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Continuing medical education section No 6
LL), ~mllon
~,
Hellsirano
aggressive initial approach to be considered in this conlmon traumatic condition.
in the diagnosis of carpal tunnel syndrome.
Electrophysiological studies cannot be used as
mostly in association with
seem to affect this.
wrist and wrist to elbow.
dorsak skin).
fracture in the hand, wrist or arm.
deformity.
this type of splint in post-traumatic mallet
These results continue to support the use of
There were no complications related to splint usage (such as pressure necrosis of the
Electrophysiology should be used in the
accurate.
presence of pain, atypical symptoms or previous
satisfied with the final result, although one-third noted impairement in executing precision tasks.
presence of typical symptoms is sufficiently
Ninety per cent of patients were subjectively
a tbird, although the presence of fracture did not
the sensory conduction velocity from palm to
Examination by an experienced doctor in the
Extensor lag greater than 10 ° was present in
again mostly in the fracture group.
Swan neck feformity was present in a third -
fracture.
the patients
The most sensitive electrical predictor was
methods of electrophysiology.
specificity (80% versus 87%) when compared to
sensitivity (94% versus 85%) but a poorer
A combination of clinical tests had a greater
Osteoarthritic changes had developed in half
12 weeks.
decompression.
made if a positive response was gained fi'om CT
All patients were treated in a hyperextension thermoplastic (Stack) splint for between 6 trod
patients, with a definite diagnosis of CTS being
sensitivity and specificity of various tests in 100
articular fracture of the DIPJ.
positive in CTS.
This prospective study examined the
average, five years after injury in this mediumterm study. One-third of injuries involved intra-
the condition since they too are not always
Thirty-one mallet fingers were reviewed, on
quoted as factors which should persuade a more
of clinical diagnostic tests and eponymous signs
definite confirmation of presence or absence of
interphalangeal joint, and extensor lag are often
Controversy exists with regard to the accuracy
J Bone Joint Surg (Br) 1997: 79-B: 544-547.
Mallet deformity of the finger.
k.JK.dlUI IZ~, iVlOuDaegDu ~,, IVlunsnl I, Williams D,
Late degenerative disease of the distal
~',
J Hand Surg (Br & Eur) 1997; 22-B: 34-37.
The diagnosis of carpal tunnel syndrome.
Leissner P, Philipson L.
L~UlIIIdlSUI|
I
i E3~LU ..j i rr" O~LU U_,-r
power and pinch grip, together with comparison
anterior metacarpal beak (the area where
workers were somewhere in between.
osteoarthrosis after a Bennett's fracture
the residual step remains less than 2 ram.
reduction and percutaneous pinning as long as
dislocation and supports the use of closed
measurements.
This study reveals no biomechanical basis for predisposition to post-traumatic
before drawing any conclusions on these simple
consider the patient's occupation carefully
degeneration usually occurs).
moderately arthritic thumbs - away fiom the
greatest difference between sides. Light manual This study elegantly illustrates the need to
The contact area shifted dorsally in all non and
manual workers had the weakest grips and the
In spite of the resulting incongruity, the total contact ,area increased by an average of 63%.
grips with little difference between sides. Non-
Heavy manual workers had the strongest
was performed and a mapping of the CMCJ contact area was obtained.
tested under controlled conditions.
at a constant 2 ram. Static and dynamic loading
dislocations in 15 hands, fixing the articular step
This cadaver study created Bennett's fracture
certain if this will be symptomatic.
of radiographic degeneration, but it is less
been proposed as a risk factor for development
light manual and heavy manual workers were
Similar demographic groups of non-manual,
dominant/uon-dominant differences.
type on power and pinch grip, and
volunteers - examined the effect of employment
This study - carried out on healthy male
accepted without challenge.
The presence of an intra-articular step has
described.
hand function. Finite objective value of actual of the uninjured hand are often printed and
Treatment of Bennett's fracture dislocation remains controversial, with over 20 methods
reporting as an end point measure of global
employed in scientific and medicolegal
J Bone Joint Surg (Am) 1997; 79-A: 413-420.
Simulated Bennett's fracture treated with closed reduction and percutaneous pinning.
t.,uuen o, t"aren[is Ivl, unumnm V, Pellegrini V.
The measurement of grip strength is often
J Hand Surg (Br & Eur) 1997; 22-B: 266-269.
Grip and pinch strength variations in different types of workers.
dusty i, ~yler iVl, onewell t~, HoDerts A.
