- Email: [email protected]
Continuing to work with a sterile thumb splint: A case report
Hand Surgery and Rehabilitation 37 (2018) 252–254
Available online at
ScienceDirect www.sciencedirect.com
Case report
Continuing to work with a sterile thumb splint: A case report Continuer a` travailler avec une attelle de pouce ste´rile : a` propos d’un cas S. Roner a,*, P. Fu¨rnstahl a, A. Schweizer b, K. Wieser b a b
Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 February 2018 Received in revised form 6 April 2018 Accepted 10 April 2018 Available online 17 May 2018
Nonoperative treatment of an injured ulnar collateral ligament of the thumb metacarpophalangeal (MCP) joint (skier’s thumb without a Stener lesion) is managed by immobilization. A splint is applied on the radial side with the thumb in slight flexion to immobilize the MCP joint and allow motion in the interphalangeal joint. Thermoplastic splints are mainly used for daily activities with the advantage of custom fabrication for optimal comfort. To immobilize the thumb during surgical procedures performed by an orthopedic surgeon, splints made of sterilizable materials are needed but not yet available to our knowledge. We present the case of a 36-year-old orthopedic surgeon diagnosed with skier’s thumb, and the development and application of a reusable, patient-specific (i.e., the orthopedic surgeon) splint to immobilize the thumb MCP joint in a sterile environment so the surgeon could continue working.
C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Skier’s thumb Ulnar collateral ligament Metacarpophalangeal joint Nonoperative Sterile splint Reusable splint
Mots cle´s : Pouce du skieur Ligament collate´ral ulnaire Articulation me´tacarpo-phalangienne Conservateur Attelle ste´rile Attelle re´utilisable
R E´ S U M E´
Le traitement conservateur des le´sions du ligament collate´ral ulnaire (pouce du skieur sans le´sion de Stener) de l’articulation me´tacarpo-phalangienne (MCP) du pouce consiste en une immobilisation. Une attelle est applique´e du coˆte´ radial avec le pouce en le´ge`re flexion, immobilisant l’articulation MCP et permettant les mouvements dans l’articulation interphalangienne. Pour les activite´s quotidiennes, les attelles thermoplastiques sont principalement utilise´es avec l’avantage d’une fabrication sur mesure pour un confort de port optimal. Pour immobiliser le pouce pendant le travail ope´ratoire en tant que chirurgien orthope´diste, des attelles en mate´riaux ste´rilise´s sont cependant ne´cessaires et, a` notre connaissance, pas encore disponibles. Nous pre´sentons le cas d’un chirurgien orthope´diste de 36 ans ayant rec¸u le diagnostic de pouce du skieur, aussi que le de´veloppement et l’application d’une attelle re´utilisable et spe´cifique au patient (ici le chirurgien) pour immobiliser l’articulation MCP du pouce dans un environnement ste´rile.
C 2018 SFCM. Publie ´ par Elsevier Masson SAS. Tous droits re´serve´s.
1. Introduction Rupture of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MCP) joint is a common thumb injury [1,2]. When excessive valgus stress is applied, disruption of the UCL
* Corresponding author. E-mail addresses: [email protected] (S. Roner), [email protected] (P. Fu¨rnstahl), [email protected] (A. Schweizer), [email protected] (K. Wieser). https://doi.org/10.1016/j.hansur.2018.04.003 C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved. 2468-1229/
complex with or without an avulsion fracture can occur [3,4]. This condition has two names: skier’s thumb when acute and gamekeeper’s thumb when chronic [5,6]. In cases of partial or complete lesions without dislocation of the distal stump of the UCL above the adductor aponeurosis (Stener lesion), immobilization for 6 weeks is the treatment of choice [7–9]. Usually, a short thumb splint is used to immobilize the MCP joint in slight flexion and allow motion in the interphalangeal joint. Tubular like thermoplastic splints at the thumb and fixation around the wrist are common. The advantage of these splints is their custom fabrication
S. Roner et al. / Hand Surgery and Rehabilitation 37 (2018) 252–254
253
to achieve optimal comfort during wear. However, the use of a patient-specific splint in a sterile environment has not been described so far. 2. Case presentation We report the case of a 36-year-old orthopedic surgeon with an acutely ruptured UCL of his right thumb, resulting from a fall after slipping on black ice on the sidewalk. The diagnosis was made by clinical examination with findings of pain and 108 instability during valgus stress application to the MCP joint. A Stener lesion of the UCL with bone involvement was ruled out by ultrasound and with fluoroscopy [9]. Consequently, nonoperative treatment with immobilization for 6 weeks was applied. A thermoplastic splint immobilizing the MCP joint was constructed by a hand therapist for daily use (Fig. 1). To immobilize the skier’s thumb during his
Fig. 3. a: polyamide splint secured to the first glove layer with sterile tape distally and proximally; b: after applying the second glove layer, the surgeon’s thumb is ready to use during surgical procedures.
