Okay, I think we're going to get started. We've got a lot to get through today. I'm Tyler Pidgeon. I'm from Duke University, and we're part of the Young Members Steering Committee, and we've submitted this talk through that committee, and it's designed to kind of reach out to younger members and actually really any member, though, and we're trying to cover topics in general that would be useful to people as they're starting out their practice or moving to a new practice, and so this one is going to be specifically about hand call. We've got six presenters today, and let's get started with Brandon Smitana from Indiana Hand and Shoulder Center, and he's going to be talking to you about open fractures. All right, so I have no relevant disclosures for this, so, you know, burnout's a major issue for everyone. I think appropriately it's getting the right spotlight in our society, so really my charge today is to talk about open fractures while taking call, and, you know, there's a lot of data out there. This is going to be, I'm sorry, a little dry talk, but what I'm really going to try to do is to kind of take that data to define standards of care and recommended optimal treatment practices, but really to then translate that to techniques to ensure a preservation of surgeon well-being while managing call. So I'll review what the data tells us, first a historical perspective of where we come from, focusing on timing of operative intervention, the treatment location, either ER or OR, and some special considerations like fight bites, management of open wrists and form injuries in touch briefly on pediatric fractures, really to drive home implications for practice while we all take call. So where do we come from? Animal models have been shown to have increased negative effects, either infection rates or mortality with wounds that are not treated within six hours, and colony formation reaches a point that is associated with infection after about five hours, which is where this golden rule for treatment of open injuries within six hours came from. We all know the Gustier-Nansen classification, it's really just mainly for the handout, but this was published in 76 and then revised in 84, where they further subdivided the type 3 injuries. Interesting point is that their 1976 study only had one month follow-up, and that the border between the type 2 and 3 injuries were often as quoted 10 centimeters, there's really no mention of that in the original publication. Two articles that really published pertaining to the hand, both in 1991, first by McLean, they looked at 150 fractures, they found 11 percent infection rate overall, but none in type 1, and really found a very strong association with gross contamination to infection rate. There's a lot of information on some of these slides, it's mainly for the handouts, I'm going to glean over it just in the interest of time, but if you want to see more information, please just reference the handout. Swanson and Szabo also looked at this in 1901, they felt particularly that the Gustier-Nansen classification did not apply to the hand, that it was more for long bones, and so they looked at this specifically in the hand and found a strong association of contamination again, and then systemic illness, as well as delay, and so they created a classification system type 1 and type 2, which may be more pertinent to the hand. So in summary, there may be a golden period of 6 hours to address open fractures, contamination may be more important than Gustier-Nansen fracture classification, and this classification may not be applicable to the small bones of the hand, and for Swanson type 2, which have three categories, contamination, delay, and illness, we really don't know which matters most based on this data. So I'm going to talk a little bit about that as we go through all the other papers here. So timing of treatment. Wellstein looked at this in 2012, about 140 open fractures in 70 patients retrospectively, they found about 11% infection rate, and they found that the time of operative treatment where their average is about 3.5 days had no effect on rates of infection, however they likely were significantly underpowered, and they were confounded by the fact that about 45% had some form of treatment in the ER, which may or may not have been a debridement. This again was looked at by Catalano in 2019, this was a retrospective NISQIP study of 300 patients, unfortunately they only found 3 infections, they were significantly underpowered, and they stated that they needed over 17,000 open fracture patients to meet power, so likely most of our literature is underpowered in this regard. So to try to address this, a meta-analysis was done from JBJS, it was a Goliath study, which I think is a very, very well done paper, it was mostly tibial fractures unfortunately for us, and so what they found is that there was a very strong association of time to treatment and infection, 12 hours was very pertinent for type 3B, and looking at all fractures to type 3, 12 hours also was a critical threshold. But again, this is mostly tibial fractures, so hard to know how much that pertains to the upper extremity, however we could probably glean that type 3 in the upper extremity should likely be addressed within 24 hours, if not 12 hours. So in summary, there's a positive reliable information based on timing, to talk about timing, there's very low rate of type 1 infection rates, both Custodianson and Swanson, so we may consider delayed treatment in these subgroups of patients, and then again, when you're looking at the literature to try to glean anything, try to pay attention if any form of confounder such as debridement was performed in the ER. So now talking a little bit to transition to that, so where to treat these, either ER or OR? Wolstein looked at this as well in 2017, 60 patients, however 70% were contaminated and 75% were hospitalized, so remember those Swanson criteria. They found that, probably unsurprisingly knowing the Swanson data, 15% infection rate, which seems pretty high, again