How to Manage Common Hand, Wrist and Upper Limb Pathology in an Urgent Care Setting
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Q&A with 2016 Spring Convention speaker Alejandro Badia, MD, FACS, CEO & chief medical officer of OrthoNOW. Learn more about Dr. Badia’s session "Management of Common Hand, Wrist and Upper Limb Pathology in an Urgent Care Setting," to be held on Tuesday, April 19 from 3:15-4:15pm.  


It has been estimated that 10% of all injuries presenting to an emergency department involve the hand and wrist, with digit lacerations representing the third leading cause of lost work. Finger injuries often do not get the attention or follow-up that they deserve and the layman's term, “jammed finger” is very often the discharge diagnosis. 

 

At the Urgent Care Association of America (UCAOA) 2016 Spring Convention (April 17-20, Orlando), Dr. Alejandro Badia, CEO and Chief Medical Officer of OrthoNOW®, the country’s only orthopedic urgent care franchise, will discuss the importance of urgent care providers being well-versed in assessing and treating the most common hand and wrist injuries, so patients can receive the most appropriate treatment.  Here’s just a sample of what you will learn:

 

Q: What percentage of industrial/domestic injuries involve the hand/wrist?

A: More than 1,000,000 U.S. workers receive treatment in emergency departments annually for acute hand and finger injuries. The U.S. Bureau of Labor Statistics estimates that approximately 110,000 workers with hand and finger injuries lose days from work annually - second only to back strain and sprain in terms of work days lost. Approximately 40% of work related fractures are in the hand and wrist.

Q: How can you outline the components of a thorough hand and upper limb injury assessment from history to physical exam, imaging and testing?

A:  A thorough history is an important first step in treating each patient. What is the mechanism of the injury, and what are the specifics regarding how it occurred? Some key physical findings during initial assessment are point tenderness, extent of open wounds, signs of infections (Kanavel), warmth, swelling and range of motion surrounding the affected area. In addition, it’s highly recommended to establish an injury and pain timeline to determine when and where the pain is at its worse and when it is relieved.


X-rays are virtually always necessary, not only to assess specific injury but also to provide baseline assessment of underlying factors such as arthritis, prior bony injuries and congenital variants. Ultrasound is critical to assess soft tissue injury, characterize masses and it can assist in performing injections or foreign body removal. MRI imaging is frequently over-utilized modality and should be ordered by the definitive treating clinician. It is most useful for evaluation of certain ligamentous lesions, TFCC cartilage tears and occult fractures such as in the scaphoid.

 

Q: How can you distinguish severe hand and upper limb injuries from those which do not require a referral outside of the urgent care setting?

A: Hand injuries can be divided into six general categories: lacerations (cuts), fractures and dislocations, soft tissue injuries/amputations, infections, burns, and high pressure injuries (grease and paint guns). Although some severe hand injuries seem obvious, a thorough evaluation is needed to detect other, more subtle injuries. Failure to diagnose, manage, and rehabilitate hand injuries has the potential to result in permanent impairment to hand and daily function. Primary care physicians must be able to recognize wrist and hand injuries that require immediate attention and be in direct communication with their hand colleagues. Besides a complete history and physical examination, limited hemostasis is necessary in patients with vessel lacerations and amputations. Amputations require an understanding of potential replant indications and how to preserve and cool the amputated appendage. Open fractures are often surgical emergencies although the hand is much more resilient to these injuries and adequate antibiosis with well applied dressing /fracture splint stabilization can temporize the problem while a subspecialist is consulted. Simple, non-displaced fractures such as of the metacarpal, PIP volar plate insertion and non-scaphoid carpal bone can be simply treated via proper fracture management and may never need the attention of the hand surgeon.

 

Q:  What is a Scapholunate ligament injury and how are they confirmed by following criteria?

A:  A scapholunate ligament tear can vary from mild sprains to complete tears and occasionally be accompanied by other torn ligaments and/or fibrocartilage complex. It can also be accompanied by other injuries such as a scaphoid fracture or a lunate dislocation. A more precise staging of scapholunate ligament tears is to divide them into four categories of increasing severity: predynamic, dynamic, static, and scapholunate advanced collapse. A scapholunate ligament tear is usually caused by a fall or by a sudden load on the dorsiflexed wrist. The patient usually has pain and tenderness in the midline and radial side of the wrist. There is usually grip weakness with occasional clunking, swelling, or popping. The Watson scaphoid shift test can be helpful. This is done by bending the wrist toward the small finger, and then the physician applies pressure to the palm side of the scaphoid (volar tubercles) as the wrist is bent toward the thumb. Relief of pressure will allow the scaphoid to slip back into place with a clunk. Scapholunate ligament tears can occasionally be diagnosed with imaging studies such as, standard x-rays, stress x-rays, and MRI. Live dynamic fluoroscopy is particularly helpful but arthroscopic evaluation has become the gold standard, particularly for dynamic tears which would then allow definitive simultaneous treatment as well.

 

Q: What is the cause of Carpal tunnel syndrome, and what is it associated with?

A:  Carpal tunnel syndrome (CTS) is caused by pressure or pinching of the median nerve that runs from the forearm to the hand via the carpal tunnel within palmar side of wrist.  Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. Pain is often worse at night and can cause difficulty sleeping. Patients have to take into consideration that chronic and severe compression of the nerve often leads to weakness of thumb pinch and opposition with subsequent difficulty in many daily tasks. Endoscopy surgery is then recommended to patients with persistent pain in order to alleviate the media nerve compression. Patients should see an orthopedic specialist if they are experiencing tingling, weakness, or pain in your fingers or hand that recurs or that has not resolved after several weeks of conservative treatment.

 


Alejandro Badia, MD, FACS is a hand and upper extremity surgeon at Badia Hand to Shoulder Center in Doral, Florida. Dr. Badia was educated at Cornell and NYU, trained in orthopedics at Bellevue Hospital/NYU Medical Center, a hand/microsurgery fellowship in Pittsburgh and trauma fellowship in Germany. Badia served as worldwide president of ISSPORTH and co-founded the world renowned Miami Anatomical Research and Training Center (M.A.R.C.) and the Surgery Center at Doral. After years of a successful medical career and a renowned international speaking legacy he saw a need for specialized orthopedic urgent care centers to immediately assess and treat a range of orthopedic and sports injuries and founded OrthoNOW®, the only orthopedic urgent care center franchise in the country. He serves as Medical Director of the franchise’s flagship location in Doral, Florida which has a team of orthopedic specialists on staff that treat broken bones, sprains, torn ligaments and muscles, sports and worker’s compensation injuries. Learn more here

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