reassured during the procedure.

[Infection of the hand: evaluation of a two-stage therapy]. / Handinfektionen: Evaluation eines zweizeitigen Therapieregimes.

INTRODUCTION: Infections of the hand are common diseases in hand surgery departments. The correct diagnosis and subsequent treatment is difficult and is often underestimated. In literature different and often conflicting treatments are recommended. The present study retrospectively analysed our two-stage surgical treatment. PATIENTS AND METHODS: 60 patients (mean age: 51 years, 38 male, 22 female) were studied retrospectively on the basis of the diagnosis hand infection (ICD L03.-). In all patients, a rapid and radical surgical debridement without wound closure was performed. An antibiotic therapy was initiated. We investigated how often wound closure during a second-look operation, following a period of open wound treatment with antiseptic dressing was successful possible. Furthermore, the patients were followed up in our outpatient clinic. RESULTS: A successful secondary wound closure was possible after on average 38.7 h and in 92% of the patients. 8% of patients required further surgical treatment. These patients presented with either an existing disease or a delayed presentation with initial antibiotic treatment. Antibiotic therapy was performed on an average for 8.7 days. Altogether for 85% of the 58 patients examined in our outpatient clinic the therapy could be terminated after 3 weeks with a full recovery of function of the injured hand and with full force measurements. The inability to work was on average 16 days. DISCUSSION: The two-stage surgical treatment, with radical debridement and open wound dressing in our collective is an adequate treatment for infections of the hand. It is a safe procedure, that allows for combination with an antibiotic therapy by which a rapid restoration of function of the injured hand is possible.

Hand surgery using local anesthesia.

Most hand traumas and elective surgical disorders of the hand can be treated quickly, easily, inexpensively, and effectively in an outpatient clinic. Although many surgeons prefer general anesthesia, the senior author routinely uses local anesthesia without sedation almost exclusively for carpal and cubital tunnel release, fasciectomy, arthrodesis, arthroplasty, synovectomy, and trauma, including the repair of tendons, nerves, ligaments, fractures, and soft tissue defects. After completing more than 10,000 procedures, the authors have found great benefits through the use of local anesthesia, which are detailed in the article.

Six years of follow-up after bilateral hand replantation.

Replantation is the gold standard surgical treatment of amputations of the upper limb; however, this demanding procedure is not always preformed in bilateral limb amputation. The objective of this study was to analyze, six years after surgery, the sensorimotor recovery of both replanted hands. A 21-year-old patient with bilateral hand amputation was benefited from limb replantation. Surgery included debridement of the amputated hands and recipient's stumps, bone fixation, arterial and venous anastomoses, nerve sutures, tendon sutures and skin closure. Rehabilitation program included physiotherapy, electrostimulation and occupational therapy. Sensory and motor evaluation was performed 6 years after replantation. At 6 years, the patient presented a good/satisfactory recovery of range of motion and strength, better at right hand. The patient was able to perform right thumb opposition. Static two-point discrimination was 20mm, sensitivity to pain and thermal stimuli and ability to sweat were present on both hands. Reinnervation was confirmed by electromyography. Functional recovery was higher at the right hand when compared to the left hand. He was highly satisfied with the result of surgery for right hand and fairly satisfied with the result for left hand. He was able to return to a secretary work 16 months after the accident. A proper functional result can be accomplished with bilateral hand replantation.