- Email: [email protected]
Outline of orthopaedics
BOOK
codes for hand surgery at present and the British Society for Surgery of the Hand is currently attempting to produce a set of codes suitable for orthopaedic and plastic surgeons. Medical audit demands that we give consideration to patient outcomes. These relate not only to the efficacy of the surgical procedure but also to the degree of damage or disability present before treatment is instituted. Any diagnostic coding system which has an inbuilt assessmentof severity of injury is of enormous benefit when assessingpatient outcomes. The A0 group has taken on this task and have produced a book of fracture codes for the long bones. A further text on hand fractures will follow. The surgeon coding a fracture is required to answer three questions, each with three options. The system can best be described in relation to fractures of the lower end of the radius. Radial fractures are prefixed with a two code with further one to three code dependent on the site within the bone (21 indicating proximal end of radius, 22 shaft and 23 distal end). Distal radial fractures thus have a prefix of 23. The first question relates to fractured type. Type A is extra-articular. Type B, partial articular and type C completely articular. The second question gives a group of one to three rating indicating the degree of bone damage and comminution. A further decimal point grouping of one to three permits more detail to be included on plane of fracture, degree of comminution or displacement. This produces 27 codings for fractures of the lower end of the radius ranging from 23 Al. 1 as the simplest fracture (the ulnar styloid) through a mean of 23 B2.2 as a dorsal rim Barton fracture associated with lateral sagittal fracture to 23 C3.3 as the most severe wrist fracture (complete multifragmentary intra-articular fracture of radial articulation extending into the diaphysis). Although the authors regard the system as a prognostic grading, it is essentially based on radiological data and this takes no account of the associated soft tissue injuries which may play so large a part in ultimate disability. There seems to be an unduly large number of options available and classification of specific injuries may pose difficult choices as to the most appropriate code. One wonders whether the reproducibility and consistency of the coding would be satisfactory. Assessment of coding systems are plagued by the dilemma over the degree of detail sought. Simple systems are readily learnt and used. More complex systemsoffer far more detail but at the risk of poor compliance of coders with low data retrieval rates. This system will permit comparisons in fracture management between units and countries but a further evolution may be required to cover the soft tissue aspects before it reaches its full potential. Frank D. Burke ATLAS OF ORTHOPAEDIC SURGERY VOL. II-UPPER EXTREMITY Edited by C. A. Laurin, L. H. Riley, R. Roy-Camille. 438 pages. Masson, 1990.
This is the second volume in a three volume series, the first being general principles-spine, and the third being the lower extremity. There are 19 contributors, six of whom are from North America, and the remainder from France. It is described as an Atlas of Orthopaedic Surgery and deals with operative technique but does not set out to deal with the indications for surgery. It is designed to be available for the practising surgeon, VOL.
16B No. 2 MAY
1991
REVIEWS
indicating that it should be close to, or in, the operating theatre environment. The chapters are divided up anatomically, starting with surgery of the shoulder and working down through the upper arm, elbow, forearm, wrist and hand. An annexe includes recent surgical procedures of the spine. 185 pages of this 438 page book are devoted to surgery of the wrist and hand. The printed text is extremely clear and well-written. There are copious illustrations, all extremely well-drawn and well-labelled, and quite easy to follow. Each section is introduced by a chapter on the surgical exposure, then various operative procedures are described. However, it is extremely difficult in a text of this size to cover every operation; although they have been able to give a description of five different operations for anterior dislocation of the shoulder, it is regretted that there is only one paragraph on arthroplasty of the elbow. The only operation described for non-union of the scaphoid is the Matte-Russe graft. There is an excellent section on tendon injuries of the hand, as well as reconstruction for various nerve palsies. It is unfortunate that only nine pages could be devoted to surgery of the rheumatoid hand, but what is written is very clear and well presented. This book has a good international flavour, combining the North American and the European points of view; it is extremely easy to read and follow step-by-step drawings for many of the operations. One of the greatest problems in trying to write a text-book on operative procedures in orthopaedic surgery is how to include all the known operations. This book is excellent for the surgeon who is looking for a solution to a problem in the operating theatre and is an easy reference book both for the trainee as well as the practising hand or orthopaedic surgeon. I. J. Leslie OUTLINE OF ORTHOPAEDICS by John Crawford Adams and David L. Hamblen, 11th Edition, Churchill Livingstone 1990. pp. 433. 371 Illustrations. ISBN 0 443 04094 X.
f14.95.
In this edition Crawford Adams has been joined by Professor Hamblen from Glasgow as co-author. Previous editions have established the book as the principal source of information and education on orthopaedics for students, general practitioners, nurses and therapists, and clearly this edition continues that tradition. Sections relevant to the upper limb, including neurological disorders, total 60 pages, and are well-written and succinct. Inevitably in a book of this nature there are many omissions; some are serious, including the lack of any description of physical examination in nerve injuries, notably the ulnar nerve, and yet half a page is devoted to nerve conduction studies. The authors have clearly seen the need to be selective, but the choice of which conditions to give prominence to is surprising. For example, De Quervain’s tenovaginitis has considerable exposure, but no mention is made of the hazards to the superficial branch of the radial nerve inherent in steroid injection and surgery. Kienbock’s disease is discussed but length-adjusting procedures not mentioned, although this is probably the most promising line of treatment. Some of the advice is questionable. Few hand surgeonswould choose to leave a divided F.D.P. tendon unrepaired routinely, and three weeks is never long enough to splint a mallet finger. I was surprised to read that two-stage tendon grafting is a recent 229
BOOK
REVIEWS-LETTERS
modification-it started to become popular at about the time of the 8th edition of this book, now in its 1 lth! The anatomy of hand infection is well described, and the section would be excellent but for the unsatisfactory incisions for draining deep palmar space infections; they are too close to the webs, especially the first. These criticisms may seem petty, but this chapter may be the first information on hand surgery to hit impressionable minds, and will mould attitudes and actions in many A & E departments. When there is limited space it is vital that what appears is relevant and correct, and sometimes unfortunately it isn’t. As a whole, however, the book remains an excellent text for its intended readership. It reads well and is clearly illustrated and presented and the references collected at the back under section headings are particularly valuable.