probably related to the contamination and the hospitalization rates. These patients were treated with debridement in the ER and antibiotics alone, which certainly raises concern that maybe the ER is not the appropriate place to manage these, but again remember the confounders of contamination and hospitalization. CAPO looked at this in 2011, a very high amount of class 3 or type 3 injuries, and 102 cases of those 145 they looked at were treated in the ER. They found a very low infection rate, about a 2% infection rate, all within type 3, and so that's even 2% in type 3, which seems pretty low. And so what to take from this? I would think that we could consider treatment of open hand fractures in the ER, possibly by the ER. The caveat may be these contaminated injuries and ones that are in systemically ill patients. So moving on to some special considerations here. So Rosenthal in 2020 looked at fight bites. Retrospective view, about 115 patients. Most of them, surprising to me, were treated with antibiotics alone. That's not my standard care of practice, at least for fight bites, but surprisingly to me they only found two infections, and their type of treatment, either a limited debridement in the ER or the OR, did not affect infection rate. So maybe this is something that we might want to pay attention to and could consider treatment either with a limited debridement in the ER and antibiotics alone. She also looked at distal radius fractures, doing a retrospective view of about 90 patients. All were debrided within 24 hours, including their type 3, and they found a very low infection rate, less than 2%, despite 11% of their patients being type 3, which seems surprising to me. So again, maybe the upper extremity doesn't necessarily match up with the lower extremity tibial data. Paul Tornetto's group in 2011 looked at this as well. Type 1 and 2 injuries with no infections in their 32 patients, all were treated within 24 hours. And again, they looked at the 6-hour cutoff to try to see if there's any difference with the 6-hour rule finding no difference. Lutzky just published a paper, and that was published in hand. All type 1 injuries, some were treated urgently, some delayed, probably underpowered to really find a difference, but no infections in either group. And finally, just moving up a little bit before trying to glean any conclusions, Zumstag looked at this in 2014, 200 fractures, very low infection rate, 5%, zero infections in type 1 injuries. They did, and they looked at differences between early antibiotic administration debridement, again looking at that 6-hour cutoff and found no difference. Again, unfortunately, they only had 10 infections, so were likely underpowered to find a difference. So what to take from this for open risk and forum. So very low infection rate in type 1 and type 2. Many treated with the caveat, with formal debridement in the OR. Type 1 and possibly 2 may be amenable to delayed treatment based on that Lutzky paper. Type 3 may be okay to treat within 24 hours versus immediately within 12 hours when comparing the Goliath data. And just one final point, just about PEDS injuries. This is a busy slide mainly for the handout, but what to glean from this is kind of a large amalgamation of the data looking at PEDS open fractures. Most of them are type 1, included some lower extremity. Again, very low infection rate. And so what this means is we most likely can treat these in the ER with definitive management. So again, Gussier and Anderson may not be the best for hand. Think about those Swanson criteria. I'm not sure if that's the best classification system, but I think those factors may play a larger role and may be important to look at. ER treatment versus OR may be acceptable for many hand injuries, and type 1 may not need urgent treatment. Unfortunately, our data is not great on this and may be significantly underpowered. So I think this is probably, if anything, the most important slide. So this is how to maybe make our lives better. So timing, the 6-hour rule probably does not apply. We could probably forget about that. 24 hours for more, or 12 hours for really more significant type 3 injuries, but we could at least probably sleep through the night and treat it within 24 hours. Second-hand fractures, type 1 and 2, may be amenable to ER management. Fight bites, you know, this is limited data, but we may consider treating them with antibiotics alone or a limited ER treatment. Dyspareidiasis-informed type 1 fractures probably can be treated non-urgently and likely within 24 hours, if more significant. And then PEDS treatment for type 1 open injuries likely could be done in the ER definitively with the debridement stabilization antibiotics. Thank you. All right, yeah, thank you. Happy to be here. That was a great talk, Brendan. Excellent. I'll be talking about infections of the upper extremity. So I wanted to make this a brief talk, so I really wanted to talk about kind of four issues that I've dealt with on call that at times have surprised me or I've, you know, made some errors in judgment and wanted to share that. So basically flexortino, deep space hand infections, neck fash, and mimickers, which we always need to kind of keep in the back of our mind. I wanted to acknowledge this article. I thought this was a great review, and I did borrow some pictures from it as well. So flexortino, everybody knows cannabis signs, and we know, in general, how to recognize it. One trick that I've learned over the years is you can do Brunner's or midaxials, but I actually like combining the two. If I can do it through a limited incision, that's what I do, but in the setting of pus that's extending to the soft tissues, and that's a little bit more severe, I like doing a Brunner combined with a midaxial back into a Brunner. And then at the end of the case, you wash it out. You can actually just lay that flat back down. It's well vascularized, and you can put a couple corner stitches in, and it works pretty well. The other thing to keep in mind is if you're dealing with a bad