For referring doctors

Melbourne Hand Surgery accepts referrals via the secure messaging systems Argus, HealthLink and Medical Objects. Our next new patient appointment is generally 4-6 months away and we request that all patients provide a referral from their general practitioner prior to scheduling an appointment so that we can ensure that urgent and emergency conditions are seen in a timely manner. Wherever possible return letters are sent to referring doctors via secure messaging delivery. 

We are able to access and upload to My Health Record.

With the necessary authority or patient ID numbers we are able to access online imaging from providers including Benson Connect, Bridge Road Medical Imaging, Cabrini, Capital Radiology, Direct Radiology, Epworth Hospital, Goulburn Valley Imaging, Imaging @Olympic Park, Lake Imaging, MIA, Medinexus, Melbourne Radiology Clinic, Northern Hospital and Alfred Radiology. 

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Guide to timely referral of hand and wrist injuries

This article is designed for general practitioners. It outlines suggestions for the appropriate timeframe for referral of hand and wrist injuries. Where possible Melbourne Hand Surgery (MHS) prefers to receive an injury referral as early as possible. If you feel that your patient requires more urgent review than suggested in this table please refer and act accordingly.

The main condition in which delayed referral is clinically useful is a "sprain, strain or ligament injury" where the x-ray shows no fracture and the severity of the pain and swelling makes it difficult or impossible to diagnose any underlying injury. In such instances a review at 10-14 days after the injury is preferable to earlier review.

Timeframe for review	Clinical problem	Action	Suggest
ASAP	Vascular compromise - eg amputation	To seek MHS treatment, refer to Epworth hospital; contact MHS on 9427 9596 or via Epworth Switchboard on 9426 6666	Apply simple non-stick dressing or covering that can be easily removed; advise patient not to eat or drink
Treatment within 24 hours	Infected or contaminated wounds - eg septic arthritis, flexor tenosynovitis, felon, animal or human bites, open dislocations, dislocations that are unable to be reduced	Contact MHS on 9427 9596; refer to Epworth hospital	Irrigate open wounds (either with saline or clean tap water), commence antibiotics if treatment delay is anticipated; advise patient not to eat or drink
Treatment within 48-72 hours	Clean or closed wounds with suspected injury to vital structures (nerve, tendon, other)	Contact MHS  on 9427 9596, email us, or message us	Splint the affected hand and/or wrist; x-ray
Review within 7 days	Fractures (any surgery required is ideally performed within 14 days), splinted closed injuries with unstable joints	Contact MHS  on 9427 9596, email us, or message us	Splint the affected hand and/or wrist; x-ray
Review within 14 days	Sprains or strains with no fracture on x-ray, dislocations that have been reduced and splinted	Contact MHS  on 9427 9596, email us, or message us	Splint the affected hand and/or wrist; x-ray

The detailed information below provides further rationale and explanation for the table above. As always, if you have any questions or concerns please contact Melbourne Hand Surgery (MHS).

Assessment of hand injuries

Accurate assessment and diagnosis is very helpful when determining the urgency of specialist review of hand injuries. When uncertainty exists it is always safer to refer early.

The mechanism of injury is important to consider as it provides clues to the likely or potential injury. Broken glass or ceramic tends to cut down to bone if it was being grasped, falling or punched at the time of injury. If a tendon is 100% cut there will be no movement at the joint it controls; if a tendon is 0-99% cut there will still be a full range movement – so when in doubt refer.

Immediate Specialist Review Is Required:

Impaired blood with tissue at risk of death supply warrants immediate patient transfer to a hospital for specialist review and management.

In such cases surgery is required and the patient should be advised not to eat until after contact with specialist as surgery within 24 hours may be desirable.  During business hours please call 9427 9596, or after hours contact Dr Jill Tomlinson via the Epworth Hospital Switchboard on 9426 6666 to confirm that MHS is able to accept cases for immediate review.

Urgent Specialist Review Is Required:

Urgent review is highly desirable for conditions where surgery is required within 24 hours, such as hand infections, contaminated wounds, open dislocations and irreducible dislocations. You should advise your patient not to eat or drink.

It may not be practicable to perform wound washouts and obtain urgent x-rays in the outpatient (GP or specialist) setting. For this reason we recommend urgent patient admissions be made through the Epworth Emergency Department (Richmond) so that the following treatments can be administered as appropriate:

• analgesia
• wound washout
• covering open wounds with a moist, non-stick, easily removable dressing or cover
• relocation of open dislocations (with a post reduction x-ray)
• updating of tetanus immunisation
• splinting and elevation of the affected area
• commencement of intravenous antibiotics
• x-ray review

Hand infections

Hand infections warrant immediate referral. Constant throbbing and pain, combined with redness and swelling are red flags. Early specialist treatment for septic arthritis or flexor tenosynovitis reduces the number and extent of surgeries required and is more likely to result in early and complete recovery.

Contaminated wounds

A contaminated wound warrants antibiotics and immediate specialist referral for urgent surgical washout. The hand should be kept still and elevated, and the patient scheduled for surgery. A common mistake is to fail to recognise that an animal, bird and human bites produce contaminated wounds. The size of bite wounds does not predict the seriousness of the injury. A small cat bite wound over the flexor tendon sheath can easily progress to the very serious condition of flexor tenosynovitis. A small cut over the knuckle can hide a penetrating wound that enters the metacarpophalangeal joint. Patients with diabetes or immune compromise are particularly at risk, but even fit and healthy patients can quickly develop severe infections from these wounds.

