List of Abbreviations
AB – antibacterial drugs
ATOR – All-Russian Public Organization "Association of Traumatologists and Orthopedists of Russia".
WSD – wound secondary surgical debridement
CT – computed tomography
ELF – extremely high frequency therapy
PT – physical therapy
MRI – magnetic resonance imaging
BV – blood volume
TAT – tetanus antitoxin
HTIG – human tetanus immunoglobulin
WDE – wound debridement and excision
SCT – spiral computed tomography
UHF – ultra-high-frequency therapy
RF – risk factors
PRM – physical and rehabilitation medicine
FS – functional status
Surgical antibiotic prophylaxis
DASH – Disability of the Arm, Shoulder and Hand Outcome Measure.
Terms and Definitions
See section 1.1 for the definition of open wounds of the wrist and hand; section 1.5 for definitions of various types of open wounds of the wrist and hand; section 1.4 for coding features of open wounds of the wrist and hand according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10); and the List of Abbreviations section for abbreviations used.
No other specific terms are used in these clinical guidelines.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
An open wound (injury) of the wrist and hand is a full-thickness disruption of the anatomical integrity of the skin and subcutaneous adipose tissue located on the hand and wrist. Within the scope of these clinical guidelines, only single or multiple mechanical wounds without functionally significant damage to muscles, tendons, nerves, and other deeper anatomical structures (simple wounds) localized on the wrist or hand of a single upper limb are considered.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The etiology of open wounds of the wrist and hand is usually discussed in the literature as part of the broader group of hand injuries. The most frequent causes are contact with machinery in the workplace, as well as contact with cutting and piercing objects at work and in everyday life [1]; in the pediatric population, contact with a door in everyday life and accidents during sports and games predominate [2-5].
The pathogenesis of open wounds of the wrist and hand corresponds to the course of the wound healing process in any location. Traditionally, three phases are described in Russian literature:
Phase I — inflammation phase (approximately days 1–5);
Phase II — regeneration phase (approximately days 6–14);
Phase III — scarring and epithelialization phase (approximately from day 15 up to 6 months).
The inflammation phase has two periods: vascular changes and cleansing of the wound from necrotic tissues.
Period of vascular changes. As a result of vascular damage and complex biochemical processes in the injury zone, microcirculation is impaired, plasma and lymph exude, and formed elements (neutrophils, lymphocytes, macrophages) escape from the vascular bed. Edema develops, and leukocyte infiltration of the tissues occurs, i.e., conditions are created for wound cleansing.
The period of wound cleansing from necrotic tissue is necrolysis. Formed elements appear in the tissues surrounding the wound, phagocytosing necrotic masses, releasing proteolytic enzymes, and removing toxins, protein breakdown products, and microorganisms from the wound with inflammatory exudate. As a result, the wound is cleansed of necrotic tissue, inflammation symptoms are resolved, and the next phase of the wound healing process begins.
Regeneration phase. Intensive growth of new blood and lymphatic vessels occurs in the wound, blood circulation improves, hypoxia decreases, and gradually, by about the 14th day, the inflammatory reaction subsides. New vessels form in the wound, and granulation tissue matures, which helps eliminate tissue defects.
Scarring and epithelialization phase. During this period, gradually, starting from the wound edges, the defect is closed by epithelium, while connective tissue matures in parallel and a scar is formed. Its final formation is completed by the 6th month or later, depending on the tissue structure. In simply structured tissues (integumentary epithelium, connective tissue), scarring occurs faster than in complexly structured tissues (nervous, parenchymal, muscular).
Also, for wounds of any localization, three types of healing are traditionally distinguished: primary intention, secondary intention, and healing under a scab. The type of healing is determined by the nature of the wound, the degree of contamination, and immune features.
Healing by primary intention is the most perfect type of regeneration, as it occurs in a short time with the formation of a thin, fairly strong scar. Aseptic surgical wounds heal by primary intention, and without suturing, small superficial wounds with insignificant edge separation. With this type of healing, there is no cavity between the wound edges and walls. The adjacent wound edges are glued together by fibrin formed from the exudate that has poured into the narrow gap between them. Simultaneously, the epithelium grows from the wound edges, forming a barrier to the penetration of microorganisms. Healing by primary intention does not cause complications, and functional changes are insignificant.
Healing by secondary intention occurs with wide gaping of the wound edges, the presence of suppuration, and the formation of excessive granulation tissue (granulations). In this case, the inflammation phase is pronounced, in the second period of which, on days 2–3, islands of granulation appear against the background of necrosis areas.
Granulation tissue is a special type of connective tissue that occurs only during secondary intention wound healing and promotes rapid filling of the cavity formed in the second period of the inflammation phase. Granulations are delicate fine-grained formations that bleed at the slightest damage. They develop from the walls and bottom of the wound. Gradually, granulation tissue fills the wound defect. The main purpose of this tissue is to protect the wound from the penetration of microorganisms, as it contains a large number of leukocytes and macrophages and has a dense structure.
Healing under a scab occurs with minor superficial injuries (abrasions, scratches, chafing, etc.). Blood, lymph, and tissue fluid that have leaked out clot on the surface of the wounds. As a result, a dense crust (scab) forms, which plays the role of a protective dressing. Under this crust, the epidermis rapidly regenerates, and the scab is rejected.
1.3 Epidemiology of the Disease or Condition
The epidemiology of open wounds of the wrist and hand is known from publications of major hand surgery centers in cities around the world. Thus, according to data from one of the leading hand surgery centers in Turkey, among 8.8 thousand patients of all ages treated from 1992 to 2005, open wounds of the wrist and hand were present in every fifth patient [1]. Males are injured more often [1–5]. Young people are injured more often than elderly people, but children are injured less often than adults [1]. No systematic reviews on the epidemiology of the considered type of injuries were found by the working group, making further generalization of numerous epidemiological indicators regarding the population of this clinical guideline difficult.
1.4 Features of Coding the Disease or Condition
This guideline provides information on open wounds of the finger(s) and hand:
S61.0 Open wound of finger(s) without damage to nail plate;
S61.1 Open wound of finger(s) with damage to nail plate;
S61.7 Multiple open wounds of wrist and hand;
S61.8 Open wound of other parts of wrist and hand;
S61.9 Open wound of unspecified part of wrist and hand.
