27 September 2008


So, I went in to the office an hour early yesterday, thinking that that way, I could get some of the pile of paperwork done. As soon as I walked in, I noticed an X-ray hanging on the view box.

"Um, P, what's this?" I asked my medical assistant as I flipped on the switch and let the buzz of the old machine warm up. "Oh, Dr C dropped that off yesterday, for whenever you had a chance to look at it," she said nonchalantly.

The machine suddenly sprang to life, and I did a... more than a double-take, that's for sure, with my mouth agape, stammering. There, on the X-ray was an innocent little finger with more than 90% dorsal and 75% lateral dislocation at the proximal interphalangeal joint. I started firing questions at my innocent medical assistant. "When did this happen? Was anything done about it? Where's the kid, now?"

She knows me well. She knows that I was not angry, just very concerned about the patient. So, she quickly produced Dr C's extension and got her on the phone, so I could fire the same questions at her.

Dr C's answers were not comforting: "It happened yesterday, and the child came right to the office. Yes, of course I did something. I took an X-ray and wrapped it with an ACE."

"Did you reduce it?!"

"Reduce...? It looked less swollen and better, so I sent him home."

You've GOT to be kidding me. That is what I wanted to scream into the phone, but I kept my composure. I said, instead, "Did you get another film before sending him home to make SURE it was better?"

"No." Of course.

"OK, I'll take it from here. Thank you."

P called the child and mother, and they swiftly got into the office. We got another X-ray, and, as expected, still dislocated. So, I explained to them that since it was now more than 24 hours since the original injury, I was not sure if a reduction would be successful. I would attempt it, however, after a digital block. I told them all of the risks and warnings, including that if this did not work, then this fourteen year old boy was looking at surgery! (In my mind, I was thinking, "Damn, all because your stupid PCP wouldn't pull on your finger!!")

So, I numbed his finger and (with a little difficulty) reduced it (YAY!). I buddy taped him securely, and got another X-ray--still reduced (YAY). And, for good measure (he IS a 14 year old boy who likes to play sports), I put him in an ulnar gutter splint. (phew)

Here's the deal: Finger dislocations are REALLY easy to reduce, if they are gotten to in time. And they do really well, if they are gotten to in time and managed appropriately. Often, especially in kids, all you have to do is anesthetize the digit, give a pull and it pops back into place. (You always hear stories of people doing this on their own without anesthesia, but we are doctors. We have the goods. So, be nice, and numb them up.) Yes, sometimes you have to maneuver a little, but just look at the X-ray, and use common sense (AFTER distracting the joint). And always, always treat dislocations like fractures--meaning immobilization for the appropriate amount of time (buddy tape or splint, NOT just an ACE). Because they WILL dislocate again otherwise.

The problem comes when the dislocation is not treated, or treated and not immobilized. That's when things can result in a chronic dislocation. That can cause volar plate laxity, ligament laxity and disruption, and finally a hyperextension (Swan neck) deformity. That necessitates surgery. NOT pretty for a simple dislocation.

Needless to say, the pile of paperwork still awaits me.

Oh, and the man from the prior post (Lucky) is scheduled for amputation on Monday. Yes, there is osteomyelitis present. And, as expected, his first reaction was, "I need a drink," quickly followed by, "I need a cigaret," when I told him he cannot have a drink. I took my time explaining to him that both alcohol and cigarets slow healing. Since his primary goal is getting back to work ASAP, it is in his best interest that the post-operative healing takes place in the best environment possible. While he was in my office, he understood, but I hope he remembers when at home, too.


rlbates said...

Sorry about your paperwork, but nice that the joint relocated for you.

Eric, AKA The Pragmatic Caregiver said...

Having just ran into my PCP while he was rounding here at The Most Expensive Hotel In Town, I'm not surprised one bit - I couldn't get him to pull my finger either.

All kidding aside, though - a third-year resident in a pretty prestigious program failed to thoroughly immobilize my fourth finger in a similar situation and was pretty much pimped by the house officer as a result. I generally don't get off on the humiliation of others, but given that the block was wearing off as they redid things, I hope he was as mortified as I was uncomfortable. ;0)


DrB said...

Eric, sorry you had that experience, but: PRECISELY why it is so important to immobilize!! At least they didn't let you go until they did properly treat you, even though it had to be done twice, and under flailing anesthetic. (argh!)