Hand injuries can take many forms, such as a laceration, crushed fingers, open fractures, or loss of fingers, a thumb or the whole hand. Infections also are common with any wound, bite or laceration. Hand injuries can be seasonal: In the fall, hand injuries from harvesting are common; in the summertime, more recreational and work-related injuries occur; and in the winter, falls on ice and hand injuries from operating snow blowers lead to numerous hand and wrist injuries.
David G. Dennison, M.D., a hand surgeon at Mayo Clinic's campus in Rochester, Minnesota, reports that while the hand surgeons at Mayo Clinic receive many urgent transfers, there are patients with injuries who can be managed initially at an outside hospital or clinic and then referred to be seen the next day. It is important to understand the urgent need of referral for some injuries and to know what conditions can be safely temporized overnight. The use of guidelines helps capture all urgent conditions and review injuries that may still need to be seen soon, perhaps the next day, if initial care can be provided at the referring hospital or clinic.
With all the potential variations in hand injuries, it is sometimes challenging to understand what the actual issue may be, as many of those calling to refer patients are often health care providers who are not trained in the care of hand injuries. Fortunately, through the Midwest Admission and Transfer Center, surrounding facilities can call to discuss cases that are in need of urgent referral.
In the following questions, Dr. Dennison responds to some of the most common issues that arise with hand injury transfer decisions in the community.
What patients need to see a hand specialist immediately? How would you suggest trauma providers decide if a patient needs to be transferred to a Level I center?
These questions can be answered using the Isolated Hand Injury Algorithm-Hand Referral for Acute Care Management graphic, which helps providers consider patient age, injury location and severity, and thumb or multiple-digit injury or amputation, all of which may identify need for transfer.
In general, ischemia, multiple digit injuries and amputations are the primary reasons for immediate transfer. It's also important to take the patient's age into account when considering transfer for a hand injury, especially in amputations, as consideration for replantation is greater with younger patients. Open fractures, multiple finger injuries, and complex wounds and infections also may require immediate transfer. We have found during our phone conversations that readily available pictures of the hand and wound, as well as radiographs, greatly facilitates the decision and activation of the transfer process.
At times, an injury requires a hand surgeon, but perhaps the definitive treatment can wait several hours or a day. In these types of cases, such as with a finger laceration that may include tendon injury, the initial wound care may be provided at the referring hospital with antibiotics and a splint until seen by the hand surgeon. If you have a patient with a hand injury and are in need of transfer or advice on treatment, a consult by phone may be appropriate. Referring personnel may call the Midwest Admission and Transfer Center, 507-255-2910, which will then contact the physician on call.
What should be done for a patient with a hand injury prior to transfer?
When the patient has an isolated hand injury, it is helpful to consider the following steps:
- Perform an initial trauma evaluation: The patient should be hemodynamically stable for transportation.
- Conduct primary care of the wound, including control of bleeding, irrigation, administration of antibiotics and elevation of the limb.
- Reduce obvious deformity: Align fingers if angled or rotated.
- Apply a dressing and splint.
- X-ray the injury, when possible, while keeping in mind that bleeding, ischemia or amputation require immediate transfer and should not be delayed.
- Amputated parts should be prepared for transportation: Wrap in saline gauze and place in a plastic bag, and then place the bag on ice.
- Obtain a photo of the hand and wound, or amputated part, and also a radiograph that may be used when communicating with the Midwest Admission and Transfer Center and the hand surgeon on call.
- If time does not allow for these steps prior to transfer, align the injured anatomy, apply a dressing and splint, and send the patient to the receiving trauma center.
What are some issues to be aware of with transferring a patient with a hand injury?
Mode of transport
Due to the expense and limited resources, carefully assess whether a helicopter is the appropriate method of transport for a patient with a hand injury, or whether ground transportation is adequate. The patient with a proximal amputation of the hand, wrist and forearm, where ischemia will limit the time allowed for consideration of replantation, should be transported as quickly as possible to arrive in the operating room less than six hours from the time of injury.
Patient wishes, health status and age
It is important to find out what treatment a patient may consider or desire for a hand injury, as well as whether he or she is healthy enough to benefit from surgical treatment. A pediatric patient with an amputation would always be considered for replantation, whereas an 80-year-old patient who has diabetes and a single-finger amputation may be treated with revision amputation of the finger.
Promises to the patient
Though wanting to reassure a patient is natural, it's wise not to make specific promises about treatment the receiving trauma center may offer to avoid any possibility of false expectations before a specialist evaluates the patient.