T01.2 Open wounds of multiple regions of upper limb(s)
T92.0 Sequelae of open wound of upper limb
Non-traumatic lesions of the wrist and hand (L89.-, L98.-, etc.), sequelae of open wounds of the upper limb (T92.0, T79.-) — including post-traumatic wound infection (T79.3), iatrogenic wounds of the wrist and hand and their complications (T80–T88), as well as the following injuries of the wrist and hand, are not to be coded with these codes and are not considered in these clinical guidelines:
foreign body in soft tissue (M79.5, L92.3, M60.2);
venomous animal bite or sting (T63.-);
frostbite (T33–T35) and burns (T20–T32, L55–L59);
fracture of bones of wrist and hand (S62.-);
injury of joints, nerves, blood vessels, tendons, and muscles of wrist and hand (S63.-, S64.-, S65.-, S66.-);
crushing injuries and traumatic amputations of wrist and hand (S67.-, S68.-);
injuries of wrists and hands of both upper limbs (T00–T07) and other and unspecified injuries of wrist and hand (S67.-, S68.-, T10, T11.-, T14).
1.5 Classification of the disease or condition
Depending on the injury mechanism and the nature of tissue damage, wounds are traditionally divided into low- and high-energy wounds. Low-energy wounds include the following types.
Incision wound — vulnus incisum (knife, razor, glass, etc.).
Puncture wound — vulnus punctum (narrow-bladed knife, bayonet, awl, needle, etc.).
Contusion wound — vulnus contusum (blunt object). It is characterized by a wide zone of damage to underlying tissues with blood imbibition and necrosis.
Crush wound — vulnus conquassatum (blunt object). The mechanism of formation of a crush wound is similar to that of a contusion wound, but the degree of tissue damage is maximal.
Laceration wound — vulnus laceratum (blunt object directed at an acute angle to the body surface, skin damage from the inside by ends of broken bones, etc.).
Chopped wound — vulnus caesum (saber, axe). The mechanism of formation and the nature of tissue damage in chopped wounds combine the features of incision and contusion wounds.
Bite wound — vulnus morsum (animals, human). A feature of a bite wound is the maximum degree of its infection with virulent oral microflora. Bites of certain animals may be accompanied by the entry of toxins and venoms into the wound. Infection of the victim with the rabies virus is possible.
High-energy injuries occur during explosions, gunshot wounds, working with woodworking and metalworking machines, and traffic accidents (TAs).
Gunshot wound — vulnus sclopetarium (bullet, shrapnel, secondary projectile). Distinctive features of gunshot wounds are the following: the presence of three zones of damage, namely a) the wound tract and necrosis within it, b) the zone of traumatic paranecrosis, and c) the zone of molecular concussion; the complex anatomical nature of the wound tract; a high degree of bacterial contamination.
Mixed wound — vulnus mixtum — combines the characteristic features of several wounds. Thus, stab-incision wounds, lacerated-contused wounds, etc., can be distinguished.
Classification of wounds by degree of contamination:
aseptic (surgical) wounds — are the result of surgical intervention performed in an operating room in compliance with all asepsis standards;
bacterially contaminated — all wounds received outside the operating room in which there are no signs of an infectious process (usually up to 3 days from the moment of injury; the degree of microbial contamination does not exceed 10^5 per 1 g of tissue); primary contamination occurs at the time of injury, secondary — during the treatment process;
infected — wounds with manifested clinical and laboratory signs of inflammation (edema, tissue hyperemia, local hyperthermia, etc.), but without a pronounced necrotic and exudative component;
purulent — wounds with a pronounced infectious-inflammatory process accompanied by the development of necrosis foci, the appearance of purulent exudate, and intoxication syndrome; primary purulent wounds are formed upon opening abscesses, secondary — are formed during the wound healing process, for example, crush wounds.
Classification of wounds by degree of complexity:
simple wounds: only the skin, subcutaneous adipose tissue, and muscles (without functional significance) are damaged;
complex wounds: trauma accompanied by damage to internal organs, major vessels, large nerve trunks, bones, joints, tendons, or functionally significant muscle damage.
Classification of wounds by the number of simultaneously inflicted injuries: a) single wounds; b) multiple wounds.
Classification of wounds by the nature of the wound tract: a) blind; b) tangential; c) through-and-through.
Classification of wounds by the type of damaged tissue:
with soft tissue damage;
with bone and joint damage;
with nerve damage;
with internal organ damage;
with major vessel damage.
Classification of wounds by damage zones:
wound with a small damage zone: marginal damage is barely noticeable with a minimal necrosis zone (surgical, incised, stab);
wounds with a large damage zone: significant damage to the wound edges: zones of non-viable tissue, massive hemorrhages (contused, crushed, lacerated, gunshot).
Classification of wounds by wound shape: linear, rounded, oval, etc., with uneven contours, circular (for limbs).
Classification of open hand injuries according to N. P. Demichev (1979) [6]
Isolated injury – damage to a single tissue or functionally important structure of the hand or finger.
Multiple injury – simultaneous damage to two or more homogeneous functional structures of the hand and fingers.
Combined injury – simultaneous damage to several heterogeneous structures of the hand and fingers.
Complex injury – a combination of mechanical injuries to the hand and fingers with radiation, thermal, and chemical injuries.
1.6 Clinical presentation of the disease or condition
Main symptoms of wounds:
presence of a wound, gaping – deep, uneven soft tissue damage;
bleeding — depends on the degree of damage to blood vessels and arteries, as well as the pressure exerted on them: incised wounds are accompanied by profuse bleeding, which is not the case for crushed wounds, which are characterized by minor blood loss;
pain sensations;
forced limb position;
edema in the limb and joint area;
traumatic skin defects.
Complaints in open wrist and hand wounds:
presence of wounds on the wrist and hand;
presence of pain in the area of the wrist and hand wound;
presence of bleeding from wrist and hand wounds.
Nail bed injuries may include lacerations, nail crushing, and nail avulsion. Avulsion can be partial, where the nail remains attached to the underlying nail bed, or the nail is completely separated from the nail bed. Similarly, an extensive subungual hematoma can mask deeper nail bed injuries.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis of an open wrist and hand wound: presence of a full-thickness skin defect localized on the wrist or hand of one upper extremity, with a suspected traumatic etiology of this defect and the absence of other conditions requiring coding by other ICD-10 codes (see section 1.4).
