Ten Foundational Principles in Hand Surgery: A Primer for Orthopedic Practice

Orthopedics is a very broad field dealing with a wide variety of cases and body parts. Over the past few decades, the field has become further sub-specialized, with arthroplasty, arthroscopy, spine surgery, pediatric orthopedics, limb reconstruction, orthopedic oncology, and regenerative orthopedics emerging as areas of sub-specialization. Another such subspecialty that has emerged is that of hand surgery [1]. While orthopedic surgeons have been performing surgeries on the hand for ages, the recent trend of sub-specialization has left the younger orthopedic surgeons to have limited exposure to hand surgery and the management of hand injuries [2]. It is, therefore, not uncommon to find many orthopedic surgeons who refer most cases related to the hand-to-hand surgeons or plastic surgeons. Despite the increasing number of hand surgeons in large metro cities, their numbers are still few. Majority of the hospitals do not have a hand surgeon or quick access to one, and so orthopedic surgeons will have to continue managing hand injuries to some extent. While sub-specializations increase expertise in a niche area, we must be able to do justice to and treat satisfactorily any orthopedic patient. Many principles of orthopedics extend into the field of hand surgery; however, there are certain unique aspects of the field of hand surgery that orthopedic surgeons should be aware of. This article is an attempt to highlight those points. We refrain from diving into complex surgical steps or “tricks of the trade” and rather focus on simple, common aspects of the management of hand cases that can have a significant impact on the outcome. These are all aspects that orthopedic surgeons would encounter in the outpatient departments and wards. While it would be an exhaustive list to include everything a hand surgeon would like to teach, we have chosen ten points that we found are often overlooked, or not taught to, or missed by orthopedic surgeons and residents. Here are the Ten Key Points Specific involved finger radiographs rather than hand radiographs When a patient presents with injury to any part of the hand, many orthopedic surgeons immediately ask for a radiograph of the hand, anteroposterior and oblique views. This is usually satisfactory for certain injuries such as metacarpal fractures or grossly displaced phalanx fractures. However, this is also the reason for a host of missed diagnosis. Phalanx fractures, interphalangeal joint dislocations, and fracture-dislocations in the fingers are very often missed due to this reason. It does not require the expert eye of a hand surgeon to identify such injuries; it merely requires the correct radiographs to be taken. When a finger injury is suspected, an isolated radiograph of that finger – anteroposterior and lateral views, is a must (Fig. 1). A contention to this, we heard from some colleagues is that the hand radiograph would identify any concomitant injuries to other digits. To them, we would like to explain that the integrity of the other digits is to always be checked by clinical examination. Radiographs cannot replace clinical examination. If multiple fingers are suspected to be injured, individual lateral radiographs of each of the digits are warranted. While it may increase the expenses to the patient, it must be insisted on because it is definitely rational and indicated. From the medico-legal point of view as well, missing an injury in the other finger due to wrong radiographs can spell real danger for the surgeon. How to preserve an amputated digit Traumatic amputations of digits come into the emergency departments, and orthopedic surgeons are the ones called in. Even if the orthopedic surgeon is not going to be performing a replant and has to refer the patient to another doctor/healthcare establishment, it is imperative that the correct preservation of the amputated digit is started at the earliest possible time. Unfortunately, improper preservation of the amputated part is often the limiting factor to potential replantation [3,4]. Here is a simple description of how an amputated digit must be preserved, along with an illustration: If the part appears contaminated, gently wipe the part with a saline-soaked gauze or rinse with saline Cover the part with a sterile, saline-soaked gauze Then place it in a plastic bag, preferably air-tight Place this plastic bag inside another bag containing ice water or ice. How to apply pillow cover elevation Elevating the limb following an injury or surgery is an important step to decrease the swelling of the injured/operated region. Pillows are most commonly used worldwide for this purpose. However, keeping an injured upper limb over the pillow does not actually provide sufficient elevation to prevent edema. A very effective method to give elevation to the upper limb is using a pillow cover. This is an extremely simple, inexpensive, and easily available method of ensure adequate