pus case, one that's been incubating for a while, it seems to be going everywhere, just remind yourself that everything goes back to the carpal tunnel. That was something taught to me by Dr. Goldner when I was at Duke as a fellow. I love it because it's easy to remember, particularly when I'm tired on call, and it works very effectively. As far as deep space hand infections go, I have a low threshold for getting a CT scan, particularly for these big infected hands where it's hard to know where it stops and where it ends. Often multiple compartments can be affected, and you can be surprised, and I have a very low threshold for going both dorsal and bolar. And sometimes you make the incision, and there's nothing there, but sometimes you do, and you're glad you did it. As far as neck fash goes, you always have to be aware of this. It can happen any time, at any point. I've probably dealt with at least one or two per year since I've been in practice. These, of course, can be limb or life-threatening. They progress very quickly, so you really wanna, if you have a suspicion for it, you really wanna do regular, frequent serial exams, I would say hourly. The learning score can be very helpful, but sometimes it takes too long to get these labs back. The low threshold, definitely have a low threshold for emergent surgery, and unfortunately, you have to counsel patients beforehand that there's a very high rate of amputation. If this is the case that you're dealing with, I frequently put them back on the OR schedule for the next day, or at least within 48 hours, understanding that I'm gonna take a second look. Of course, don't forget about atypical infections. You wanna do a thorough history. This can be hard when you're on call and dealing with time constraints, but if you're seeing something that just doesn't look right, you wanna ask about travel, occupation, hobbies. Any exposure to animals or seawater, even in the last couple of months. Unfortunately, these things can show up late. Intraoperative cultures, you wanna include acid, fast bacilli, and fungal, don't forget that. And then, if there's a notable delay in healing after you've done the operation, start to think outside of the box. Maybe you're missing something. Maybe you're missing an atypical that has not been treated correctly with appropriate antibiotic treatment. Finally, don't forget about mimickers, herpetic whitlow. This is the easy one, I think, in some respects, because it's on the test, and you usually often see it in kids. But avoid surgery. You can be dealing with a super infection, unfortunately, after that, and the treatment, of course, is a cyclophere. This is the one that I hate, because it can really pop up on you, and you can find yourself doing surgery on this problem, pyoderma gangrenosum, when really, you should have avoided surgery in the first place. Biopsy is okay, but try to avoid large debridements. You may be dealing with a wound that will not heal despite multiple additional debridements until you finally realize you're dealing with pyoderma. The treatment, of course, is steroids, and if you do that, if you recognize it, the results can be quite excellent, as you see at the bottom. So, in conclusion, accurate and quick diagnosis is key. Close follow-up is really important, particularly in the acute setting for neck fash, and also for these atypicals, where it's just not healing. Something's not right. And then, finally, proper therapy to avoid stiffness, if possible, post-operatively, is critical. Thank you. Joe Gill from Brown University. I'll be talking about nerve injuries in the ER. So like with any other injury, begin with an exam, exploring the extent and level of injury, as well as for looking at associated injuries, such as vascular injuries, as well as fractures. The next step would be to administer antibiotics and tetanus prophylaxis, perform an irrigation, and close it loosely. A lot of these don't have to go emergency, like emergency. So again, you don't have to rush the OR with these, but again, I think you have to reassess the situation. It's a mixed motor nerve. Ideally, you probably want to get to it within 24 hours, if possible. And again, we'll talk about where that comes from in a little bit from the data standpoint. For sensory nerves, again, up to you. of scarring as far as realigning the nerve. So this is just a brief overview of the cells, and approximately the cell body goes from neurotransmitter production mode to structural protein production mode to build axons. And again, if your ends are not re-approximated, you're starting to... into the distal stump. So discussion points that come up with nerve injuries include reconstruction timing, allograft versus autograft, distal nerve decompression, and again, postoperative management. So for, so where do the timing stuff come from? I think a lot of people talk about two weeks after injury, but if you look at the, you know, studies that don't really necessarily support that from a basic science standpoint, this is a RAD study that looked at sciatic nerve transection with repair of a one-centimeter defect immediately at one month, three months, and six months. They could see that at three months after the injury, the axonal number in the proximal stump increases two to three-fold, followed by a significant reduction in axons in the distal stump, suggesting that you should probably do it at three. As far as satisfactory motor recovery, you can see here 85% recovery if you have 5 centimeter defect or less, you have again a 75 percent recovery. So with this study, this database here suggests that you could potentially consider using allograft for sensory up to 3 to 5 centimeters. For motor nerve recovery, you could see a significant drop in meaningful recovery after a 3 centimeter. So again, no more than 3 centimeters for allograft for mixed motor. But again, from my standpoint, I think the gold standard is autograft still. Thank you. looked at length up to three centimeters, I think it was 85% was pretty much where it started to drop off. But