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Three Part Question

In [a patient with hand injuries] is [telemedicine valuable] in [referrals to regional plastic surgery centre].

Clinical Scenario

A 50 year old man presents to accident and emergency department after an assault and has injuries to his hand. On examination you are not sure if it needs plastic surgery, you try your best to relay the relevant information to plastic surgeon in the regional centre and transfer the patient to the centre. At the centre he is evaluated and it is found that he does not need plastic surgery. Could we have avoided this scenario by using teleconsultation.

Search Strategy

MEDLINE 1950-06/2007 using the OVID Interface
[(telemedicine.mp. or exp telemedicine) AND (wound.mp. or exp wound and injuries)] LIMIT to
humans and English and Core Clinical Journals.
[(telemedicine.mp. or exp telemedicine) AND (wound.mp. or exp wound and injuries)] LIMIT to
humans and English and Core Clinical Journals.

Search Outcome

A total of 8 papers were found by Medline search. 3 papers had relevance to our clinical question. 1 more was found by cross referencing the papers.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ching-Hua Hsieh et al 2004 Taiwan	Teleconsultation of 45 patients with 81 digital injuries was made using mobile camera phone. Male 34, female 11. Age range 15-54	Prospective cohort study	The patients were triaged in to three groups;Group I: Primary closure.Group II: Local flap coverage.Group III: Microsurgery	79% sensitivity and 71% specificity in remote diagnosis of skin defect. 76% sensitivity and 75% specificity in remote identification of bone exposure. In 12 (15%)cases there was disagreement of triaging.	No statistical power. Triage did not identify tendon injuries.
			Time for E consultation	The mean operation time for consultation was 3-4 minutes.
Stephen A.Pap et al 2002 USA	20 Patients evaluated over 6 weeks. 12 hand injuries. 8 soft tissue injuries. Consultations were done using digital camera	Case series	Out of 20 E consultations	1 patient had reimplantation attempt. Generated an algorithm.	Small number of patients. Convenience study. Biased.
			Attending surgeons reported thorough satisfaction with picture quality ,speed of transmission and screen resolution
			Time for E consultation	Consult Email generated in less then 10 mins and received by attending Physician in less then 5 minutes. There were no delays. Photo resolution was satisfactory.
G .V .Scerri , D. J Vassalo, 1999 British Journal Of Plastic Surgery	133 telemedicine referrals were made over 16 months which included images of xrays, of patients wounds, of ECGS,of burn injuries, of skin and eye lesions and of blood films througha microscope.	Case Reports	11 plastic surgery referrals were made.	9 underwent surgery. 2 were managed conservatively.
			Image quality.	Images were reliably diagnostic. Patient confidentiality was preserved by the use of code numbers for each patient.
			Time for E consultation	15 seconds to 2 minutes
Rudolf F.Buntic et al 1997 USA	Teleconsultation of a single patient was made using high resolution camera.	Case Report	E consultation of 1 patient was made	Reimplantation was successful

Comment(s)

The work done in these studies clearly show the benefit of telemedicine in assessment of hand injuries which may require specialist plastic surgery input. Cost effectiveness and confidentiality/security needs appraisal. It is safe and easy to use. It reduces unnecessary referrals and transfer of patients, potentially saves money and improves clinical acumen of the Accident and Emergency residents

Clinical Bottom Line

There is some evidence of the usefulness of telemedicine in wound assessment for hand injuries.

References

1. Hsieh, Ching-Hua. Tsai, Hui-Hong .Yin, Jer-Wen, et al Teleconsultation with the mobile camera phone in digital soft tissue injury: a feasibility study. Plastic & Reconstructive Surgery. 114 (7):1776-82, 2004 Dec.
2. Pap, Stephen A. Lach, Elliot. Upton, Joseph Telemedicine in plastic surgery: E-consult the attending surgeon. Plastic & Reconstructive Surgery. 110 (2):452-6, 2002 Aug.
3. Scerri,G. and Vassallo, D.J. Initial plastic surgery experience with the first telemedicine links for the British Forces. British Journal of Plastic Surgery. 52:294, 1999.
4. Buntic, R F. Siko, P P. Buncke, G M, et al. Using the internet for rapid exchange of photographs and X ray images to evaluate potential extremity replantation candidates. Journal of Trauma-injury Infection & Critical Care. 43(2):342-4,1997 Aug.