This edition o f 'Journal Club' presents four recent articles on H a n d Surgery of relevance to General Orthopaedic Surgeons.
Fasciitis
High pressure injection injuries
Human bite
Osteomyelitis Acute (e.g. open fractures) - Chronic
Pyogenic arthritis
Flexor synovial sheath
Deep space infections - Interdigital web space - Thenar space - Hypothenar space - Midpalmar space - earona's space (Subtendinous space in distal forearm
Herpetic whitlow
Felon (distal pulp space infection)
Paronychia
Ceilulitis
Operative management General anaesthesia Tourniquet (exsanguinate by elevation) Surgical drainage/lavage Debridement No formal wound closure Continue antibiotic therapy
Non operative management Appropriate antibiotics Elevation Splintage for 2-3 days Aggressive physiotherapy
Investigation Blood cultures/FBC Wound swab/pus sample Radiology Ultrasound MRI with contrast
Examination Swelling Erythema/local heat Tenderness Fever Posture of hand Pain on digital extension Lymphadenopathy Lymphangiitis
History Pain Loss of function Penetrating injury Sleep loss Systemic illness
Diabetics Steroid therapy Immunocompromised HIV
Remember unusual infections in:
Rare causative organisms Mycobacterium marinum (= fishtank granuloma) Mycobacterium avium Caprocytophagia canimorsus (dog bites) Pasteurella multicida (cat bites) Erysipelothrix rhusiopathiae (abattoir workers)
Common causative organisms Staphylococcus aureus Streptococcus Pseudomonas Beta haemolytic Strep grp B Anaerobes (e.g. Clostridia) Eikenella corrodens (seen in 30% of human bites) Klebsiella Escherichia coli Enterobacter Bacteroides Proteus Candida albicans (esp. chronic paronychia)
Psychiatric Factitious disorder (self-mutilation, oedema, contractures)
Turnouts Epithelioid sarcoma Metastatic carcinoma Squamous cell CA
Granulomatous disease Pyogenic granuloma Pyoderma gangrenosum
Inflammatory Acute calcific tendinitis Insect bites Foreign body reaction Gout Pseudogout Rheumatoid arthritis
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rll
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(I) E :U
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"I"
01
0
~,
Hellsirano
aggressive initial approach to be considered in this conlmon traumatic condition.
in the diagnosis of carpal tunnel syndrome.
Electrophysiological studies cannot be used as
mostly in association with
seem to affect this.
wrist and wrist to elbow.
dorsak skin).
fracture in the hand, wrist or arm.
deformity.
this type of splint in post-traumatic mallet
These results continue to support the use of
There were no complications related to splint usage (such as pressure necrosis of the
Electrophysiology should be used in the
accurate.
presence of pain, atypical symptoms or previous
satisfied with the final result, although one-third noted impairement in executing precision tasks.
presence of typical symptoms is sufficiently
Ninety per cent of patients were subjectively
a tbird, although the presence of fracture did not
the sensory conduction velocity from palm to
Examination by an experienced doctor in the
Extensor lag greater than 10 ° was present in
again mostly in the fracture group.
Swan neck feformity was present in a third -
fracture.
the patients
The most sensitive electrical predictor was
methods of electrophysiology.
specificity (80% versus 87%) when compared to
sensitivity (94% versus 85%) but a poorer
A combination of clinical tests had a greater
Osteoarthritic changes had developed in half
12 weeks.
decompression.
made if a positive response was gained fi'om CT
All patients were treated in a hyperextension thermoplastic (Stack) splint for between 6 trod
patients, with a definite diagnosis of CTS being
sensitivity and specificity of various tests in 100
articular fracture of the DIPJ.
positive in CTS.
This prospective study examined the
average, five years after injury in this mediumterm study. One-third of injuries involved intra-
the condition since they too are not always
Thirty-one mallet fingers were reviewed, on
quoted as factors which should persuade a more
of clinical diagnostic tests and eponymous signs
definite confirmation of presence or absence of
interphalangeal joint, and extensor lag are often
Controversy exists with regard to the accuracy
J Bone Joint Surg (Br) 1997: 79-B: 544-547.
Mallet deformity of the finger.
k.JK.dlUI IZ~, iVlOuDaegDu ~,, IVlunsnl I, Williams D,
Late degenerative disease of the distal
~',
J Hand Surg (Br & Eur) 1997; 22-B: 34-37.