again, just overall, I think still right now the gold standard is autographed. So distal decompression, should we do it? I didn't find much support out there for this concept, but I think clinically in my practice I do it. If I do a repair of an ulnar nerve or a median nerve, I do release the distal compression sites to potentially alleviate the theoretical compression points associated with swelling. This was just a short case series of two cases where they found that their recovery was inhibited by distal compression. Post-operative management as far as things like electrical Okay, so I'm going to cover replantation, fingertip and arm replantation. Just a quick show of hands, how many people here do replant call or plan on taking a job that they are going to do replant call? Quite a few. Okay. I don't have any disclosures. I did steal some of these slides from Richard Goldner. So, epidemiology, this is a condition that affects mostly male patients, 86% of replants and amputations are in males. Factory workers and carpenters, in North Carolina we used to build a lot of furniture, so we had a lot of replantations 20, 30 years ago, and that's all been pushed out overseas, so we see a lot less of them. Replants are most, are at a mean age of 36, and amputations. So what do we do from an emergency room perspective? Well, I think a lot of us know that, but it's good to cover. First of all, this patient has to end up in a replantation capable center. I think that that is obvious. And so that might be you accepting a patient from elsewhere and it might be you sending a patient to somewhere else if you don't have the capability at your hospital. Before you send them, you really wanna assess their candidacy for replantation. There's no reason to put a patient in a chopper to fly all the way to another hospital to find out that they're gonna get a revision amputation. So I think you gotta get that good data. A lot of times what I'll do, if it's questionable, is I'll ask them to put a SAT monitor on the finger. And if the digit is getting like 92, 93%, it's probably not gonna need to be replanted, probably just needs to be fixed and closed up, but it's not necessarily a dead finger. You wanna follow the ABCs of trauma management. When patients are seen in the emergency room with a limb that's off, everybody panics, and they forget to do the other things. So if they had an ATV accident. The parts should be collected, put into saline, placed in a plastic bag, and then placed into an ice slurry. The key is to keep the part cold, but not to freeze the part, which will kill it. Pressure dressings and elevation control to the patient, avoid tourniquets, and avoid any cautery in the emergency room or in the field. And then you need to evaluate. So indications, I think that this is probably the crux of the talk. When should you be doing a replant? If you look at the literature, people say thumb amputation at any level. I think in reality a very distal thumb amputation, patients do really well with just the very very distal part of their thumb. And so you may not have to replant that, especially Multiple digit amputations, that's kind of an indication many people agree on, it's better to have three stiff fingers and no fingers at all. Amputation at the mid-palm wrist, forearm, and elbow, with the caveat being a lot of times we can put them back on, but they may not work that well, especially if it's very proximal. The nerves aren't going to always make it all the way down to the hand, so patients need to know that. Also, the bigger the part, the more myon is going to be. And then relative, sharp amputations are much more likely to survive than a crush and a single digit distal to the FTS. I think that that is debatable. There's going to be certain centers like Funky Clinic that put those all back on. They're cosmetically better. They may have a little sensation, but there's going to be a lot of centers that don't do that because the amputated finger actually functions very well. Contraindications, medical instability, of course, we're not going to kill a person to put a finger back on. Relative contraindications, zone 2s don't do very well. multi-level or segmental, I almost never Ischemia time is very important. Digits can potentially live 6 to 12 hours with warm ischemia, but they get up to 24, even 94 hours in some cases with cold. So therefore, For a major limb replant, warm and cold ischemia time are super critical because of all the muscle bulk. That's what's going to harm the patient when you put all that dead muscle back on. And all of those toxin metabolites get hooked back up to their veins and go right back into their body. It's sterile, and you connect the vessels, just the artery, and then you let all the blood flow out of the veins. You start giving them transfusions, and it gets all those toxin catabolites out of them. It keeps the part alive while you do your bony work, and then you go from there. Early aggressive debridement is incredibly important so that you don't have a bunch of dead muscle attached to the patient that gets infected, and early and aggressive transfusion is very important as well. For outcomes, digit survival rates anywhere from 57 to 90%, I think I'm somewhere in the middle of that range. For crush injuries, even if you get it back on, they don't do as well from a sensation perspective. Sharp injuries. Good to have a conversation. having leeches attached to your finger to save this, or do you wanna go back to work in 48 hours? And I think that's an important conversation to have for a lot of patients. The caveat to that is that there is a functional superiority to a successful replant, a moving digit that is sensate is gonna be better than a prosthetic or no digit at all. So replant versus revision amputation, it's really all about length. Avoiding, you know, with a replant, you definitely get all the length back, but if you have enough length after a revision amputation, the patient may function very well. I was talking a little earlier about that Goldner study, which