Fig. 1. A thermoplastic splint to immobilize the MCP joint and allow movement in the interphalangeal joint of the injured right thumb.
Fig. 2. a: Thermoplastic splint template. b: 3D splint model after CT scan segmentation; c: reusable splint made of polyamide.
Fig. 4. a: demonstration of scalpel use with the MCP joint stabilized with a radial splint; b: use of an arthroscope by the right-handed surgeon.
254
S. Roner et al. / Hand Surgery and Rehabilitation 37 (2018) 252–254
work as an orthopedic surgeon, patient-specific splints made of ISO-certified biocompatible polyamide material were produced [10]. In the first step, a CT scan of a modified thermoplastic template splint with contact only on the radial side of the thumb was done (Fig. 2). After segmenting the CT data, a 3D model was generated using commercial software (Mimics; Materialise NV, Leuven, Belgium). The polyamide splints were 3D-printed with a laser sintering device (EOS, Krailling, Germany) by an external company (Medacta SA, Castel S. Pietro, Switzerland). After testing in nonsterile conditions, the polyamide splints were steam sterilized. When preparing for surgery, the orthopedic surgeon put standard sterile gloves on as the first layer. The splint was attached with sterile tape around the proximal phalanx and the wrist (Fig. 3a) before the second layer of sterile gloves was put on over top (Fig. 3b). By stabilizing the MCP joint, the orthopedic surgeon was able to perform open and arthroscopic surgeries of the shoulder as usual (Fig. 4). The hospital administration, which is responsible for all medical and legal issues, was informed and the patients agreed to be operated by an injured surgeon. Each splint was reused multiple times after re-sterilization without any deterioration in the material characteristics. The cost to design and produce four splints was 500 EUR (600 USD). 3. Conclusion To our knowledge, this is the first description of an individualized and reusable splint being used to immobilize a joint in a sterile environment. The patient was able to continue his work as a senior orthopedic surgeon as scheduled, performing open and arthroscopic surgeries of the shoulder. If sterile splinting had not been possible, the surgeon would have required several weeks of sick leave. The manufacturing costs of the splints were amortized in less than a single surgery. Further areas of application are miscellaneous injuries of the hand and wrist requiring a sterile splint to immobilize during surgery.
Funding None. Disclosure of interest A.S. is shareholder of a computer-assisted surgical planning application. P.F. is shareholder of a computer-assisted surgical planning application. The other authors declare that they have no competing interest. References [1] Moutet F, Guinard D, Lebrun C, Bello-Champel P, Massart P. Metacarpophalangeal thumb sprains based on experience with more than 1,000 cases. Ann Chir Main 1989;8:99–109. [2] Coonrad R. A study of the pathological findings and treatment in soft-tissue injury of the thumb metacarpophalangeal joint. With a clinical study of the normal range of motion in one thousand thumbs and a study of post mortem findings of ligamentous structures in relation to function. Bone Joint Surg Am 1968;50:439–51. [3] Smith R. Post-traumatic instability of the metacarpophalangeal joint of the thumb. J Bone Joint Surg Am 1977;59:14–21. [4] Hinke DH, Erickson SJ, Chamoy L, Timins ME. Ulnar collateral ligament of the thumb: MR findings in cadavers, volunteers, and patients with ligamentous injury (Gamekeeper’s thumb). Am J Roentgenol 1994;163:1431–4. [5] Gerber C. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb’s metacarpophalangeal joint. Am J Sport Med 1981;9:171–7. [6] Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg Br 1955;37:148–9. [7] Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med 2010;20:106–12. [8] Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Relat Res 1993;292:165–71. http://dx.doi.org/10.1016/S09694765(04)00066-9. [9] Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: a clinical and anatomical study. J Bone Joint Surg Am 1962;44:869–80. [10] International Organization for Standardization Geneva S. International Organization for Standardization, standard 10993:2009: biological evaluation of medical devices, 4th edition, 2009 [Available from: https://www.iso.org/ standard/44908.html].
