Emergency Hand and Reconstructive Microsurgery in the COVID-19–Positive Patient

Abstract

The case spectrum in hand surgery is one of extremes—purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19–infected patients may be asymptomatic or have mild, nonspecific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for perioperative care of the COVID-19–positive patient have been published. However, our practices differ from those of general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the perioperative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring the safety of the attending staff.

The influence of SARS‐CoV‐2 vaccination on post‐operative outcomes in microsurgery patients

“…At 30 and 60 days post‐operatively, flap failure risk was found to be significantly reduced in SARS‐CoV‐2‐vaccinated microsurgery patients (Table 2 ). This finding is particularly notable given that flap procedure protocols have been impacted by the current pandemic with recommendations deferring reconstruction for SARS‐CoV‐2‐positive patients and advocating for the use of less complex closures (Das De et al, 2020 ; Thacoor et al, 2021 ). Although this study propensity score matched and balanced for numerous factors including age, race, diabetes, BMI, smoking, and pre‐operative SARS‐CoV‐2 status, the increased likelihood of non‐vaccinated microsurgery patients developing flap failure may simply have been due to an increased risk of contracting pro‐inflammatory SARS‐CoV‐2 during the acute post‐operative period.…”

Important updates of finger fractures, entrapment neuropathies and wide-awake surgery of the upper extremity

“…Some surgeons are using WALANT for long bone fractures, as we will discuss below (Ahmad et al, 2018(Ahmad et al, , 2020(Ahmad et al, , 2021Kurtzman et al, 2021). Moreover, the scope of WALANT surgery could be affected by the departmental settings and the contemporary working conditions (Das De et al, 2020;Kurtzman et al, 2021;Tang et al, 2019b). The pandemic in 2020 has expanded the scope of WALANT surgery to limit exposure of both patients and health care workers to viral infections (Das De et al, 2020;Kurtzman et al, 2021).…”

“…Moreover, the scope of WALANT surgery could be affected by the departmental settings and the contemporary working conditions (Das De et al, 2020;Kurtzman et al, 2021;Tang et al, 2019b). The pandemic in 2020 has expanded the scope of WALANT surgery to limit exposure of both patients and health care workers to viral infections (Das De et al, 2020;Kurtzman et al, 2021). In many countries, including Canada, China, Singapore, Turkey, Indonesia, United Kingdom and Egypt, WALANT is a popular setting for hand surgery (Tang et al, 2019b).…”

Severe spaghetti wrist injury: Should we expand the terminology from wrist to proximal forearm?

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Constant use of hand to carry out daily living makes the superficial anatomic structures of the wrist and distal forearm vulnerable to major injuries which may result in lifelong dysfunction as well as psychological, economic, and social consequences. [1,2] Multicomponent soft tissue injuries of the wrist and distal forearm, also known as "spaghetti wrist injuries", refer to an extensive volar laceration which at least three structures of the 12 flexor tendons, two arteries and two nerves are transected between the distal wrist crease and flexor musculotendinous junction. [3,4] Among the severed structures, devastating functional deficiency is more common in those whose medial and/or ulnar nerves are completely severed.Objectives: This study aims to point out the key principles for the management of multicomponent soft tissue injuries of the wrist and forearm to discuss whether we should expand the term "spaghetti" from the wrist to forearm in such terrifying cases.Patients and methods: Data from a total of 50 patients (44 males, 6 females; mean age: 48.5±25.7 years; range, 10 to 70 years) who were treated for multicomponent soft tissue injuries of the wrist and forearm, including at least one major artery and one major nerve, between February 2020 and December 2021 were retrospectively analyzed.

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“…Constant use of hand to carry out daily living makes the superficial anatomic structures of the wrist and distal forearm vulnerable to major injuries which may result in lifelong dysfunction as well as psychological, economic, and social consequences. [1,2] Multicomponent soft tissue injuries of the wrist and distal forearm, also known as "spaghetti wrist injuries", refer to an extensive volar laceration which at least three structures of the 12 flexor tendons, two arteries and two nerves are transected between the distal wrist crease and flexor musculotendinous junction. [3,4] Among the severed structures, devastating functional deficiency is more common in those whose medial and/or ulnar nerves are completely severed.…”