is listed down there below, but what they found is that the revision amputation was less costly. Patients had less time out of work. They had a shorter hospital stay and their function can be quite good. So at the thumb level, as long as they had at least a third of their proximal phalanx, they functioned almost as well as the replant. The only thing they didn't do as well, if you talk to Dr. Goldner. And before we leave this talk, I think if you've never read this article, it's really, really interesting. It's called Less Than Ten by Brown et al. in the Journal of Hand Surgery. It's an older one, but you can still get up the PDF. And what they looked at is 183 surgeons that had less than 10 fingers, and they found that only three of those surgeons gave up surgery because of the amputation, and one of them was an ophthalmologist that had a very large disability insurance policy. And so there was a reason for maybe not to go back to work. Twenty-nine of these people lost a significant part of their thumb. Twenty-eight lost multiple digits. Slightly over half acquired the amputations after they became a surgeon. And what they found is that with acceptance, adaptation, and incentive, they did very well. And what they ultimately said was they thought that the motivation of the patient to get back to work was more important than the number of digits, and I think that quote is very poignant. Finger loss in a highly motivated patient whose livelihood depends on manual dexterity may not be so serious as to mandate reattachment. So, even though we can do it. So I get charged with the discussion of compartment syndrome and being that this is sort of our Hopefully a guide to help you optimize patient care Avoiding pitfalls and ensuring process self-preservation This one's a little tougher topic because this one kind of still gets me up out of bed every night But thank you guys for hanging out for the afternoon. That's my disclosures so I'll try to go through for you a little historical background just to kind of as a refresher the diagnosis of the We often have to manage this for a few days, maybe even weeks, and then some tips and tricks, again, to try to keep your practice survivable. So the history is actually quite long. and in World War II, patients suffered more bombing victims that died of sort of minor necrosis from sort of the crush injury and the trauma and kidney failure. So in the 1970s, these were all unified under one heading of compartment syndrome. And so what really... So, what can cause the decreased compartment? closure of fascial defects, sort of after trauma. Limb lengthening procedures are also known to cause this sort of decrease in compartment size. There's traction injuries after fracture reduction. but really don't forget about the increased volume. So this is like a child with post-revascularization. Here's a clinical presentation of a patient who had a dog bite, sewed up at the ER, sent home. Credit Dr. Lace at UC Irvine for the case, but sent home and then the patient was inconsolable at home. Lots of pain medicine, just screaming, brought back. So the classical symptoms are the five P's, pain, pallor, paresthesia, paralysis, and then lastly, pulselessness. You know, you can consider pressure as one of them. But I think overall, you know, this is still classic, but it's not as useful, because not all. And then pain, again, it can be variable because if it's been a little too long and the nerve is actually not viable, patients may actually not have pain. Again, I was discussing adults and pediatrics. And so this study, and this study by Bay and Waters also noticed this severe increased need in analgesia. And it's seven hours preceding the actual documented compartment syndrome. So you can, these patients have it kind of increasing. And so more than 90% had pain, but only 70% had enough. So when you check the compartment pressures, I think, you know, when the exam's equivocal, So that's obvious. I still kind of, I usually still do. on its own. So, if you do do a compression, Now if the patient's sick, their diastolic is pretty low, you'll do the diastolic minus the compartment pressure. So if their diastolic is, let's say, 50, because they're septic. So if their pressure that's perfused in that compartment is lower and they still have that much pressure, it's not going to perfuse. So let me just, I just wanted to offer the review. So here's the classic Stryker device. You can do it sterilely. Usually the needle is sterile and then the device is not. Here's how the bevel looks where the fluid comes out the end for the approaching the compartment, but then there's space for the pressure to be measured. You want to get the air out of the device, put it in the Stryker monitor and actually So, set up the regular A-line monitor. These patients are usually in the ER or ICU, so this is readily available. Zero, again, with that device at the level of the compartment. they're showing the leg. So, what's the number one cause of... And so here's a case from Dr. Stevanovich, a pretty. Casting and compartment syndrome. So if you use a plaster cast, I think that's less likely. I guess we don't, we don't always use that as a cast. Usually now it's mostly fiberglass. But this study showed that if you univalve it, you get a 40 to 60% reduction in pressure. And if you really suppress the padding itself, you get another 80% reduction in the pressure. Fiberglass casts, if you use that, you should apply with stretch relaxation or otherwise if you do that, you also bivalve it. I typically, for my kids, I bivalve it just to make sure any post-injury swelling doesn't go away. So what is our timing how much time do we really have I think you know if you identify you know for me Studies show in three to four hours duration you have or still have a pretty These are the And we try to put the index has the superficial arch, here's the dorsal approach in the forearm, and then the rest of the hand is released. So I definitely do the thenar hypothenar here. And again, it's important, obviously, we show