elevation of the upper limb. The pinprick test When patients come with an injury to any digit or hand, it is essential that the vascularity of the part distal to the site of injury is checked. When it comes to the hand, this becomes a little tricky because no major pulse can be felt distal to the wrist. While one should assess the capillary refill, it is a little subjective and may yield inconclusive results at times. The difficulty in detecting loss of capillary refill after pulp pressure is compounded by the loss of contrast between brown skin and blood as compared to white skin and blood, where the contrast would be more obvious and easy to detect. The pinprick test is an objective way to assess the vascularity of the digit [5]. Another advantage of the pinprick test is that it is independent of skin color and swelling of the digit. The pinprick test is reliable even if the color of the fingertip is distorted by grease or other substances. The pin-prick test is performed by simply taking a sterile needle and pricking the pulp of the digit. Ideally, the test is to be done after anesthetizing the digit. We usually use the needle of a 5 mL syringe as it is less painful than larger needles, but any sterile needle can be used. If the finger is well perfused, a small drop of blood would immediately pour out. If the finger perfusion is hampered marginally, there would be a very minute drop in blood formed after a few seconds. The absence of any bleeding would indicate an absence of blood flow to that part. The test can be done even without having to remove the finger dressing entirely. The finger flexion cascade The Verdan’s cascade is the position of flexion the fingers adopt when the wrist is passively allowed to drop into extension. The flexed position is greater as we move from the index to the little finger. This is because of the tenodesis effect of the flexor tendons, which happens when the wrist is passively extended. Whenever there is a discontinuity in the flexor tendons, the affected digit lies extended instead of flexed because of the loss of the tenodesis effect. This is classically described as “finger lying out of cascade.” It is noted that all the fingers point towards the scaphoid (Fig. 2a). This is a useful guide for the normal alignment of the fingers. This is especially useful in cases of phalanx fractures to assess for a rotational component to the fracture. This clinical test can be used when assessing the acceptability of a fracture for conservative management, intraoperative judgment on the adequacy of reduction of the fracture, and postoperatively to assess the outcome. How to assess fracture malalignment in an injured finger? There are three displacements that can happen in a finger fracture: rotatory, angular, and axial (shortening). They can happen in isolation or in combination. Rotatory malalignment can be made out by asking the patient to flex the fingers. Normally, the fingers do not overlap with each other as they flex. If there is scissoring (or overlap of one over the other), this indicates that the fracture is malrotated. If the patient is asked to extend the fingers, the finger with an angulatory malalignment (mediolateral plane) will deviate away from the adjacent finger. An easy way is to compare it with the same maneuver in the uninjured hand. Shortening (axial collapse or angulation in the sagittal plane) is detected by asking the patient to extend the finger and observing the extensor lag in the joint distal to the fracture. For example, in a metacarpal neck fracture, this is made out by observing the extensor lag in the proximal interphalangeal joint. Early mobilization and monitored physiotherapy When it comes to hand cases, more often than not, early mobilization means really early mobilization. By that, we mean, mobilization is to be started on the operating table itself. Stiffness develops in fingers much earlier than it would in larger joints [6]. So even if a period of immobilization is required, it is rarely ever more than 3 weeks. If only certain movements are to be restricted, one should splint the finger in such a way that the opposite movement is still possible [7]. For example, after fixing a volar fracture-dislocation of the middle phalanx, an extension block splint can be done, which would prevent extension of the proximal interphalangeal joint but allow for flexion of the joint. This room for movement would prevent stiffness of the joint. Only in certain situations, for example, in replantation, etc., the mobilization is delayed. Like in most orthopedic cases, the physiotherapy for hand cases is of utmost importance. This is further exaggerated due to how fast stiffness can develop in small joints of the hand compared to larger joints. Similar to how orthopedic surgeons may not have sufficient experience handling all types of hand surgery cases; physiotherapists also have limited exposure to specific hand physiotherapy. If hand surgeons are rare, hand physiotherapists are even rarer to