Open dislocations 

Dislocated joints that have overlying wounds suggestive of an open dislocation warrant urgent referral for specialist surgical washout.

Irreducible dislocations

These require urgent operation to reduce the joint.

Semi-urgent Review Is Required:

To arrange review within 48-72 hours call 9427 9596, email infoATmelbournehandsurgery.com or fax 8677 9116. Appointment requests can also be submitted via the “emergency appointment” button on the top right of the this website; we do access and respond to these electronic messages throughout the day and night, 7 days a week.

Hand and wrist fractures that will require surgery

If the x-ray of the fracture shows significant displacement, intra-articular fracture, obvious clinical rotation, or if you think surgery may be required then please seek an appointment within 7 days - we are also very happy to see patients at 1-2 days after injury. It is desirable for surgery to be performed within 14 days of a hand fracture; early referral facilitates planning.

Keeping the limb immobilized and the hand elevated assists in reducing swelling, which facilitates healing and surgery. Where practicable, closed reduction should be attempted for significantly displaced fractures prior to splinting, although most fractures tend to drift back to a displaced position. It is particularly important to perform a closed reduction on a displaced distal radius fracture as grossly displaced fractures can create pressure or tension on the median nerve.

Suspected flexor tendon (FDP) rupture

Inability to flex the distal interphalangeal joint after trauma points to a so-called “rugger jersey” injury. Surgery should be undertaken within 1-10 days if the tendon is ruptured. Delays in seeking surgery can mean the difference between being able to have a primary repair of the tendon (eg the tendon ends are stitched together, and the 6-12 week rehab process begins), or requiring a 2 stage tendon repair (which includes a rehab process of at least 6 months).

Clean wounds with suspected digital nerve or tendon injuries

An accidental penetrating injury with a clean knife in the kitchen is a typical example of this. It is prudent to splint such injuries as there may be a partial tendon laceration, which could rupture and become complete if force is applied through the tendon. Altered sensation along the side of one or more fingers is suspicious for nerve injury, but does not guarantee that there is a nerve injury. Exploratory surgery will be performed; early surgery is convenient but if the wound is clean and the area is splinted it is not dangerous to treat such injuries in the same timeframe as a closed hand fracture.

Review Within 7 Days is Advisable:

To arrange review within 7 days call 9427 9596, email infoATmelbournehandsurgery.com or fax 8677 9116. Appointment requests can also be submitted via the “emergency appointment” button on the top right of the this website.

Fractures that are thought unlikely to require surgical management

These are fractures that are undisplaced, not involving a joint, and with no clinical rotation. Review will involve assessment as to whether surgery is required, advice and referral to a hand therapist to commence graduated exercises at a time appropriate for the fracture pattern, application of a customized splint and control of swelling.

Closed dislocations 

If a joint dislocation has been reduced and the position confirmed on x-ray it is appropriate to wait 7 days prior to specialist review. If the x-ray suggests that the joint remains subluxed specialist review should be obtained within 72 hours as surgery is likely indicated.

Before seeing the specialist the patient should be advised to keep his or her hand elevated at or above the level of the heart to reduce swelling. A splint or buddy taping should be kept on at all times. Review will involve assessment as to whether surgery is required, advice and referral to a hand therapist to commence graduated exercises, further control of swelling and appropriate strapping or splinting.

Mallet finger injuries without fracture

Mallet finger injuries that affect the extensor tendon only are not treated with surgery. After specialist patient assessment and review of the x-rays confirms the diagnosis the patient will be referred for hand therapy treatment.

Review in 10-14 Days is Advisable:

To arrange review within 10-14 days call 9427 9596, email infoATmelbournehandsurgery.com or fax 8677 9116. Appointment requests can also be submitted via the “emergency appointment” button on the top right of the this website.

Sprains and strains

If an x-ray shows no fracture but there is significant bruising or pain after an injury it is wise to apply rest, ice (for up to 48 hours), compression and elevation. Waiting 1-2 weeks for a review is sensible as it allows the bruising, swelling and pain to settle down, which makes subsequent clinical diagnosis more reliable.

Suspected scaphoid fractures

If the initial x-ray is not diagnostic of a scaphoid fracture but there is clinical suspicion then review at 1-2 weeks with a repeat x-ray is appropriate. In the meantime a splint (thumb spica) should be applied to immobilize the wrist and thumb joints. If your patient needs urgent accurate diagnosis for pressing occupational or sporting reasons then a CT scan and more urgent review may be appropriate.

Correct Splinting Position

When splinting the hand and/or wrist it is great to be able to place the hand in a safe, comfortable  position and to minimise the restriction that the splint places on daily activities.

The correct type of splint varies according to the type of injury. When in doubt it is better to over-splint in the first week (with a splint that covers more joints than the bare minimum) rather than to under-splint.

The ideal position for splinting is suggested in the position in the picture on the right. The interphalangeal joints are straight, the metacarpophalangeal joints are flexed and the wrist is comfortably extended. The thumb is comfortably extended.

If a fracture is known or suspected you should splint the joint above and below. For a finger fracture it is reasonable to splint more than one finger, as this will encourage your patient to rest his or her hand and keep it elevated, which will allow swelling to resolve more quickly.

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