Treatment in Hand Surgery: Practical Tips to Make Complex Cases Simple

Jin Bo Tang, MDjinbotang@yahoo.com,     Department of Hand Surgery, Affiliated Hospital of Nantong University, The Hand Surgery Research Center, Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China

The composition of this issue of Clinics in Plastic Surgery coincided with the 2014 annual meeting of the American Association for Surgery of the Hand in Hawaii, which carried the theme “Simple Solutions Welcome.” The subtitle of this Clinics in Plastic Surgery issue was intended to be “simple and complex.” In surgical practice, we aim to make cases simple; or, at least, to avoid complicating difficult cases.

Searching for simpler solutions for complex problems is one of our goals in all medical specialties. Unnecessary complexity should be avoided. Simplification represents the utmost sophistication and understanding of the central issues.

Practical tips to surgeons to make complex cases simple

The simplest method is often an effective method; not only does it accomplish the repair goal, but it also prevents complications encountered when attempting elaborate techniques. For daily simple cases, it is absolutely right to “KISS” (keep it simple, stupid!).

Unfortunately, we often make the simple cases more complex or use complex procedures for those remediable with simple ones. Treatment that is overcomplicated is harmful to the patient; it is a misuse of medical resources and surgeons’ energy and time. Here, I take my three recent “simple” cases to illustrate how these cases could end with more complex approaches.

A 10-year-old Boy with Radiographic Nonunion of a Phalangeal Shaft Fracture

Plain radiographs show an indistinct tiny connection between the fracture fragments of the proximal phalanx 3 months after trauma following pinning and splinting. The treatment could be a bone graft. On examination, with active finger flexion the boy had no abnormal motion at the fracture site. The boy was treated with buddy-taping for protection at nighttime and school, coupled with gentle active digital motion at home. The fracture healed after 2 months.

Practical tip: Healing of phalangeal fractures shown on plain radiographs is usually less notable and delayed than actual healing. Phalanges do not bear weight; gentle digital active motion adds little bending force to the healing callus and it stimulates healing. Fracture healing often appears delayed in children—callus is harder to see in kids, but these fractures actually heal better than appear in plain radiographs. We must stick to conservative treatment, not rushing to a surgery with bone grafting.

Infection After Internal Fixation of Compound Extra-Articular and Intra-Articular Fractures of the Metacarpophalangeal Joint in a Young Adult

Infection occurred at the operative site 4 weeks after multiple Kirschner wire (K-wire) fixation, with marked swelling and purulent discharge at the surgical site but without abscess formation. One solution is to remove the K-wires, open and irrigate the wound, and prepare for a later bone graft or arthrodesis when necessary. A simple solution is to admit the patient for observation, perform dressing changes, and treat the infection with antibiotics. The latter method was adopted for this case. The key point was not to rush to remove the hardware of internal fixation. The infection subsided after 2 weeks and the fracture healed entirely after 4 weeks.

Practical tip: Be in no rush to surgically remove hardware unless the patient is severely septic locally. When the hand is infected, removing the hardware does not achieve true source control. The phalanges or metacarpals are less likely to get severely infected than the long bones in other parts of the body. Risk of osteomyelitis is low. Removing hardware could disrupt the repair horribly and require multiple subsequent surgeries. Antibiotics and preserved fixation can lead to successful healing without further setbacks. The key is to judiciously assess the patient's clinical presentation and to be in no rush to remove the internal fixation.

Laceration of Flexor Tendons and Digital Nerves in Zone 2 of All Five Digits of One Hand and the Thumb of the Other in a Young Adult

We repaired all four lacerated flexor digitorum profundus and two flexor pollicis longus tendons, and 10 digital nerves. Active digital flexion and extension were started at day 5 after surgery. Swelling was significant in the first 2 weeks, and stiffness was prevalent and persistent in all finger joints of the right hand over the 2 months—as is common after trauma to multiple digits of a hand. Function was rated as fair at the third month in all four fingers; the thumb function was excellent. Physical therapy was then continued and improvement was significant from the fourth to the sixth month after surgery. At 7 months, all fingers were rated either good or excellent and fingertip sensibility was rated as S3+ or S4.

Practical tips: With tendons lacerated in multiple fingers, recovery to close-to-normal joint motion usually takes more than 3 months. Even if the laceration does not involve the finger joint and exercise is properly implemented after surgery, such trauma to multiple fingers frequently leads to digital stiffness. Simultaneous flexor and extensor tendon injuries have a similar impact on the digits. It is important to patiently continue exercise and not to rush to plan any revision surgery. Waiting to reach the plateau of recovery is a basic requirement; at times, more than 6 months is needed! Do not lose faith on unhappy outcomes at 2 or 3 months after surgery. Function does improve after 3 to 6 months in almost all cases. I have observed improvement after as long as a year. Do not rush to return to the operating room. An unnecessary surgery makes these outcomes worse. Regarding fingertip sensibility, this patient recovered good sensation at 7 months. The practical tip for a digital nerve repair is accurate cooptation of the nerve ends.

The above cases exemplify how simple treatment modalities achieve treatment goals. We see in the real world that some surgeons are too active in operating or “treating” patients, particularly when they are fresh in the field or rely on stagnant teachings—textbooks hardly cover many variants seen every day. Treatments described in textbooks usually tend to be conservative, providing more typical and secure options. As one accumulates experience and clinical judgment, his or her practice molds to incorporate clinical observations and personalized treatment regimens, which deviate from the cited standard-of-care. Few experts overlap significantly in their technical detail and perspectives regarding ideal management. Small, but often important, personal tips or pearls in clinical judgment, technique, and management are particularly useful and can become keys to simplifying treatment.

Tips about what to avoid in making complex cases simpler

We are continually faced with decisions among presently available treatment options. Our choices impact patients’ care and ultimate outcomes. A gray area exists in indications for surgery. I estimate that 15% to 20% of surgical hand cases—especially for fractures and secondary repair surgeries—would have similar good results without surgical intervention. In other words, I believe, conservatively speculating, 10% of the surgeries are unnecessary. More than a few cases that other surgeons choose to treat surgically, I would manage conservatively. Surgeons do not want to admit—but it is a fact—that some cases are made worse or are unnecessarily complicated by surgery. In some doctors’ hands, overtreatment is common. Sometimes poor outcomes are not caused by the disease, but by an initially unfulfilling surgery, which have to be addressed with additional surgery. A case that can be successfully managed nonoperatively may end up having had multiple surgeries. Knowing when NOT to operate is the most important factor in avoiding overcomplicating a case.

Although at times necessary, multiple surgeries always potentially cause harm to the patient. Limit the number of surgeries to the minimum necessary. Remind yourselves not to do another surgery that is unnecessary. If a surgery is necessary, knowing when to operate is critical. Do not rush into a surgery if the patient would benefit from waiting. Intraoperatively, modifications of surgical plans are always necessary; thus, judgment during surgery is essential as well. Most textbooks describe standard approaches, but they cannot guide every clinical decision that a surgeon has to make. The surgeon must rely on his or her own creativity in designing a procedure and problem-solving ability while adhering to fundamental surgical principles.

Finally, avoid being a “traumatic” surgeon. Being “atraumatic”—using small incisions and respecting the tissues by limiting damage during dissection and repair—is a must! Bad surgical habits cause excessive damage to tissues. Remind yourself to handle tissues gently to become a less-damaging surgeon—this tip is particularly useful if implemented at the beginning of a surgeon’s career. This is especially...