Adult upper limb referral triage

NHS Tayside ED Guidance
NHS Tayside

This is a guide and does not encompass all possible scenarios.

If in doubt, please discuss your case with the on call Plastics team.

For the emergency and virtual patient referral and booking process, please refer to the Standard Operating Protocol disseminated to ED, MIU and H@N.

The limb soft tissue injury protocol will be updated for 2019.

H@N to call ext 32597 (Area 3A Nurses Station) at 8am (Mon to Fri) to leave name and details of any overnight admission.

  • Generic Plastics email for emergency and virtual clinic patient referrals: Tay-uhb.plasticsurgeryreferrals@nhs.net
  • Generic Plastics email for advice: Tay-uhb.plasticsurgeryoncall@nhs.net

Hand fractures +/- dislocation

Review in virtual clinic (V) or review in trauma clinic (T):

  • Metacarpal fractures +/- dislocations:
    •  Reduced, undisplaced & stable (V)
    • Angulated/rotated (T)
    • Comminuted/unstable (T)
  • Phalangeal fractures +/- dislocations:
    • Reduced, undisplaced & stable, proximal and middle phalanx (V)
    • Angulated/rotated (T)
    • Comminuted/unstable (T)

Discuss with on call/H@N for admission:

  • Metacarpal fractures +/- dislocations
    • Open
    • Multiple fingers

For admission - inform Plastics registrar urgently:

  • Metacarpal fractures +/- dislocations:
    • Vascular compromise despite fracture reduction
  • Phalangeal fractures +/- dislocations:
    • Amputation proximal to DIPJ
    • Vascular compromise despite fracture reduction

Upper limb ligament and tendon injuries / infections

Review in virtual clinic (V) or review in trauma clinic (T):

  • Stable ligament sprains (V)
    • Reduced, stable, closed dislocations (V)
    • Closed collateral ligament/volar plate/mallet injuries (V)
    • Closed, unstable/unreducible injuries (T)
    • Extensor/flexor injuries (T)

Discuss with on call/H@N for admission:

  • Vascularised but have concerns
  • Open injuries involving joint
  • Open injuries contaminated

For admission - inform Plastics registrar urgently:

  • Vascularity compromised
  • Flexor tendon sheath infection

Neurovascular injuries

Review in virtual clinic (V) or review in trauma clinic (T):

  • Nerve injury distal to midpoint of distal phalanx (unlikely requiring review)
  • Isolated digital nerve injuries proximal to midpoint of distal phalanx (T)

Discuss with on call/H@N for admission:

  • Injury with bleeding controlled with firm dressing

For admission - inform Plastics registrar urgently:

  • Any devascularisation
  • Uncontrollable bleeding despite external pressure, pressure dressing and elevation
  • Compartment syndrome of the hand

Skin and nail injuries / infections

Review in virtual clinic (V) or review in trauma clinic (T):

  • Pulp loss (>1cm), exposed bone (T)
  • Nail bed injury +/- underlying fracture (T)
  • Amputation distal to DIPJ (T)

Discuss with on call/H@N for admission:

  • Felon (pulp infection)
  • Human / animal bites (deeper than epidermis) +/- cellulitis

For admission - inform Plastics registrar urgently:

  • Infected bites with evidence of collection/ascending lymphangitis/sepsis

Other upper limb injuries

Review in virtual clinic (V) or review in trauma clinic (T):

  • Lacerations – unable to close in ED (T)

Discuss with on call/H@N for admission:

  • Organic foreign bodies that cannot be removed in ED
  • Infected foreign bodies

For admission - inform Plastics registrar urgently:

  • Severe crush and/or degloving injuries
  • High pressure injection injuries