Available online at
ScienceDirect www.sciencedirect.com
Case report
Continuing to work with a sterile thumb splint: A case report Continuer a` travailler avec une attelle de pouce ste´rile : a` propos d’un cas S. Roner a,*, P. Fu¨rnstahl a, A. Schweizer b, K. Wieser b a b
Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 February 2018 Received in revised form 6 April 2018 Accepted 10 April 2018 Available online 17 May 2018
Nonoperative treatment of an injured ulnar collateral ligament of the thumb metacarpophalangeal (MCP) joint (skier’s thumb without a Stener lesion) is managed by immobilization. A splint is applied on the radial side with the thumb in slight flexion to immobilize the MCP joint and allow motion in the interphalangeal joint. Thermoplastic splints are mainly used for daily activities with the advantage of custom fabrication for optimal comfort. To immobilize the thumb during surgical procedures performed by an orthopedic surgeon, splints made of sterilizable materials are needed but not yet available to our knowledge. We present the case of a 36-year-old orthopedic surgeon diagnosed with skier’s thumb, and the development and application of a reusable, patient-specific (i.e., the orthopedic surgeon) splint to immobilize the thumb MCP joint in a sterile environment so the surgeon could continue working.
C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Skier’s thumb Ulnar collateral ligament Metacarpophalangeal joint Nonoperative Sterile splint Reusable splint
Mots cle´s : Pouce du skieur Ligament collate´ral ulnaire Articulation me´tacarpo-phalangienne Conservateur Attelle ste´rile Attelle re´utilisable
R E´ S U M E´
Le traitement conservateur des le´sions du ligament collate´ral ulnaire (pouce du skieur sans le´sion de Stener) de l’articulation me´tacarpo-phalangienne (MCP) du pouce consiste en une immobilisation. Une attelle est applique´e du coˆte´ radial avec le pouce en le´ge`re flexion, immobilisant l’articulation MCP et permettant les mouvements dans l’articulation interphalangienne. Pour les activite´s quotidiennes, les attelles thermoplastiques sont principalement utilise´es avec l’avantage d’une fabrication sur mesure pour un confort de port optimal. Pour immobiliser le pouce pendant le travail ope´ratoire en tant que chirurgien orthope´diste, des attelles en mate´riaux ste´rilise´s sont cependant ne´cessaires et, a` notre connaissance, pas encore disponibles. Nous pre´sentons le cas d’un chirurgien orthope´diste de 36 ans ayant rec¸u le diagnostic de pouce du skieur, aussi que le de´veloppement et l’application d’une attelle re´utilisable et spe´cifique au patient (ici le chirurgien) pour immobiliser l’articulation MCP du pouce dans un environnement ste´rile.
C 2018 SFCM. Publie ´ par Elsevier Masson SAS. Tous droits re´serve´s.
1. Introduction Rupture of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MCP) joint is a common thumb injury [1,2]. When excessive valgus stress is applied, disruption of the UCL
* Corresponding author. E-mail addresses: [email protected] (S. Roner), [email protected] (P. Fu¨rnstahl), [email protected] (A. Schweizer), [email protected] (K. Wieser). https://doi.org/10.1016/j.hansur.2018.04.003 C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved. 2468-1229/
complex with or without an avulsion fracture can occur [3,4]. This condition has two names: skier’s thumb when acute and gamekeeper’s thumb when chronic [5,6]. In cases of partial or complete lesions without dislocation of the distal stump of the UCL above the adductor aponeurosis (Stener lesion), immobilization for 6 weeks is the treatment of choice [7–9]. Usually, a short thumb splint is used to immobilize the MCP joint in slight flexion and allow motion in the interphalangeal joint. Tubular like thermoplastic splints at the thumb and fixation around the wrist are common. The advantage of these splints is their custom fabrication
S. Roner et al. / Hand Surgery and Rehabilitation 37 (2018) 252–254
253
to achieve optimal comfort during wear. However, the use of a patient-specific splint in a sterile environment has not been described so far. 2. Case presentation We report the case of a 36-year-old orthopedic surgeon with an acutely ruptured UCL of his right thumb, resulting from a fall after slipping on black ice on the sidewalk. The diagnosis was made by clinical examination with findings of pain and 108 instability during valgus stress application to the MCP joint. A Stener lesion of the UCL with bone involvement was ruled out by ultrasound and with fluoroscopy [9]. Consequently, nonoperative treatment with immobilization for 6 weeks was applied. A thermoplastic splint immobilizing the MCP joint was constructed by a hand therapist for daily use (Fig. 1). To immobilize the skier’s thumb during his
Fig. 3. a: polyamide splint secured to the first glove layer with sterile tape distally and proximally; b: after applying the second glove layer, the surgeon’s thumb is ready to use during surgical procedures.
