Most people who can negotiate an office visit with a hard-to-access hand surgeon can at least cooperate with the examination and voice subjective complaints. Not so in the ED at 3 a.m. Every article on the treatment of hand injuries states that the patient must be cooperative, alert, and otherwise intelligent enough to participate in his care, obviously a naïve assumption by someone who has never worked an ED shift (aka a hand surgeon). Intelligence and cooperation are not prerequisites for any ED visit, and the EP is often faced with a situation that makes proper evaluation simply impossible. Occasionally a few hours of sobering up, a shot of morphine or a lidocaine injection, or the help of a caretaker or family member can facilitate an examination, but it's unrealistic to believe that you will always glean all the information you are requesting on the first visit. Fortunately, there are few times when you have to commit totally to a specific diagnosis, so share the liability with a colleague, and have the patient assume some personal responsibility.
It's best to consider the worst-case scenario. Subjective numbness, less than perfect motor function, varying light touch sensation, and only three of five two-point discrimination tests positive may be due to malingering, anxiety, alcohol, or local inflammation or swelling. The crafty clinician, however, assumes that inconsistent or ambiguous findings suggest a possible problem, perhaps a partial tendon or nerve injury, but certainly a problem that needs another evaluation in a few days after the rage, alcohol, and pain have dissipated.
Actually, the uncooperative patient who has an equivocal examination is a very straightforward case. One simply assumes that there is a tendon or nerve injury, and proceeds along the standard guidelines for treatment and referral for such pathology. If you are wrong, nobody cares, and you look like a concerned pro. I again caution the clinician to believe a patient when he says he can't feel normally or won't move a finger, even if the laceration looks benign and the exam is anatomically screwy. Complete absence of flexion or persistent numbness is rarely conversion, malingering, or noncompliance.
Even a tendon that is 80 to 90 percent lacerated can flex the finger, but if left alone, it will surely rupture later. This should not be a surprise finding 10 days later when the sutures are removed. When some function is preserved, subtle clues to the presence of a partial tendon laceration are weakness of flexion against resistance and pain in the laceration with passive and active flexion.
Partial flexor tendon injuries, even significant ones, are commonly handled without surgical repair. But even in this day, there is controversy about the best course of action for known partial tendon lacerations. (J Hand SurgAm 2001;26:821; Plast Reconstr Surg 1977;59:231; J Biomech Eng 2000;122:604; J Bone Joint Surg Am 2002:84-A:1006.) All sorts of trimming procedures, splinting, and physical therapy protocols have been advocated. eMedicine details about 20 different suture configurations. Once healed, sutured tendons are not as strong as those allowed to heal without surgery, so allowing natural healing is acceptable as long as the tendon is protected. Fortunately, EPs don't have to know the specifics.
As a general rule, most surgeons will not suture a tendon that is cut 50 percent or less. Others allow even greater partial lacerations to go unsutured. Some evidence suggests that suturing a partial tendon laceration provides a worse outcome than splinting and physical therapy. Of course, one has to make the diagnosis of a partial tendon laceration in the first place, before the course of therapy is set. Some surgeons will explore a laceration with the thought of obtaining definitive information on the extent of injury, and then make a decision.
Most hand surgeons prefer to make a definitive evaluation or repair complete flexor tendon lacerations a number of days post-injury. This fits nicely with a two- to three-day first office visit or clinic follow-up after the ED visit. This often, however, requires the EP to stress the importance of follow-up to the patient, and occasionally help with the appointment. Unless the EP becomes personally involved, no patient in my ED has easy access to a Philadelphia hand surgeon in two to three days, even with insurance, persistence with an office appointment desk, and a good command of English.
Occasionally a primary repair will occur on the same day as the ED visit if the wound is clean and the surgeon available. I rarely encounter this scenario. A general standard mandates that any primary repair of tendons, nerves, or arteries be done when the wound is clean, and there are no associated injuries, bleeding has been controlled, edema has subsided, and the wound is infection-free. Many surgeons prefer to operate two to three days after the ED visit, but that means they believe your exam in the first place. Practice varies, so get it in writing on the chart.
A delayed primary repair can be performed up to 10 days after injury with reasonable results. A secondary repair of a flexor tendon can be performed within two to four weeks post-injury. Generally, the results are equal with immediate, delayed, and early secondary repair. Repair of flexor tendons after three to four weeks is often fraught with poor results, however.
A missed flexor tendon injury that progresses from partial to complete rupture by suture removal is generally amenable to a final result similar to that expected if the diagnosis had been made in the ED. But this is an inopportune time to make the diagnosis. Because flexor tendons often have some morbidity under the best of circumstances, making the diagnosis as soon as possible is preferable. After three to four weeks, a two-stage procedure, tendon transfers, or tendon grafting are often required, usually with stiffness and lack of full range of motion being the final result.
Patients who are noncompliant, have financial problems, or lack transportation or the requisite social support are a nightmare for all physicians. Everything can be done correctly, and all follow-up carefully spelled out, yet the patient and the hand surgeon never meet within the appropriate timeframe or consistently enough to get the best possible result. Unfortunately, the EP is often blamed for the poor outcome, regardless of gargantuan (but often undocumented) time and efforts during the initial visit. The most common response to a bad outcome are allegations that the EP missed an injury, failed to seek proper consultation in the ED, or never informed the patient of the important issues or possible consequences. This is where proper and detailed charting saves the day. I have seen many charts that state only: “N/V/T intact.” While this seems standard, and is OK if nothing is actually askew, get into the habit of performing your best hand exam on all cases, even those with minimal findings, just to keep in practice.
When in doubt or to finalize the otherwise ideal ED encounter, short-term splinting of all injuries, even remotely potential problems, can never be faulted. Consider a routine repeat examination within a few days of most injuries to ferret out unexpected complications. Expectant treatment and even a documented incorrect overdiagnosis that erred on the side of caution should be the clinician's mantra.
Next month: Extensor tendon-injuries.
Comments about this article? Write to EMN firstname.lastname@example.org.
Click and Connect!Access the links in this article by reading it onwww.EM-News.com.
Readers are invited to ask specific questions and offer personal experiences, comments, or observations on InFocus topics. Literature references are appreciated. Pertinent responses will be published in a future issue. Please send comments to email@example.com. Dr. Roberts requests feedback on this month's column, especially personal experiences with successes, failures, and technique.© 2011 Lippincott Williams & Wilkins, Inc.