References
Reduction of a finger in the out-of-hospital arena?
Abstract
Introduction:
Paramedics can find themselves called to digit dislocations. This is challenging as a dislocation can present in various ways, bringing residual damage to tissue and underlying structures from prolonged displacement. The aim is to limit impact on the welfare of the patient and the paramedic's objective is always to get the dislocation reduced as soon as a possible in a quick and safe manner.
Dislocation:
The most common dislocation of the digit is at the proximal interphalangeal joint (PIPJ), also known as the ‘coach's finger’. PIPJ injuries are commonly seen in ball sports; the dislocation is mainly dorsal in presentation, and normally closed and stable. It is vital that the paramedic undertakes an in-depth digit assessment in order to be equipped with an appropriate treatment plan for the presentation, which can manage the dislocated digit.
Discussion—pain relief:
While there has been extensive study of systemic analgesia in emergency medical services (EMS), there is little out-of-hospital research on digit ring blocks and the use of regional anesthetics by paramedics in the pre-hospital setting.
X-ray:
The evidence is contradictory as some insist that X-ray must be carried out pre-reduction, where other authors state that reduction first is acceptable, but only after a thorough assessment.
Reduction:
There is a distinct lack of evidence for out-of-hospital digit reduction, too sparse for any robust argument to be built.
Conclusion:
The suggestion is that reduction of the PIPJ dislocation in the out-of-hospital arena is not supported, owing to a lack of evidence. Until more studies are carried out and patient follow-up is proved to be negative with no ongoing digit impact, this skill needs to be undertaken in appropriate locations supported by X-ray.
Paramedics find themselves called to digit dislocations, which is challenging as they can present in various ways. Digit dislocations bring residual damage to tissue and underlying structures from prolonged displacement owing to misaligned bones. The paramedic's objective is always to get the dislocation reduced as soon as a possible, which was eluded to by Simpson et al. (2012) who identified that quick and safe out-of-hospital reduction was a far better option than transport to an accident and emergency (A&E) department.
It can be advantageous to reduce discomfort and pain for the patient more quickly, thus reducing anxiety and emotional stress, and at the same time limiting further tissue damage. The specialist or advanced practitioner needs a good understanding of the anatomy and techniques required to undertake a detailed evaluation and assessment of the injury, and identify any complications that could unfold (Freiberg et al. 2006). With various specialist and advanced practitioners now working across a variety of clinical environments bringing additional knowledge and skill, they are able to recognise and treat a number minor injuries, which includes in-depth assessment of digits and soft-tissue damage. Specialist or advanced practitioners undertake accurate and informed clinical decisions, underpinned by specialist knowledge and education, and taking into account the patient's wishes and concerns. This allows for a patient-centred approach and appropriate patient consultation. Specialist or advanced practitioners must be transparent about the available choices, reducing poorly informed decisions, and making way for their patients (who must clearly demonstrate capacity) to make good choices. This article will look at the evidence for out-of-hospital digit reduction, namely the proximal interphalangeal joint (PIPJ) in a dorsal presentation. After reviewing the evidence, the author will determine if the procedure is safe and effective in this new and emerging arena.
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