the skin release, but getting inside the fascia and releasing that fascia. Oftentimes, once you release the fascia, the skin's not necessarily too tight. Here are the two dorsal incisions. And like I say, I use this index finger incision and go and join the thumb and release it there. And then these are demonstrating the dermatomy releases, if you're concerned with finger ischemia as well in this infrared pattern. Spreading will allow for decompression via release of Cleland's ligament. The location of the incisions protects the surfaces most important for pinch and grasp. So like I was saying, the index finger, middle finger, on the owner side for aesthetics and for sensibility. And see, oftentimes, you can actually get some of the skin closed after the fascia's released. So here's an example of crush injury. An adult patient, intrinsic minus of the hand, very swollen forearm, as well as fractures in the forearm. And you can see the amount of soft tissue injury. And then after release already, the finger reaches to the forearms and then the hand for the full release. And then a few days later, you can see the soft tissue swelling's improved, but doesn't get primary closure of the skin, so she skin grafts it here. And with a very excellent functional result in the end, even though, again, skin grafts may be ugly, but you can actually, later on, if it really does bother you or the patient, you can serially excise these tissue expanding and get these out if you wanted to. Here's another pediatric case. Crush injury and great video of, look at this, kids. I mean, kids are just great anyways, but she got the incision closed primarily. And then look at the function of this child, really with minimal atrophy or muscle necrosis or loss. Lastly, just to review, hand, 10 compartments to release, five to six incision, I think that varies, just depending on what you're comfortable with. So here's a child with the six incisions here in the hand after release and his post-operative functional result. And then lastly, again, I was mentioning the fingers. So there's not really any true muscle there, but the skin can actually cause quite a bit of ischemia. So here's a six-year-old sent to her clinic seven days after a supposed fingertip injury with this dressing that was clearly too tight, left with an amputation of that digit, which is pretty devastating. And so here's a patient who has crush injury. You can see the other compartment released, but they also did dermatomies along the fingers. What they didn't do is the thumb, and what you can see is the fingers are perfused and maintained even despite this sort of the wound, but then ended up losing the thumb tip. So it's not something you want to forget. You just consider that when you're taking care of the hand, you might wanna just put those axial incisions in just to ensure that the finger stays perfused. But here's his post-op recovery again. As Dr. Pidgeon mentioned, the little distal tip of the finger is not the most horrific loss of function. And so once you've done the release, everything looks good, the muscle's viable, and or the patient may not even be stable, I tend to just leave the wound open. I may tack a few if the skin's really loose and you can get some of it closed. I prefer back. My only caveat is I try not to place any of those stickers circumferential just to make sure if the patient is in the ICU, heavily resuscitated, they don't get a compartment syndrome pressure from the stickers. You can certainly just do ectodrius, especially if they're really unstable. And then other options are retention closer. I do close the carpal tunnel. Again, I don't find that the skin has any pressure along the median nerve and I don't want that to dry out. And so you have options of primary closure later. You can do skin graft. And then the hand incision's really often closed by secondary intention, so sometimes you don't have to do anything with that. So a couple examples of what you can do, Dr. Lavrasich here showed examples of sort of a Jacob's ladder retention sutures. And so this is in combination with a wet to dry and basically at different intervals, maybe two, three days, go in, tighten these little retention sutures and tie them again and slowly kind of close the wound. As the patient improves in their status, you can even do that as a outpatient. And here's a technique that I like. You know, you have these healthy muscle, you could definitely compartment syndrome, but there's no myonecrosis. So we like putting, closing what we can. You can see the compartment is slightly closed distally by the median nerve where it's very superficial. We put a vac on it with what you can see there is a tissue, external tissue expander, or called a dermaclose. And we just serially go back every three to four days, change the vac, put on a new tissue expander device, external tissue expander, and really get the wound closed to a primary closure. And it sort of helps if you're, you know, you don't have OR time every single day. And so you can put the vac on, it stays sterile, the patient continues to recover, and you book it for your next OR that you have available. So in summary, the compartment syndrome is still one that, like I said, gets me out of the OR, I mean, out of bed and into the OR right away. You can do compartment measures if the exam's equivocal, kind of sometimes give you time as you're kind of driving into, have the resident or fellow get a compartment measure, but mostly to me it's a clinical exam. Don't forget the fasciotomies in the forearm and the hand, and then also consider the dermatomies in the fingers, sometimes it helps. Wound management, so many different options, whatever you're comfortable with. If you have more OR time, you might be able to get them in sooner, but wound vac, I find negative pressure wound therapy devices helpful for delayed closure. And then again, secondary tension, retention, sutures, dermal clothes, skin graft, or even just the vac till it's closed. So thank you very much. Thank you. Hi, good evening. I know