Handy Reference: Guidance for Hand Conditions in Outpatient Clinics

Surgeons who specialize in hand surgery are in short supply in the United States. For this reason, many patients who have conditions affecting their hands may seek management in other health care settings, or have difficulty finding a surgeon to whom they can be referred.

A new article in the journalPlastic Surgery Nursingdescribes the surgeon shortage briefly and shows how nurse practitioners can manage certain conditions independently if their state's scope of care allows them to do so. The article, which addresses conditions often seen in outpatient practice, indicates that in many cases, nurse practitioners (NPs) can manage or even resolve certain conditions.

The authors looked at 4 conditions: trigger finger, mallet deformity, carpal tunnel syndrome, and ganglion cyst. In each section, they talk about the condition's origin and diagnostic characteristics, and then describe levels of approach—conservative and moderate.

Trigger finger, which manifests as inflammation and stiffness often accompanied by a clicking sound, can be managed with no intervention, or with injected steroids into the inflamed tendon. The authors noted that repeated corticosteroid injections can lead to tendon thinning and rupture, so they indicated that a maximum of 2 injections spaced 3 months apart is reasonable in digits 2 through 5. They also advised that health care providers should inject corticosteroids into the thumb only once. After that referral is prudent.

Mallet deformity is caused by blunt force to the interphalangeal joint, disrupting the terminal extensor mechanism. Patients will report an inability to fully extend the affected finger. The authors recommend lateral x-ray to screen for fracture, and splinting. In this case, referral sooner rather than later is recommended to avoid permanent damage, especially if there's a fracture or the patient cannot tolerate a splint.

Carpal tunnel syndrome, a condition that follows median nerve compression, is a repetitive use injury. Here, the authors are advocates for prevention, rest from the offending activity, and nonsteroidal anti-inflammatory drugs for 7 to 10 days. Again, corticosteroid injection may help. Pregnancy often precipitates this problem and clinicians should wait until the woman delivers to treat.

Ganglion cyst, fluid-filled sacs that follow a trauma, used to be called Bible bumps. Uninformed individuals would simply slam a heavy book like a Bible onto the ganglion cyst and break it. This is no longer recommended, and in fact is very dangerous. Although no intervention is usually needed, if patients report pain or tenderness, health care providers can aspirate. Aspiration does have its risks including damage to the surrounding structures.

Overall, the authors concluded that NPs can independently manage and even resolve many of the conditions, which is especially important in areas where access to a plastics-trained surgeon is limited. Knowing when to refer to a surgeon is essential.

Reference

Young AL. Common conditions of the hand for the nurse practitioner: how to diagnose, how to manage, and when to refer to a hand surgeon.Plast Surg Nurs. 2018 Jan/Mar;38(1):34-37.