In this section, you'll find a clinical scenario, consent, call the boss,
Clinical Scenario
1. What would you ask in your history?
The aim of my history would be to determine if the patient does indeed have carpal tunnel syndrome, the degree/severity, and patient expectations.
History of Presenting Complaint
- What exactly are his symptoms? Pins and needles in median nerve distribution or the entire hand.
- When did the symptoms begin and have they progressed
- Any exacerbating factors such as sleeping at night, manual work
- Any relieving factors such as "flicking of the hand".
Past Medical/Surgical History
Patient
- Social History: dexterity, occupation
- Medical History including smoking status
- Patient Expectations
Current Management
- Storage of Finger
- Imaging
- Medications: Antibiotics, Tetanus, Analgesia
- Fasting Status
2. How would you transport the finger?
I would urgently transport the finger with the patient.
The finger should be stored as follows:
- Wrapped in moist gauze and placed in a secure plastic bag
- The bag is then placed in another bag container, which contains icy water
I would definitively point out that the finger tip should never be in direct contact with the ice. I would ask them to record the time the finger was placed in this cooling transport container.
3. What are the indications for replantation?
- Thumb
- Multiple digits
- Paediatric
- Single-digit distal to FDS*
- Mid-palm/hand
These are relative indications and other factors should be considered – such as patient preferences, patient motivations & expectations, and overall health.
*As a side note, this may seem strange and is controversial - why distal to FDS insertion? Evidence suggests that a replanted finger with limited function has an overall negative effect on dexterity, especially with a poorly-functioning PIPJ. When the injury is distal to FDS, the PIPJ and FDS are presented.
4. What are the indications for replantation?
- Thumb
- Multiple digits
- Paediatric
- Single-digit distal to FDS*
- Mid-palm/hand
These are relative indications and other factors should be considered – such as patient preferences, patient motivations & expectations, and overall health.
*As a side note, this may seem strange and is controversial - why distal to FDS insertion? Evidence suggests that a replanted finger with limited function has an overall negative effect on dexterity, especially with a poorly-functioning PIPJ. When the injury is distal to FDS, the PIPJ and FDS are presented.
5. What are the key steps during a finger replant operation?
- Equipment: Microscope, microsurgical instruments, radiography
- Teams: ideally two teams each preparing the 2 segments
- Bone: ORIF ± shortening with K-wires
- Tendons: Flexor and Extensor Tendon repair
- Nerves: epineural repair
- Artery Anastomosis +/- Vein Graft
- Vein Anastomosis: A strong predictor of survival
- Skin: also has a role in venous drainage
*There is no "perfect order". There is a general agreement for bone and tendons first. Some may prefer to do artery/veins before the nerve to reduce the ischemia time.
Consent
Good evening, my name is P'Fella and I am here to consent you for this operation. I am going to explain what will happen before, during, and after the surgery. At any stage feel free to ask questions. But first, I just need to confirm your name and understanding of the procedure.
Before the operation, you will be meeting different health care staff. They are all here for your treatment and will be involved in performing your surgery or the anesthetic. To start off, there will be a surgical checklist to confirm your details. Then you will receive the anesthetic. This will involve a mask being gently placed over your face as you fall asleep.
During the operation, our goal is to replant your finger. This involves several steps, techniques, and potentially further skin incisions. You will be asleep for several hours as we fix your bones, tendon, nerves, arteries, veins, and skin. This operation may be prolonged so a urinary catheter will be placed. There is no guarantee we can save your finger.
After the operation, you will have dressings on the arm. You and your finger will be monitored closely by the Plastics team and nursing staff. This is to ensure blood is entering and leaving your finger. Further treatments might be necessary on the ward. This includes warming blankets and leeches. You may need to be brought back to the theatre and you may require multiple operations. If successful, the rehabilitation process does take time and patience.
With any operation, there are risks and complications you need to be aware of. These may be related to the surgery or the anesthetic or the necrotizing fasciitis.
• Bone: osteomyelitis, non- or mal-union, graft
• Tendon: rupture, stiff finger, tenolysis
• Nerve: delayed sensation return, neuroma, CRPS, conduits, grafts
• Artery: thrombus, embolus, ischaemia, vein grafts
• Vein: congestion, leeches,
• Skin: scarring, hypersensitivity, poor wound healing
• Anaesthetic complications
• Multiple operations
• Blood transfusion
• DVT/PE
• Urinary Catheter complications
Without this operation, there is a risk it will not be successful. If this is, unfortunately, the case, you will need to return to the theatre for a revision terminalisation.
I understand this is a lot of information to take on. Before I get you to sign the consent form, do you have any questions for me?
5 Follow-Up Questions from the Patient
- "How long will this operation take?"
- "Promise me you'll save my finger"
- "Will I be able to feel and move my finger again?"
- "You mentioned bone graft, where do you get the from?"
- "Will you be doing the operation?"
Call the Boss
- 37-year-old male is transferred to your emergency department.
- A 2mm circular saw cut his right index finger 2 hours prior
- He is right hand dominant and works as a plasterer
- Fit & healthy, non-smoker, no previous surgeries.
- He last ate and drank ~9 hours ago.
- He is very keen for the finger to be saved.
Examination:
- ATLS assessment performed by Emergency Physicians.
- Finger amputation has been transported appropriately.
- Total amputation just distal to the FDS insertion
- It appears to be a clean-cut with no crush.
- The stump is clean.
Investigations
- Bloods: Normal
- Vitals: Normal
- Xray of Stump and Amputation: Amputation at the shaft of the middle phalanx with no intra-articular extension. Appears to be small bone loss.
Task:
Call your Boss and outline the patient's clinical history, examination, working diagnosis, and management plan.
Show Example Answer
Good afternoon, this is P'Fella, the Plastic Surgery Trainee.
Am I speaking to Prof. P'Fella? Yes
I am calling you in relation to a finger amputation that is suitable for replantation. I plan to bring him to the theatre urgently and would like you to help me with the surgery, please.
In terms of his history, he is a 37-year-old male transferred to our emergency department 2-hours after a 2mm circular saw caused a total amputation of his right index finger. He is a fit and healthy non-smoker with a 9-hour fasting status. He is very keen for surgery.
On examination, his right index finger is a total amputation distal to the FDS insertion. It is clean-cut with no crush appearance. The proximal stump is viable and the amputated finger was transported appropriately.
In terms of investigations, the x-ray shows the amputation to be at the shaft of the middle phalanx. There is no secondary fracture but there is some bone loss. His vital signs and blood results are all within normal limits.
My management so far has included:
- ATLS Assessment
- Anaesthetics have pre-operatively reviewed
- Consented and marked the patient
- Informed theatre
- Microsurgical equipment and warming blankets requested
- Leeches are available if needed
So, in summary, this 37-year-old male is a good candidate for finger replantation. Anesthetics have been informed and will send for the patient shortly. The patient has been marked, consented, and next-of-kin contacted. I would really appreciate your help intra-operatively.
Is there anything else you would like to know or want me to do?
5 Follow-Up Questions from your Boss
- What makes this patient a good candidate for finger replantation?
- What are the key steps to the operation?
- What instruments would you like theatre to have ready for you?
- What are the contraindications for finger replant?
- Post-operatively, what are the signs of venous congestion?