Differential diagnosis of an open wrist and hand wound: open fracture of the wrist and hand bones; wounds with functionally significant damage to nerves, blood vessels, tendons, and muscles of the wrist and hand; closed injuries of the wrist and hand (when the skin defect was not detected during the initial examination); non-traumatic lesions of the wrist and hand.
2.1 Complaints and Anamnesis
It is recommended to collect complaints and anamnesis in all patients with an open wrist and hand wound to clarify the circumstances of seeking medical care [7, 8].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: collection of complaints and anamnesis is part of the corresponding medical service provided to the patient from section "B" of the nomenclature of medical services (approved by Order of the Russian Ministry of Health No. 804n dated October 13, 2017, with subsequent amendments and additions).
2.2 Physical Examination
It is recommended to perform a visual examination of the wound area in all patients with an open wrist and hand wound to clarify the diagnosis [7, 8].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: visual examination of the wound area is part of the corresponding medical service provided to the patient from section "B" of the nomenclature of medical services (approved by Order of the Russian Ministry of Health No. 804n dated October 13, 2017, with subsequent amendments and additions).
It is recommended to perform palpation of the wound area in all patients with an open wrist and hand wound to clarify the diagnosis [7, 8]
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: palpation of the wound area is part of the corresponding medical service provided to the patient from section "B" of the nomenclature of medical services (approved by Order of the Russian Ministry of Health No. 804n dated October 13, 2017, with subsequent amendments and additions).
2.3 Laboratory Diagnostics
It is recommended upon admission to the hospital to perform the following laboratory tests for the patient [29]:
complete blood count (CBC) (to prepare for surgery, if required);
determination of ABO blood groups (to prepare for surgery, if required);
determination of Rh factor (D antigen) (to prepare for surgery, if required);
blood clotting time or coagulogram (screening test of the hemostatic system) (as decided by the attending or on-duty trauma surgeon/orthopedist to prepare for surgery in case of extensive injuries associated with the risk of blood clotting homeostasis disorders);
general general-clinical biochemical blood test (in the presence of a chronic wound and/or extensive injuries requiring large-scale surgical treatment and/or anamnesis of internal organ diseases and/or corresponding medical opinion);
detection of infectious disease pathogens:
hepatitis B virus surface antigen (HBsAg) in the blood;
antibodies to hepatitis C virus in the blood;
immunoglobulin M and G (IgM, IgG) antibodies to human immunodeficiency virus HIV-1 in the blood;
immunoglobulin M and G (IgM, IgG) antibodies to human immunodeficiency virus HIV-2 in the blood;
antibodies to Treponema pallidum using non-treponemal tests (RPR, VDRL) (qualitative and semi-quantitative test) in blood serum.
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to perform a complete blood count and determine the serum C-reactive protein level in patients with a mammalian bite-induced open wrist and hand wound and suspected wound infection [10].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to perform a microbiological (culture) examination of wound discharge for aerobic and facultatively anaerobic microorganisms with subsequent determination of sensitivity to antimicrobial drugs (rapid endotoxin antibiotic susceptibility testing in purulent discharge) in patients with a mammalian bite-induced open wrist and hand wound presenting with signs of wound infection to verify the pathogen [10].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
2.4 Instrumental Diagnostics
It is recommended to perform wrist radiography and hand radiography in patients with an open wrist and hand wound suspected of having an upper extremity bone fracture to clarify the diagnosis [11].
CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).
Comments: "radiography of the injury area" at the discretion of the prescribing medical professional corresponds to one or more medical services of the "radiological examinations with their subsequent description and radiation therapy" type, including — but not limited to — the following medical services:
upper extremity radiography;
ulna and radius radiography;
wrist radiography;
metacarpal radiography;
hand radiography;
radiography of the phalanges of the fingers;
radiography of the phalangeal bones of the hand;
radiography of the thumb of the hand.
It is recommended to perform a repeat X-ray examination of the injury area in patients with an open wound of the wrist and hand who, according to the initial X-ray report of the area of interest, showed no definitive evidence of bone and traumatic changes, in order to clarify the diagnosis [11].
CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).
It is recommended to perform an X-ray examination in all patients with an open wound containing foreign bodies or at risk of foreign body retention, in order to detect radiopaque foreign bodies [12, 56].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: Radiopaque foreign bodies include bones, metal objects, teeth (from animal bites), glass, and stone objects.
It is recommended to perform an ultrasound examination of soft tissues (one anatomical zone) in patients with an open wound containing foreign bodies or at risk of foreign body retention, in order to detect foreign bodies in the soft tissues [12, 56].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: When ordering the examination, the sensitivity of the method for various types of materials tested (foreign bodies made of glass, metal, plastic, stone, wood, etc.) must be taken into account.
It is recommended to use computed tomography of the upper extremity (CT) and magnetic resonance imaging of the upper extremity (MRI) in patients with an open wound of the wrist and hand to visualize very small foreign bodies (<0.5 mm) or focal infection of unknown origin that may be caused by a foreign body [13].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is not recommended to use MRI for visualizing metallic foreign bodies due to the potential risk of foreign body displacement during the procedure, which can lead to additional tissue damage or artifacts on the MRI [13].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
2.5 Other Procedures
No.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
The goals of treatment for patients with an open wound of the wrist and hand include hemostatic wound closure with optimal cosmetic outcomes without increasing the risk of infection or other complications. Determining which wounds are at high risk of infection and choosing the appropriate wound closure method are essential to achieving the treatment goals for open wounds of the wrist and hand.
It is recommended to apply a dressing in case of skin integrity breach in all patients with an open wound of the wrist and hand to prevent wound infection [8].
CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).
Comments: wound sealing using skin (surgical) adhesive compared to wound suturing is associated with lower pain levels, shorter medical care delivery time, comparable cosmetic outcomes, a slightly higher rate of wound dehiscence, and a comparable rate of other complications (Level of Evidence: 1) [14].
In all patients with an open wound of the wrist and hand with suspected hypovolemic shock due to blood loss, it is recommended to restore circulating blood volume (at the discretion of the on-duty or attending surgeon or orthopedic traumatologist — transfusion of solutions affecting water-electrolyte balance (crystalloids and/or, as indicated, colloids) and/or blood substitutes and plasma preparations and/or other blood products (B05AX)) [15].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
3.1.1 Prophylactic use of antibiotics in wound treatment
For uncomplicated soft tissue wounds that are not contaminated with water or soil and are not associated with mammalian bites, assessed clinically and anamnesticially by the attending medical professional (surgeon, orthopedic traumatologist, general practitioner (family doctor), paramedic) as uninfected, prophylactic systemic antibiotics are not required [8, 19, 23].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comments. The main means of preventing infection in uncomplicated wounds are adequate irrigation, removal of foreign bodies, and appropriate wound closure techniques.
