Minor Office Procedures

Nursemaid’s elbow

“pulled elbow”

Subluxation of radial head

Almost always <5 yrs old

“Pulling injury”

X-rays normal

Clinical diagnosis

Pseudo-paralysis of entire arm

Pain with manipulation

How to repair nursemaids elbow? Reduction techniques…

TWO methods:

1. Hyper supinate wrist > flex elbow 90 degrees

2. Pronation of wrist

Feel “click” beneath thumb confirms dx and reduction

Don’t need to immobilize

Recurrence up to 30%, rare > 5 y/o

• Child will use arm after 10-15 minutes of technique

Supination - Flexion Technique

Hypersupinate forearm, press thumb lightly on radial head (aka near elbow)

Flex elbow 90 degrees

“click”

Hyperpronation

Pressure on radial head

Grasp distal forearm with other hand

Hyperpronate the forearm

Finger / Toe Dislocation most common causes and joints

• Most common PIP joint

• Often d/t ball handling

• Closed Dislocation

Relocate Procedure

Exaggerate the dislocation

Apply traction distally

Pull it back into proper position

PIP dislocation - dorsal

Most frequent injured hand joint

Ball playing

Playing field reductions

X-ray considerations (xray before and after to r/o fracture with relocation procedure)

Splint finger after reduction

Ulnar PIP dislocation

Subungual hematoma

blood under nail

Most common fracture of the hand

Mechanism – crush injury, direct blow

TX = Nail trephination

What to use for nail trephination in subungual hematoma

NO anesthesia/digital block

• Heated paper clip (takes a long time)

• Cautery tool (more used in adults)

• 18 G needle (more used in children)

AVOID nail bed puncture - very sensitive

Procedure steps for nail trephination

cleanse nail area

identify center of subungual hematoma

avoid lunula area (white area at top of nail near skin)

video in part 1 w/ 2 minutes left

Digital block (anesthesia techniques)

Conventional/Traditional - both sides

Transthecal - palmar/plantar aspect of midline

Consider massage - 5-10 minutes for anesthesia

Medications Digital Blocks

Lidocaine (Xylocaine) 1%

• 4-10 minutes for onset

• 30 - 120 min duration

Bupivacaine (Marcaine, Sensorcaine) 0.25-0.5%

• 8-12 minutes for onset

• 4-6 hours of duration

— ADULT FINGER MAX 5ml (let tissue talk to you)

you can mix medications works fast and long

Conventional digital block

2 injections each side of finger (2.5 mL each side)

MUST ASPIRATE before injection to make sure you don’t hit artery

Traditional digital block

1 needle stick - 45 degree angle to each side

do not need to aspirate

Olecranon Bursitis Procedure

fluid along elbow after hitting it on something

18-gauge needle

20- to 30-mL syringe

Cleansing prep (betadine alcohol)

Aspiration of fluid

ACE wrap for compression (for 5-10 days or will reoccur)

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Ingrown toenail

Need to do digital block

Next take wedge out of the nail

• Scissors or hemostat

• Slowly advance, lift plate

• Wedge removal nail

• Grasp nail firmly

• Remove from nail bed

Use phenol if available to kill ingrown nail root

Paronychia

Digital nerve block (may do in large)

Lift skin - #11 or #15 blade or scissors

18-gauge needle

Sweep toward BLUNT end of the blade

Frequent soaks (20 minutes 3 times a day with warm water) if streak abx if not no need for abx

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Furuncle

an abscess or boil = walled off collection of pus that forms a painful, firm or fluctuant mass

*If firm not ready to drain; have patient go home use warm wash clothes and return when fluctuant to drain

Perirectal and Pilonidal Abscess

refer to surgeon

How to make incisions

Along skin tension lines / Langer lines

Equipment needed for Abscess Drainage

Local anesthetic (1% or 2% lidocaine)

Syringes with 25-gauge to 27-gauge needle

Topical antiseptic

4 x 4-inch gauze

No. 11 or 15 scalpel

Hemostat (curved or straight)

Scissors

Plain packing ( ¼- to ½-inch width) [not iodoform]

I&D Procedure

Prep skin with antibacterial solution

Field block or local anesthesia with Xylocaine (lidocaine)

• inject anesthetic ½ cm around abscess cavity (NOT into it)

Incise over center of abscess

Express purulence and break up any loculations

Consider culture

Suction cavity & pack gently with packing

Post Procedure Care/Management

Incision

• Length of incision ½ size of abscess

• Break up loculations

• Suction or gently irrigation

• Abscess Management

  • Review culture of wound

  • Consider MRSA

  • Warm compresses

  • Repack every other day

  • Surgical referral

Loop Drain / Dermastent

Bartholin Abscess

2% of adult women

Tend to be recurrent on labia

Causes

• Blocked duct • Gonococcus • Staphylococcus • Streptococcus • Escherichia coli • Trichomonas

S/S

• Edema of labia • Enlarged nodes • Dyspareunia • Fluctuant mass

Treatment

• Drain Abscess > word catheter OR I&D with packing

Procedure for Bartholin Abscess

Set Up

• 3cc 1% lidocaine for anesthesia • Word catheter kit • 3 cc sterile water with syringe in WC kit • Betadine swabs • “Sterile” gloves • Initial needle decompression if high pressure

Express the contents

• Push in from vagina • Break up loculations with curved hemostats • If no Word catheter available, placement of gauze with 1-inch tail

Aftercare

• Antibiotic treatment is at discretion of clinician • Gauze packing should be removed in 24-48 hours • Sitz baths 1-2 days post procedure • Abstain intercourse • Patients >40 years – refer to gyn for f/u to r/o cancer

Indications for Punch Biopsy

Pigmented lesions

Inflammatory lesions

Chronic skin disorders

Cutaneous neoplasms

Punch Biopsy procedure steps

Local anesthesia with lidocaine (Xylocaine) with epi

3- to 4-mm punch held perpendicular to surface

Instrument pressed down while rotated clockwise & counterclockwise (epidermis, dermis, and little subq layer)

Remove punch biopsy instrument

Lift biopsy specimen with needle to avoid crush

Use scissors to cut specimen below dermis

If 4- to 5-mm punch, consider closure to reduce healing time & scarring

Place specimen in properly labeled formalin container

Foreign body removal - nail gun

x ray first r/o not in bone

need to make sure no glue remains in skin

irrigate after removal

Embedded earring

Topical Vaso coolant - pain ease spray

grab front and back of earing with hemostats pull apart

Tick removal

pointed curved forcepts

grasp head of tick

Hair thread tourniquet syndrome

Causes •

• Mittens, socks, blanket threads, hair • Fingers, toes, genitalia

• Treatment •

  • Digital block • Dorsal slit • Tease out with 25- gauge needle • Depilatory (do not use hair dissolvent)

Ring Removal

Exsanguinate finger with tourniquet

Insert tape with hemostat

Wind tape proximal to distal

Pull proximal edge to unwind

Fish hook removal ways

1 - Retrograde removal = pull it back

2 - String technique = tie string around bend of hook, press down on eye, while pulling string

3 - Needle sheath method = 18 g needle put over barb of hook and remove so barb does not catch on tissue

4 - Advance hook and cut

Topical Hemostasis

For Avulsive lacerations

Use:

Silver nitrate (not on face may stain skin)

Absorbable gelatin (leave in place until falls off)

Foreign body removal top lid (aka tarsal plate)

Have patient look down • Grasp patient's upper lid lashes with fingers • Use firm cotton swab to press down • Lift lid with fingers • Examine underside of upper eyelid