Fig. 1. A thermoplastic splint to immobilize the MCP joint and allow movement in the interphalangeal joint of the injured right thumb.
Fig. 2. a: Thermoplastic splint template. b: 3D splint model after CT scan segmentation; c: reusable splint made of polyamide.
Fig. 4. a: demonstration of scalpel use with the MCP joint stabilized with a radial splint; b: use of an arthroscope by the right-handed surgeon.
254
S. Roner et al. / Hand Surgery and Rehabilitation 37 (2018) 252–254
work as an orthopedic surgeon, patient-specific splints made of ISO-certified biocompatible polyamide material were produced [10]. In the first step, a CT scan of a modified thermoplastic template splint with contact only on the radial side of the thumb was done (Fig. 2). After segmenting the CT data, a 3D model was generated using commercial software (Mimics; Materialise NV, Leuven, Belgium). The polyamide splints were 3D-printed with a laser sintering device (EOS, Krailling, Germany) by an external company (Medacta SA, Castel S. Pietro, Switzerland). After testing in nonsterile conditions, the polyamide splints were steam sterilized. When preparing for surgery, the orthopedic surgeon put standard sterile gloves on as the first layer. The splint was attached with sterile tape around the proximal phalanx and the wrist (Fig. 3a) before the second layer of sterile gloves was put on over top (Fig. 3b). By stabilizing the MCP joint, the orthopedic surgeon was able to perform open and arthroscopic surgeries of the shoulder as usual (Fig. 4). The hospital administration, which is responsible for all medical and legal issues, was informed and the patients agreed to be operated by an injured surgeon. Each splint was reused multiple times after re-sterilization without any deterioration in the material characteristics. The cost to design and produce four splints was 500 EUR (600 USD). 3. Conclusion To our knowledge, this is the first description of an individualized and reusable splint being used to immobilize a joint in a sterile environment. The patient was able to continue his work as a senior orthopedic surgeon as scheduled, performing open and arthroscopic surgeries of the shoulder. If sterile splinting had not been possible, the surgeon would have required several weeks of sick leave. The manufacturing costs of the splints were amortized in less than a single surgery. Further areas of application are miscellaneous injuries of the hand and wrist requiring a sterile splint to immobilize during surgery.
Funding None. Disclosure of interest A.S. is shareholder of a computer-assisted surgical planning application. P.F. is shareholder of a computer-assisted surgical planning application. The other authors declare that they have no competing interest. References [1] Moutet F, Guinard D, Lebrun C, Bello-Champel P, Massart P. Metacarpophalangeal thumb sprains based on experience with more than 1,000 cases. Ann Chir Main 1989;8:99–109. [2] Coonrad R. A study of the pathological findings and treatment in soft-tissue injury of the thumb metacarpophalangeal joint. With a clinical study of the normal range of motion in one thousand thumbs and a study of post mortem findings of ligamentous structures in relation to function. Bone Joint Surg Am 1968;50:439–51. [3] Smith R. Post-traumatic instability of the metacarpophalangeal joint of the thumb. J Bone Joint Surg Am 1977;59:14–21. [4] Hinke DH, Erickson SJ, Chamoy L, Timins ME. Ulnar collateral ligament of the thumb: MR findings in cadavers, volunteers, and patients with ligamentous injury (Gamekeeper’s thumb). Am J Roentgenol 1994;163:1431–4. [5] Gerber C. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb’s metacarpophalangeal joint. Am J Sport Med 1981;9:171–7. [6] Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg Br 1955;37:148–9. [7] Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med 2010;20:106–12. [8] Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Relat Res 1993;292:165–71. http://dx.doi.org/10.1016/S09694765(04)00066-9. [9] Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: a clinical and anatomical study. J Bone Joint Surg Am 1962;44:869–80. [10] International Organization for Standardization Geneva S. International Organization for Standardization, standard 10993:2009: biological evaluation of medical devices, 4th edition, 2009 [Available from: https://www.iso.org/ standard/44908.html].