For complicated wounds (as well as in patients at high risk of infection) not contaminated with water or soil and not associated with mammalian bites, it is advisable to prescribe systemic antibiotic therapy for up to 24 hours [23].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comments. For patients with an unremarkable allergy history regarding beta-lactam antibacterial drugs (J01C, J01D), one of the first-generation cephalosporins should be chosen, for example, cefazolin**. For patients with allergies to beta-lactam antibacterial drugs (J01C, J01D), it is advisable to choose clindamycin**, taking into account age restrictions for children.
Patients at high risk of wound infection (immunodeficiency, asplenia, severe liver disease, edema in the bite area, moderate to severe trauma, injury to the joint capsule or periosteum), as well as those with contaminated wounds, should have an antibacterial drug selected in accordance with the contamination factors and prescribed systemic antibacterial therapy for 3–5 days, taking into account age restrictions in the instructions for medical use [22, 23].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comments. For wounds contaminated with saltwater, it is advisable to administer systemic antimicrobial therapy from the tetracycline group (J01AA) and third-generation cephalosporins (J01DD), or prescribe fluoroquinolone monotherapy (J01MA). In case of freshwater contamination, one of the fluoroquinolones (J01MA), third-generation cephalosporins (J01DD), or fourth-generation cephalosporins (J01DE) should be prescribed. In case of soil contamination, high-dose beta-lactamase-susceptible penicillins (J01CE) must be prescribed, and for mammalian bites, systemic antimicrobials from the group "Penicillin combinations, including combinations with beta-lactamase inhibitors" (J01CR) should be prescribed, or a combination of lincosamides (J01FF) with sulfonamide and trimethoprim combinations, including derivatives (J01EE), for patients with allergies to beta-lactam antibacterial drugs. Pregnant women with allergies to beta-lactam antibacterial drugs or other contraindications to these drugs should be considered for macrolides (J01FA) with careful monitoring of treatment efficacy. When administering antibacterial therapy, regardless of the chosen treatment duration, age restrictions must be taken into account, and the standard therapeutic dosing regimen described in the instructions for medical use should be selected.
3.2 Surgical treatment of open wounds of the wrist and hand
It is recommended to perform primary wound closure (without skin grafting) in patients with a non-bite open wound of the wrist and hand sustained less than 24 hours ago and clinically and anamnesticially assessed by the attending medical professional (physician, paramedic) as uninfected, in order to close the wound defect if, at the discretion of the attending medical professional, the applied dressing does not provide adequate approximation of the wound edges [14, 19–26].
CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).
Comments: irrigation of the wound with tap water compared to irrigation with sterile isotonic sodium chloride solution** does not increase the risk of wound infection [28].
It is recommended to perform primary surgical debridement of the wound or infected tissue in patients with a non-bite open wound of the wrist and hand sustained 24 hours or more ago, or sustained less than 24 hours ago and clinically and anamnesticially assessed by the attending medical professional (surgeon, orthopedic traumatologist, general practitioner (family doctor), paramedic) as infected, in order to close the wound defect [19–26].
CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).
It is recommended to perform primary surgical debridement of the wound or infected tissue in patients with a mammalian bite open wound of the wrist and hand in order to close the wound defect [25, 28, 29].
CGR CLEL 5Level of recommendation validity — C (level of evidence reliability — 5).
3.3 Pain management
It is recommended to prescribe medicinal products from the "other analgesics and antipyretics" group (ATX N02B) to all patients with an open wound of the wrist and hand who complain of pain in the wound area, do not refuse this intervention, and have no contraindications, in accordance with the instructions for medical use of the medicinal product, for pain relief [9, 29].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: Medicinal products for pain relief in adults and children are presented in Appendices A3.1–3.2.
It is recommended to prescribe local anesthetics (N01B Local anesthetics), taking into account age restrictions in the instructions for medical use, to patients with an open wound of the wrist and hand for perioperative pain relief [15, 17].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: local anesthetics, such as lidocaine** 1% (10 mg/mL, duration of action 1 to 2 hours) or bupivacaine** 0.5% (5 mg/mL, duration of action 4 to 8 hours), are often used for pain management, taking into account age restrictions for children. Epinephrine** may be added for adults to help stop wound bleeding through vasoconstriction. The addition of epinephrine** to bupivacaine** prolongs analgesia for another 1.5 hours with the added benefit of improved hemostasis. The maximum recommended doses for local anesthesia are: lidocaine 3–5 mg/kg without epinephrine or up to #7 mg/kg with epinephrine** [66, 67]; bupivacaine** 1–2 mg/kg without epinephrine** and up to #3 mg/kg with epinephrine** [67]. Topical anesthetic creams/solutions may be used in children as an adjunct. For large wounds, a regional block may be required to avoid administering toxic doses of the anesthetic.
3.4 Dietary Therapy
No.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
The evidence base for recommendations on the rehabilitation of patients with open wrist and hand wounds is currently insufficiently developed, although physiotherapy methods have long been successfully used in the treatment of soft tissue injuries [34, 36, 39, 40].
It is recommended to prescribe physiotherapy for extensive open wounds of the wrist and hand to prevent infection, reduce edema, and minimize scar formation [31, 33, 37, 39, 40].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: Patients with an open wrist and hand wound without tendon and nerve injuries do not require rehabilitation.
For aseptic wounds, low-level laser therapy of the skin, pulsed electromagnetic field therapy, extremely high frequency (EHF) electromagnetic radiation therapy, and ultra-high frequency (UHF) electric field therapy are prescribed from the first days after injury to reduce tissue edema, improve microcirculation and blood rheology, thereby accelerating wound healing. Laser therapy is performed during dressing changes. UHF, EHF, and magnetotherapy are applied through the dressing [32, 34, 35, 39].
For infected wounds, post-surgical wound debridement is followed by UV irradiation, UHF therapy, and drug iontophoresis with novocaine and antibiotics to the affected area in order to combat infection, reduce pain, and provide anti-inflammatory and dehydrating effects on the wound surface [31, 33, 35, 39].