I'm between everyone and their dinners tonight, so hopefully we will get through this quickly, but my charge was talking about maintenance of surgeon well-being while on call and sort of how to handle the rigors of call in your home life and your family life and all those things. I'm Genevieve Rambeau coming from Eglin Air Force Base and so I actually do quite a bit of locums work, so I've gotten comfortable with walking into a hospital you've never been in before and how do you organize your life there and how do you get set up to for success. So I'm not representing the DoD right now. So the big thing I think is really when you think about getting through call is how do you minimize stress and so that's kind of what I focused on for this is different things that will stress you out when you're getting calls in the middle of the night. So we'll talk about ways just be prepared on call. First thing being when you get called in the middle of night having phone numbers already on hand and saved before your call shift starts can really help decrease some of that stress. So knowing how to book cases, having the OR front desk number on hand, common numbers that you'll need like PACU and floor and then I get a lot of calls from these outside tertiary ERs and they'll say hey I have a patient that just needs follow-up do you have your clinic number on hand and if it's not your clinic at least having that information available to say oh here's how you can get in touch with my partners or the practice I'm covering for that week. And then most importantly I think is IT support because nothing will fail at 3 in the morning you'll find out you can't prescribe narcotics like happened to me two weeks ago. And so it's good to have those numbers on hand for quick reference. Other things that are really important is before you get started having a good familiarity with what implant companies exist at your hospital, who has contracts with them, knowing your rep numbers and then knowing what common things are in-house versus what needs to be brought in because you might be in the middle of night needing a bridge plate and they say no that that lives at a different hospital in town we have to bring that over and get it processed. So just being familiar with what you need to ask the reps to bring in versus what you can do right away and maybe you don't book that case immediately because you need a couple hours for them to get implants over there. On that same vein knowing what your hospital can provide so you know what kind of equipment do they have. I think the microscope and instruments are a big thing that they'll tell you like oh yeah we have a microscope but no one's turned it on in eight years and the bulbs burnt out or you don't know how to use it because it's a different system. So kind of knowing what things are available and how they work and maybe pre-testing some of that stuff if you're gonna be doing micro on call. And then I think this is probably the most important is knowing what your hospital is limited by. So what level trauma are you? Are you a true level one? Are you like a level one light where they'll say actually we don't have vascular right now or we don't have this coverage. And really knowing what you can keep and what you have to send away and not just because of your hospital limitations but also your partner limitations. You know if you're out doing locums coverage or you're covering a different practice you know maybe they don't want to treat all the things that you're willing to treat. I've had that before where I wanted to do limb salvage but my partner said we'd really rather not take those cases they should go to a different centers. And so I think the kind of big things that are replants knowing are you a replant center? Are you gonna send those patients elsewhere? Pediatrics sometimes gets tricky where the hospital will tell you they take care of peds but you'll find out in the middle of the night the anesthesiologist on call doesn't do peds. So they're not always a pediatric center you have to kind of keep those things in mind. And vascular is another one well sometimes the vascular surgeon will be like yeah I do but I don't do kids. So you may not want to do that really really tough superconductor if you're worried that you might get into a sticky situation. So and then the limb salvage not just from a partner standpoint but also what other resources you know do they have a department that will help you do flaps if you're not going to be there to do that stuff? Do they have all the you know resources to kind of really take care of that patient full-time? Because transferring them after they've already come to your hospital can sometimes be really difficult on the patient and on the providers. So and then just knowing what your support is at the hospital. Do you have PA support? Is it sometimes? Are they always available or maybe they only do day shift? So kind of knowing how much you're gonna be extended on your own. And then I think really having some good people on hand who will be very supportive for you. So knowing you know partners, friends, colleagues who you can reach out to and kind of having your go-to folks for different problems. A lot of times you'll get this stuff and it's time sensitive and so you want to know who you can rely on that will respond quickly and they'll give you good advice that you're you know you're willing to follow. So and then sort of managing your work life on call. I think it's really helpful to have a good idea of what your upcoming call schedule or your work schedule looks like. So a lot of times you'll get these calls in the middle of the night where the ER they have a flexor tendon you know when you want to see them and it's nice to be able to answer right away. Like I have space Tuesday morning have them come in at seven and I'll book them for the OR on Wednesday. And depending on how busy your center is you know if you know you're getting a ton of call cases maybe saving a little block time so that you're not always stuck having