The diagnosis of carpal tunnel syndrome.
Leissner P, Philipson L.
L~UlIIIdlSUI|
I
i E3~LU ..j i rr" O~LU U_,-r
power and pinch grip, together with comparison
anterior metacarpal beak (the area where
workers were somewhere in between.
osteoarthrosis after a Bennett's fracture
the residual step remains less than 2 ram.
reduction and percutaneous pinning as long as
dislocation and supports the use of closed
measurements.
This study reveals no biomechanical basis for predisposition to post-traumatic
before drawing any conclusions on these simple
consider the patient's occupation carefully
degeneration usually occurs).
moderately arthritic thumbs - away fiom the
greatest difference between sides. Light manual This study elegantly illustrates the need to
The contact area shifted dorsally in all non and
manual workers had the weakest grips and the
In spite of the resulting incongruity, the total contact ,area increased by an average of 63%.
grips with little difference between sides. Non-
Heavy manual workers had the strongest
was performed and a mapping of the CMCJ contact area was obtained.
tested under controlled conditions.
at a constant 2 ram. Static and dynamic loading
dislocations in 15 hands, fixing the articular step
This cadaver study created Bennett's fracture
certain if this will be symptomatic.
of radiographic degeneration, but it is less
been proposed as a risk factor for development
light manual and heavy manual workers were
Similar demographic groups of non-manual,
dominant/uon-dominant differences.
type on power and pinch grip, and
volunteers - examined the effect of employment
This study - carried out on healthy male
accepted without challenge.
The presence of an intra-articular step has
described.
hand function. Finite objective value of actual of the uninjured hand are often printed and
Treatment of Bennett's fracture dislocation remains controversial, with over 20 methods
reporting as an end point measure of global
employed in scientific and medicolegal
J Bone Joint Surg (Am) 1997; 79-A: 413-420.
Simulated Bennett's fracture treated with closed reduction and percutaneous pinning.
t.,uuen o, t"aren[is Ivl, unumnm V, Pellegrini V.
The measurement of grip strength is often
J Hand Surg (Br & Eur) 1997; 22-B: 266-269.
Grip and pinch strength variations in different types of workers.
dusty i, ~yler iVl, onewell t~, HoDerts A.
This edition o f 'Journal Club' presents four recent articles on H a n d Surgery of relevance to General Orthopaedic Surgeons.
Fasciitis
High pressure injection injuries
Human bite
Osteomyelitis Acute (e.g. open fractures) - Chronic
Pyogenic arthritis
Flexor synovial sheath
Deep space infections - Interdigital web space - Thenar space - Hypothenar space - Midpalmar space - earona's space (Subtendinous space in distal forearm
Herpetic whitlow
Felon (distal pulp space infection)
Paronychia
Ceilulitis
Operative management General anaesthesia Tourniquet (exsanguinate by elevation) Surgical drainage/lavage Debridement No formal wound closure Continue antibiotic therapy
Non operative management Appropriate antibiotics Elevation Splintage for 2-3 days Aggressive physiotherapy
Investigation Blood cultures/FBC Wound swab/pus sample Radiology Ultrasound MRI with contrast
Examination Swelling Erythema/local heat Tenderness Fever Posture of hand Pain on digital extension Lymphadenopathy Lymphangiitis
History Pain Loss of function Penetrating injury Sleep loss Systemic illness
Diabetics Steroid therapy Immunocompromised HIV
Remember unusual infections in:
Rare causative organisms Mycobacterium marinum (= fishtank granuloma) Mycobacterium avium Caprocytophagia canimorsus (dog bites) Pasteurella multicida (cat bites) Erysipelothrix rhusiopathiae (abattoir workers)
Common causative organisms Staphylococcus aureus Streptococcus Pseudomonas Beta haemolytic Strep grp B Anaerobes (e.g. Clostridia) Eikenella corrodens (seen in 30% of human bites) Klebsiella Escherichia coli Enterobacter Bacteroides Proteus Candida albicans (esp. chronic paronychia)
Psychiatric Factitious disorder (self-mutilation, oedema, contractures)
Turnouts Epithelioid sarcoma Metastatic carcinoma Squamous cell CA
Granulomatous disease Pyogenic granuloma Pyoderma gangrenosum
Inflammatory Acute calcific tendinitis Insect bites Foreign body reaction Gout Pseudogout Rheumatoid arthritis
-<
rll
Q
(I) E :U
Z
"I"
01
0