It is recommended for secondary intention healing of wrist and hand wounds complicated by finger and wrist joint contractures to undergo outpatient rehabilitation under an individual program using exercise therapy (kinesiotherapy) and physiotherapy to restore hand and finger function [36–38].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: The rehabilitation program is developed by a physical and rehabilitation medicine physician / exercise therapy physician and a physical therapist, selecting modalities in accordance with the nature and severity of the cicatricial-adhesive process and joint contracture rigidity. Prescribed interventions include: paraffin therapy for bone system disorders, medicinal electrophoresis for microcirculation disorders, ultrasound therapy, low-frequency pulsed electrostatic field therapy, therapeutic whirlpool baths, manual therapy for joint disorders, positioning, robotic mechanotherapy, hydrokinesitherapy for joint diseases and injuries, and occupational therapy [36-38].
Prevention and treatment of pathological scarring are recommended using therapeutic, physical therapy, radiological, surgical, and cosmetic intervention methods [61–63].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: The exact causes of hypertrophic and keloid scars have not yet been identified. These scars develop due to disorders in collagen synthesis and degradation processes at various stages of scar formation. The problem of treating patients with keloid and hypertrophic scars has not been fully resolved, as there is no single effective management method for such patients [64].
Treatment methods are based on various physical effects on the pathological scar and include:
silicone-based products (sheets, patches, gels) that affect keloids by applying uniform pressure to the scar, leading to a decrease in extracellular matrix volume and a correct, orderly arrangement of collagen fibers in the wound, while maintaining the moisture of the scar surface and protecting it from drying out and trauma;
ultraphonophoresis with medicinal products (e.g., Longidase or Imoferase) using ultrasonic vibrations in continuous or pulsed mode at a frequency of 880 kHz – 1 MHz. The course duration is about 20 procedures, to be repeated no earlier than 3 months later [64].
There are indications for the use of panthenol-based ointments and creams, 5% potassium iodide iontophoresis, heparin ultraphonophoresis, and corticosteroids [64].
Compression therapy is the preferred conservative method for both the prevention and treatment of hypertrophic scars and keloids, despite conflicting data on their value in reducing excessive scarring [65].
It should be noted that the effectiveness of therapeutic and physical therapy agents depends on the age of the scar – the older it is, the lower the treatment efficacy. This is due to the predominance of scar tissue and a decrease in the number of blood vessels in the connective tissue formation, which impairs its trophism [64].
However, for an already formed keloid scar, treatment should be carried out by a dermatologist-cosmetologist, who utilizes laser scar resurfacing, liquid nitrogen cryotherapy, and surgical treatment with scar excision followed by glucocorticoid administration.
5. Prevention and Dispensary Observation
It is recommended to administer tetanus toxoid** to patients with open wounds of the wrist and hand for the purpose of tetanus prophylaxis [54, 55].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: In accordance with clauses 4156-4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is performed for any injuries involving a breach of the integrity of the skin and mucous membranes. Emergency tetanus prophylaxis is carried out up to the 20th calendar day from the moment the injury was sustained [54]. The prescribing of drugs for emergency tetanus immunoprophylaxis is carried out differentially depending on the availability of documentary confirmation of a prophylactic vaccination or data from immunological monitoring of anti-tetanus immunity levels, as well as taking into account the nature of the injuries.
Emergency tetanus immunoprophylaxis is carried out in the form of:
passive immunization or seroprophylaxis with human tetanus immunoglobulin** (HTIG), or in its absence, with tetanus antitoxin** (TAS);
active-passive prophylaxis, consisting of the simultaneous administration into different anatomical sites of human tetanus immunoglobulin** (or in its absence, TAS) and tetanus toxoid** (TT);
emergency revaccination with tetanus toxoid** (or diphtheria-tetanus toxoid with reduced antigen content** – Td-M) to stimulate immunity in previously vaccinated individuals [54, 55].
It is recommended to vaccinate against rabies all patients with an open wound of the wrist and hand following an animal bite, in the absence of contraindications, in accordance with current regulatory legal documents governing the prevention of rabies in humans, with the aim of preventing this disease [9, 54].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
6. Organization of Medical Care
Stages of medical care provision for open wounds of the wrist and hand (in accordance with Order of the Russian Ministry of Health No. 901n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile of 'Traumatology and Orthopedics'"):
primary pre-medical health care;
primary physician-delivered health care;
primary specialized health care;
emergency, including specialized emergency, medical care;
specialized, including high-tech, medical care.
Indications for elective hospitalization for open wounds of the wrist and hand: long-term non-healing wounds.
Indications for emergency hospitalization for open wounds of the wrist and hand: acute mechanical damage to the skin of the hand and wrist joint area with ongoing bleeding; presence of deep, extensive wounds with damage to muscles, tendons, limb vessels, and joints requiring the restoration of damaged structures; presence of a foreign body in the wound that is difficult or impossible to remove in an outpatient setting.
Indications for discharge in open wounds of the wrist and hand: clinical improvement.
7. Additional Information
Risk factors for an unfavorable outcome of surgical treatment in patients with an open wound of the wrist and hand:
systemic diseases;
advanced age;
immunodeficiency states;
cachexia;
infection;
oncological disease.
To assess treatment outcomes in patients with fractures at the shoulder girdle and arm level, questionnaires have been developed to evaluate the functional result of treatment.
Disabilities of the Arm, Shoulder and Hand questionnaire (Disabilities of the Arm, Shoulder, and Hand, DASH) was developed jointly by the American Academy of Orthopaedic Surgeons, the Council of Musculoskeletal Specialty Societies, and the Institute for Work and Health (Canada). It belongs to patient-reported outcome measures and was introduced in 1996 for standardized evaluation of the impact of various musculoskeletal injuries and diseases on upper extremity function [41]. DASH is a 30-item questionnaire with response options presented as a 5-point Likert scale. Scores range from 0 (no functional limitations) to 100 (most severe functional limitations). The questionnaire is intended for patients with any musculoskeletal disorders of the upper extremities [42]. DASH has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require specific physical fitness, and functional limitations may occur only under high loads exceeding the scope of the 30 DASH items. Approved translation versions of DASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health (Canada), which owns the copyright to the questionnaire (https://dash.iwh.on.ca/available-translations).
Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) is a shortened 11-question version of the DASH questionnaire with the same response options [43, 44]. Like DASH, it is designed for patient self-assessment of the degree of upper extremity function impairment in various diseases and injuries. QuickDASH also has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require specific physical fitness, and functional limitations may occur only under high loads exceeding the scope of the 11 QuickDASH items. Additional modules are evaluated separately. In a number of studies, comparison of the DASH and QuickDASH questionnaires showed that both instruments have approximately equal sensitivity, specificity [45–49], and minimal clinically important difference values (12–14 points for DASH and 12–15 points for QuickDASH) [50]. In a systematic review of 23 self-assessment instruments for patients with various upper extremity pathologies, the QuickDASH questionnaire showed the highest content and construct validity, reliability, and sensitivity [51]. There are reports of successful use of QuickDASH in children aged 8–18 years [52, 53]. Approved translation versions of QuickDASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health (Canada), which owns the copyright (https://dash.iwh.on.ca/available-translations). The Russian translation of QuickDASH in the author's version is given in Appendix G1.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1. | Performed surgical debridement of the wound or infected tissue | Yes/no |
2. | Administered tetanus toxoid** or tetanus antitoxin**, or human tetanus immunoglobulin** (depending on medical indications and in the absence of medical contraindications) | Yes/no |
3. | Rabies vaccination performed (for animal bite wounds, depending on medical indications and in the absence of contraindications) | Yes/no |
4. | Applied a dressing for compromised integrity of the skin | Yes/no |
5. | Treatment with "other analgesics and antipyretics" (ATC N02B) and/or local anesthetics was performed (depending on medical indications and in the absence of medical contraindications) | Yes/no |
6. | Administered treatment with systemic antibacterial drugs (in case of a high risk of wound infection, contaminated wounds, depending on medical indications and in the absence of medical contraindications) | Yes/No |
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Appendix A1. Working Group Composition
Geroeva I.B., MD, Professor, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow.
Golubev I.O., MD, PhD, Chairman of the Interregional Public Organization "Society of Hand Surgeons – Hand Club", Moscow; member of ASRA.
Gorbatyuk D.S., PhD, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Ministry of Health of the Russian Federation, Moscow; member of the Association of Trauma and Orthopedic Surgeons (ATOR);
Dubrov V.E., MD, PhD, Professor, Chief freelance specialist traumatologist-orthopedist of the Moscow Healthcare Department, Moscow; member of ASRA.
Kleymenova E.B., MD, PhD, Professor, National Medical Research Center for Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.
Kutyanov D.I., MD, PhD, Associate Professor, Professor of the Department of Traumatology and Orthopedics, First Pavlov State Medical University of the Russian Ministry of Health, Saint Petersburg.
Nazarenko A.G., MD, Professor of the RAS, Director of the Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow, Vice President of ATOR.
Otdelenov V.A., PhD, National Medical Research Center for Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.
Shikhaleva N.G., MD, PhD, Head of the Clinic of Reconstructive Plastic Surgery and Hand Surgery, National Medical Research Center for Traumatology and Orthopedics named after Academician G.A. Ilizarov of the Russian Ministry of Health, Kurgan; member of ASRA.
Conflict of interest: the members of the working group declare no conflict of interest in the development of this clinical guideline.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Trauma and orthopedic surgeons
Surgeons
Pediatric surgeons
General practitioners (family physicians)
Physical and rehabilitation medicine physicians.
Stages of evaluating the levels of evidence and grades of recommendation:
Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.
Systematic search and selection of CT publications in accordance with the previously defined criteria.
Systematic search and selection of clinical trial publications:
The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.
Table. Scale for grading levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
The procedure for providing medical care in the profile of "traumatology and orthopedics" was approved by Order of the Ministry of Health of the Russian Federation No. 901n of November 12, 2012.
Order on Approval of Criteria for Assessing the Quality of Medical Care dated May 10, 2017 No. 203n.
Appendix A3.1. Guidelines for pain management in adult patients undergoing traumatological and orthopedic procedures [57]
Stage of treatment | Opioid analgesics | Non-opioid analgesics and gabapentin |
|---|---|---|
Inpatient setting | Trimeperidine** 25–50 mg orally. Maximum single dose is 50 mg, maximum daily dose is 200 mg. | Ketorolac** 15 mg IV every 6 hours x 5 doses, then #ibuprofen** 600 mg orally every 8 hours [57] |
OR Trimeperidine** 10–40 mg (from 1 ml of 10 mg/ml solution to 2 ml of 20 mg/ml solution) IM, SC, or IV. Maximum single dose is 40 mg, daily dose is 160 mg. | Gabapentin 300 mg 3 times daily | |
Morphine** 10–30 mg IM or SC as needed for severe breakthrough pain | Paracetamol** 500 mg orally every 12 hours | |
Outpatient stage | ||
First week (after discharge) | Tramadol** single dose 100 mg orally as needed; if analgesia is insufficient, repeat 100 mg after 30–60 minutes. Maximum daily dose is 400 mg. | #Ibuprofen** 600 mg orally every 8 hours for 7 days [57] |
#Gabapentin 100 mg 1 tablet orally 3 times a day for 7 days [57] | ||
Paracetamol** 500 mg orally every 12 hours for 7 days | ||
Second week | Tramadol** single dose 50 mg orally as needed; if analgesia is insufficient, repeat 50 mg after 30–60 minutes. Maximum daily dose is 400 mg. | NSAIDs as needed |
Gabapentin 300 mg 3 times a day (gradually titrate up to the maximum daily dose if necessary: 3600 mg/day) | ||
Paracetamol** 500 mg orally every 12 hours (dose may be increased as opioid doses are tapered) | ||