to add stuff on. Maybe considering changing your clinic schedule if you know you're gonna be you know hammered operating for 48 hours straight and maybe you don't want to do a 60 patient clinic that next morning. So and I think this is probably the most important is managing life stress. The things that really make life difficult are when you can't take care of the things at home and that's going to affect how you are doing your job. So big things like pet and child care you know your outside obligations and really setting your family expectations. And I think you know I went through this in residency like I just told my husband assume I'm never gonna be home. Don't ever wait on me for dinner. And then if I am home it was lucky like oh this is great we have it you know a dinner night together. So if you just assume you're not gonna be there you can set up all these things in advance. So you know what I got a call case but that's fine because my neighbors are gonna help pick my kids up from school or you know I have someone to let my pets out or those kinds of things. And then not over extending yourself. So don't agree to anything that you really can't miss because you're just gonna end up being disappointed and disappointing other folks. If you want to go to dinner you know maybe consider taking two cars and keeping your work bag with you. So you can still enjoy life but you're not gonna get in hot water where you've maybe wandered too far from the hospital and now you have something emergent you can't get back in time. And then just ways to make your family life less stressful. So if I have a really busy call week or I'm gonna be gone a lot you know maybe pre prepping meals so that when I get home late I'm not tempted to like eat bad food and you have something already made and it takes stress off of you know my spouse having to do all that stuff. So and that all kind of goes into managing really your mind. I try to think about when I get consults and it's late or you're tired you've had a really long week of call. Sort of thinking about it in two camps. Either it's an easy call it's something you've taken care of a million times and you have an easy answer and then it doesn't take any brainpower. Or it's something that you've really never seen before and that can stress you out. But trying to think of it as hey this is an opportunity and this is clearly something I'm lacking in my you know my practice I haven't seen before and now it's a chance to learn about something. Having really good resources available on hand and call can help decrease your stress. So you know I keep all my books and papers on a tablet that I have with me. So if I see something weird I haven't seen before you have really quick references and you're not trying to Google something on your phone in the middle of the night. And then I think kind of the obvious stuff is taking care of yourself. You know sleep is the first priority and if you don't sleep well you'll make bad food choices and you'll feel like crap. And if you're not exercising and doing all you know you won't exercise as well if you're not sleeping. So figuring out how busy your call schedule is gonna be when I cover some locums like level ones. I know I'm not sleeping for five days straight so I prioritize if I have a break or telling the PA's like I just need an hour to kind of reset then it kind of helps everything else. Then you make better food choices get some time to exercise. And a lot of that stuff is tricky you know in the physician lounges it's always like chips and cookies and really high calorie foods. So other things that have helped like carrying protein bars or I carry protein powder things like that so I can have a little bit of a better option when I'm on call. And then doing laps in the hospital or going up and down the stairwell stairs can help if you can't get to the gym. The last little thing just to touch on is figuring out what kind of a person you are like knowing yourself and knowing what you can handle on call. When I first started doing locums I was real gung-ho and I take 10 days at a time and just not sleep for 10 days and it's tough it's really tough on your life. So you know kind of understanding how busy is that place gonna be that you're covering how much you're gonna have to take on and how to set up your call schedule with your practice based on that. Is it feasible to take a week at a time because you have a slower call schedule or are you just gonna get crushed and it makes your regular job very difficult to do. The other thing about figuring out how you want to get reimbursed for call too I think that's different I think for locums negotiating those contracts is a big deal and so you can consider if you just want a daily rate or if you want a daily rate plus an hourly and that is kind of nice because then when you get called about a fingertip in the ER you're not that mad you're like okay well I can go and make some extra money. So I think those help mentally to kind of keep you motivated instead of looking at everything like great now it's just more work for me to do already. So thank you everyone for your evening and enjoy your night. Well I know we all have dinner and drinks to get to I did want to there's one question in the in the QA that was about single-digit non-thumb replant what level do you consider to distal replant? I'll let some of my panelists answer that too. I think in my hands I might try a DIP joint disarticulation if the patient wanted to and I probably wouldn't go much more distal that after that I'd probably try to talk them out of it but that's about as good as I can get like a DIP joint level is about it. I don't know if you guys agree disagree. We've got two minutes I don't know if anyone has a burning question or they just want to come up and ask the panelists themselves but we'd be happy to do that for you. Thanks very much everybody.

open fractures

infections

nerve injuries

replantation

compartment syndrome

phone numbers

hospital resources

managing stress

maintaining well-being