Third week | Tramadol** single dose 50 mg orally as needed; if analgesia is insufficient, repeat 50 mg after 30–60 minutes. Maximum daily dose is 400 mg. | NSAIDs as needed |
Gabapentin as needed (max. 3600 mg/day) | ||
Paracetamol** 1000 mg orally every 12 hours (dose may be increased as opioid doses are tapered) | ||
Fourth week | Tramadol** single dose 50 mg orally as needed; if analgesia is insufficient, repeat 50 mg after 30–60 minutes. Maximum daily dose is 400 mg. | NSAIDs as needed |
Gabapentin as needed (max. 3600 mg/day) | ||
Paracetamol** 1000 mg orally every 8 hours (dose may be increased as opioid doses are tapered) | ||
Fifth week and beyond | - | NSAIDs as needed |
Paracetamol** as needed | ||
Gabapentin as needed, then discontinue. | ||
Appendix A3.2. Postoperative pain management recommendations in children
Medicinal products | Single dose | Dosing regimen | Maximum daily dose | Maximum duration of use | |
|---|---|---|---|---|---|
Non-narcotic analgesic | |||||
Paracetamol** | Rectal suppositories: | ||||
3-6 months (6-8 kg): 50 mg | rectally at intervals of at least 4-6 hours | 100 mg/day | Not specified in the instructions | ||
7-12 months (8-11 kg): 100 mg | 200 mg/day | ||||
1-4 years (12-16 kg): 100 mg | 400 mg/day | ||||
5-9 years (17-30 kg): 250 mg | 1000 mg/day | ||||
10-14 years: 500 mg | 2000 mg/day | ||||
over 15 years: 500 mg | 4000 mg/day | ||||
IV infusion: | |||||
10 kg and under: 7.5 mg/kg (0.75 ml/kg) | no more than 4 times/day, interval between infusions at least 4 hours | no more than 30 mg/kg/day | Not specified in the instructions | ||
from 10 kg up to 33 kg inclusive: 15 mg/kg (1.5 ml/kg) | less than 60 mg/kg inclusive, but not more than 2 g | ||||
from 33 to 50 kg inclusive: 15 mg/kg (1.5 ml/kg) | less than 60 mg/kg inclusive, but not more than 3 g | ||||
over 50 kg: 1 g (100 ml) | no more than 4 g/day | ||||
Tablets | |||||
3-5 years: 200 mg | Every 4-6 hours | no more than 4 times a day | |||
6-8 years: 250 mg | no more than 4 times a day | ||||
9-11 years: 500 mg | no more than 4 times a day | ||||
Over 12 years: 500-1000 mg | no more than 4 g/day | ||||
Nonsteroidal anti-inflammatory drugs | |||||
Diclofenac** | Powder for oral solution | ||||
14-18 years: 50-100 mg | 0.5-2 mg/kg per day orally, daily dose divided into 2-3 single doses | 150 mg | 7 days | ||
Tablets: | |||||
6-14 years: 25 mg | 0.5-2 mg/kg per day orally, daily dose divided into 2-3 single doses | 150 mg | 7 days | ||
14-18 years: 25-50 mg | |||||
Ibuprofen** | Suspension (100 mg/5 ml): | ||||
3-6 months (5-7.6 kg): 2.5 ml (50 mg) | orally up to 3 times/day at intervals of 6-8 hours | 7.5 ml (150 mg) | Not specified in the instructions | ||
6-12 months (7.7-9 kg): 2.5 ml (50 mg) | orally 3-4 times/day at intervals of 6-8 hours | 10 ml (200 mg) | |||
1-3 years (10-16 kg): 5 ml | orally up to 3 times/day at intervals of 6-8 hours | 15 ml (300 mg) | |||
4–6 years (17–20 kg): 7.5 ml | 22.5 ml (450 mg) | ||||
7–9 years (21–30 kg): 10 ml | 30 ml (600 mg) | ||||
10–12 years (31–40 kg): 15 ml | 45 ml (900 mg) | ||||
Suspension (200 mg / 5 ml): | |||||
1–3 years (10–16 kg): 2.5 ml (100 mg) | orally up to 3 times/day at intervals of 6-8 hours | 7.5 ml (300 mg) | Not specified in the instructions | ||
4–6 years (17–20 kg): 3.75 ml (150 mg) | 11.25 ml (450 mg) | ||||
7–9 years (21–30 kg): 5 ml (200 mg) | 15 ml (600 mg) | ||||
10–12 years (31–40 kg): 7.5 ml (300 mg) | 22.5 ml (900 mg) | ||||
over 12 years (over 40 kg): 7.5–10 ml (300–400 mg) | 30 ml (1200 mg) | ||||
Tablets: | |||||
aged 6 to 12 years (body weight > 20 kg): 200 mg | orally up to 4 times/day with an interval of at least 6 hours | 800 mg | Not specified in the instructions | ||
children over 12 years: 200 mg | orally 3–4 times/day with an interval of at least 6 hours | ||||
rectal suppositories, [FOR CHILDREN] | |||||
3–9 months (6.0 kg – 8.0 kg): 1 suppository (60 mg) | Up to 3 times per 24 hours, maximum 180 mg per day | 30 mg/kg with dosing intervals of 6–8 hours | Maximum 3 days | ||
9 months – 2 years (8.0 kg – 12.0 kg): 1 suppository (60 mg) | Up to 4 times per 24 hours, maximum 240 mg per day | ||||
Ketorolac** | Tablets: | ||||
children over 16 years: 10 mg | orally up to 4 times/day | 40 mg | 5 days | ||
Parenteral solution | |||||
over 16 years: 10–30 mg | IV, IM with an interval of at least 6 hours | 90 mg | 2 days | ||
Opioid and opioid-like analgesics | |||||
Morphine** | Oral solution/tablets | ||||
3 to 7 years: 5 mg | orally, every 6 hours | 20 mg | Not specified in the instructions | ||
7 to 17 years with body weight up to 70 kg: 5 mg | orally, every 4 hours | 30 mg | |||
7 to 17 years with body weight of 70 kg or more: 10 mg | 60 mg | ||||
17 years and older: 5–10 mg | Not specified in the instructions | ||||
Parenteral solution: | |||||
birth to 2 years: 100–200 mcg/kg body weight (0.1–0.2 mg/kg) | SC, if necessary every 4–6 hours. | 15 mg | Not specified in the instructions | ||
over 2 years: 100–200 mcg/kg body weight (0.1–0.2 mg/kg) | SC if necessary every 4–6 hours | ||||
Tramadol**1 | Parenteral solution | ||||
1 to 12 years*: 1–2 mg/kg | IV, IM, SC | 8 mg/kg/day or maximum 400 mg/day | |||
from 12 years: 50–100 mg | IV, IM, SC; if satisfactory analgesia is not achieved 30–60 minutes after the initial dose, an additional 50 mg may be administered | 400 mg/day | Not specified in the instructions | ||
Tablets: | |||||
children over 14 years of age: 50–100 mg | orally; if satisfactory analgesia is not achieved within 30–60 minutes after the initial administration, an additional 50 mg may be prescribed | 400 mg/day | Not specified in the instructions | ||
Trimeperidine** | Parenteral solution | ||||
Children2 over 2 years of age: 3–10 mg | IV, IM, SC | Not specified in the instructions | Not specified in the instructions | ||
Fentanyl** | Parenteral solution | ||||
children from 1 year of age with spontaneous breathing: initial dose 3–5 mcg/kg, additional dose 1 mcg/kg. | IV | Not specified in the instructions | Not specified in the instructions | ||
children from 1 year of age receiving mechanical ventilation: initial dose 15 mcg/kg, additional dose 1–3 mcg/kg. | IV | Not specified in the instructions | Not specified in the instructions | ||
1 In children under 12 years of age, morphine** is preferred if opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [58, 59].
2 Use in children is not recommended, because its metabolite accumulates in the body and provokes seizures upon repeated use [60].
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
After discharge from the hospital, all patients are advised to continue treatment and follow-up by an orthopedist on an outpatient basis. In the presence of infected wounds as well as chronic wounds, follow-up and treatment by a surgeon at the place of residence is required.
A course of antibiotic therapy not completed prior to hospital discharge must be continued in an outpatient setting. When treating infected wounds, the attending physician may prescribe an additional (outpatient) course of antibiotic therapy.
Dressings must be changed and the wound condition assessed in a medical facility, depending on the availability of care, at least once every 2 days. If signs of inflammation are detected, measures must be taken to arrest this process (at the discretion of the attending physician: early removal of sutures, wound edge separation, establishment of wound drainage (including placement of wound drains), or administration of an additional course of antibiotic therapy). If inflammation cannot be resolved in an outpatient setting, the patient must seek inpatient care (a surgical infection unit or a surgical department providing specialized care).
Outpatient follow-up is carried out until complete wound healing; in cases of joint contractures, until complete restoration of limb function.
Suture removal may be performed in an outpatient setting (dressing room, equipped surgical office). The optimal time for suture removal is the 14th day after placement during primary or secondary surgical debridement. In the presence of circulatory insufficiency and/or neurological disorders, suture removal may be delayed beyond 14 days post-placement.
At 6 months, the patient should receive a booster tetanus vaccination to establish long-lasting immunity.
If the patient was prescribed a course of rabies immunoglobulin and it is not completed before hospital discharge, it must be continued during the outpatient follow-up period.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
QuickDASH upper extremity disability questionnaire
Russian title: The shortened disabilities of the arm, shoulder and hand questionnaire.
Original title: The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH)
Source: Quick DASH Outcome Measures: Russian translation. Institute for Work & Health, 2006. https: //dash.iwh.on.ca /available-translations
Type: questionnaire
Purpose: assessment of the impact of musculoskeletal injuries and diseases on upper extremity function.
Content:
INSTRUCTIONS: This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer each question based on your condition over the last week by circling the appropriate number. If you did not have the opportunity to perform a specific activity last week, please choose the most appropriate response. It does not matter which hand you use to perform the activity; please answer based on your ability, regardless of how you independently perform the task.
Please rate your ability to do the following activities in the past week by circling the number of the appropriate response | |||||
|---|---|---|---|---|---|
no difficulty | mild difficulty | moderate difficulty | severe difficulty | Unable | |
1. Open a tight or new jar with a screw cap | 1 | 2 | 3 | 4 | 5 |
2. Do heavy household chores (e.g., wash walls, mop floors) | 1 | 2 | 3 | 4 | 5 |
3. Carry a shopping bag or briefcase | 1 | 2 | 3 | 4 | 5 |
4. Wash your back | 1 | 2 | 3 | 4 | 5 |
5. Cut food with a knife | 1 | 2 | 3 | 4 | 5 |
6. Activities or occupations that require some strength or exertion through your hand or arm (e.g., tennis, sweeping, hammering, etc.) | 1 | 2 | 3 | 4 | 5 |
none | mild | moderate | severe | extreme | |
7. To what extent has your arm, shoulder, or hand problem interfered with your normal social activities (with family, friends, neighbors) over the past week? | 1 | 2 | 3 | 4 | 5 |
No limitation | mild | moderate | severe | Unable | |
8. Were you limited in your work or other regular daily activities due to your arm, shoulder, or hand problem over the past week? | 1 | 2 | 3 | 4 | 5 |
Please rate the severity of the following symptoms in the past week: | none | mild | moderate | severe | extreme |
9. Pain in the arm, shoulder, or hand | 1 | 2 | 3 | 4 | 5 |
10. Tingling (pins and needles) in your arm, shoulder or hand | 1 | 2 | 3 | 4 | 5 |
no difficulty | mild difficulty | moderate difficulty | severe difficulty | So severe that I cannot sleep | |
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? | 1 | 2 | 3 | 4 | 5 |
WORK MODULE (OPTIONAL) The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work). Please indicate what your job/work is: ___________________________________________ c I do not work. (You may skip this section). Please circle the number that best describes your physical ability in the past week. | |||||
|---|---|---|---|---|---|
Did you have any difficulty: | no difficulty | mild difficulty | moderate difficulty | severe difficulty | Not able |
1. Using your usual technique for your work? | 1 | 2 | 3 | 4 | 5 |
2. Because of pain in your arm, shoulder, or hand when performing your usual work? | 1 | 2 | 3 | 4 | 5 |
3. Doing your work as well as you would like? | 1 | 2 | 3 | 4 | 5 |
4. Spending your usual amount of time doing your work? | 1 | 2 | 3 | 4 | 5 |
COMPETITIVE ATHLETES / MUSICIANS (OPTIONAL) The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport. If you play more than one sport or instrument (or do both), please answer with respect to that activity which is most important to you. Please indicate the sport or instrument which is most important to you: _________________________________________________________________________________ c I do not play a sport or an instrument. (You may skip this section). | |||||
|---|---|---|---|---|---|
Please circle the number that best describes your physical ability in the past week. | no difficulty | mild difficulty | moderate difficulty | severe difficulty | Impos- sible |
1. Using your usual technique for playing an instrument or participating in sports? | 1 | 2 | 3 | 4 | 5 |
2. Because of pain in your arm, shoulder, or hand when playing an instrument or participating in sports? | 1 | 2 | 3 | 4 | 5 |
3. When playing an instrument or participating in sports as well as you would like? | 1 | 2 | 3 | 4 | 5 |
4. Spending your usual amount of time playing sports or playing a musical instrument? | 1 | 2 | 3 | 4 | 5 |
OPTIONAL MODULE SCALING. All 4 questions must be answered. Simply add the assigned values for each response and divide by 4 (number of items); subtract 1 and multiply by 25.