One of the main problems with scaphoid fractures, real and suspected, is that we over-treat many patients in our anxiety to avoid under-treating the ones which are going to give trouble. What we need most is better prediction of the outcome and Mr Herbert’s classification is designed to provide this. The book will make every reader think afresh and is full of useful tips and observations. For those who, like me, are fascinated by this awkward little bone, this book is a must. Those who are not yet fascinated will be when they have read the book. Nicholas Barton
Letters to the Editor
David M. Evans THE FRACTURED SCAPHOID By Timothy J. Herbert. Quality Medical PubZishing,Inc., St.
Louis, Missouri, USA. 1990. f69. (Available in U.K. from Williams and Wilkins Ltd., Broadway House, 2-6 Fulham Broadway, London S W6 IAA). ISBN o-942219-06-6. 26.2 x 18.4 cm. xii+ 202pages. 255 illustrations, Index. 30 years ago, nobody gave much thought to fractures of the scaphoid. They were not considered to be a problem. In the 1960’s, Geoffrey Fisk awakened interest in the subject and in the last 15 years other workers have shown that much of what has been believed is, at best, unproved and, at worst, untrue. Tim Herbert has been in the vanguard of progress and has now gathered his knowledge and wisdom into a book. It is not an operative manual or a lengthy advertisement for the Herbert screw, but a thoughtful and stimulating survey of the whole problem. He has probably operated on more scaphoids than anybody ever has before, so his experience is unique and now we can to some extent share it. The book reviews the anatomy, diagnosis, natural history, classification and treatment of fresh fractures and non-union. There are also chapters on avascular necrosis, ma&union and rotary subluxation. It is one of those rare textbooks, like those by Watson, Jones and Flatt, which is a joy to read because it is written in clear simple straightforward English. It is also beautifully produced and illustrated. The publishers, an American firm whom I had not heard of before, have done a superb job and this reader appreciated their acceptance of the author’s preference for English spelling and usage. It is an almost-forgotten pleasure to read a textbook in which the lines go right across the page, like an ordinary book, instead of being in two columns. I wish that journals could go back to that! (The argument for columns is that the lines can be printed closer together and therefore more can be printed on one page.) I have heard it said that fractures of the scaphoid are intracapsular fractures, like sub-capital fractures of the femur, and should therefore always be treated in the same way: by open reduction and internal fixation. Mr Herbert does not go as far as this, though he does incline much more to operative intervention than is usual in Britain or, indeed, than would be practical in most British centres. He also advocates corrective osteotomy of the scaphoid for mal-union, but cautiously and admitting that good long-term results will be needed to justify the possible risks of this procedure. 230
Dear Sir, Nathan et al. (1988) found no association between occupational hand activity and slowing of sensory conduction of the median nerve at the carpal tunnel. Unfortunately, this study suffers from “exposure misclassification.” Re-analysis of the author’s data using a more logical classification system actually supports the association of occupational hand activity and slowing of sensory conduction of the median nerve at the carpal tunnel. In Nathan’s study “occupational hand activity”, or exposure, was evaluated using two major variables : “rate of repetition” and “amount of resistance [force]“. Rate of repetition was divided into the following 5 groups : low, moderate, moderately high, high, very high. Force was divided into the following 5 groups: very light, light, moderate, heavy, very heavy. In addition, an occupational classification grouping was generated according to the employee’s job title. Then, rather than comparing the exposure variables of repetition and force to the nerve conduction results, the authors compared the occupational classification grouping (based on job title only) to the nerve conduction results. Table 1 demonstrates the inadequacy of this grouping. Table l-Occupational and repetition
classification groups by exposure variable of force
Repetition 1
High
1
I
I
I
I
Moving from the upper left to the lower right of the table, jobs have more exposure to repetition and force; factors reported to cause upper extremity cumulative trauma disorders, one of which is carpal tunnel syndrome (Armstrong and Chaffin, THE
JOURNAL
OF HAND
SURGERY
codes for hand surgery at present and the British Society for Surgery of the Hand is currently attempting to produce a set of codes suitable for orthopaedic and plastic surgeons. Medical audit demands that we give consideration to patient outcomes. These relate not only to the efficacy of the surgical procedure but also to the degree of damage or disability present before treatment is instituted. Any diagnostic coding system which has an inbuilt assessmentof severity of injury is of enormous benefit when assessingpatient outcomes. The A0 group has taken on this task and have produced a book of fracture codes for the long bones. A further text on hand fractures will follow. The surgeon coding a fracture is required to answer three questions, each with three options. The system can best be described in relation to fractures of the lower end of the radius. Radial fractures are prefixed with a two code with further one to three code dependent on the site within the bone (21 indicating proximal end of radius, 22 shaft and 23 distal end). Distal radial fractures thus have a prefix of 23. The first question relates to fractured type. Type A is extra-articular. Type B, partial articular and type C completely articular. The second question gives a group of one to three rating indicating the degree of bone damage and comminution. A further decimal point grouping of one to three permits more detail to be included on plane of fracture, degree of comminution or displacement. This produces 27 codings for fractures of the lower end of the radius ranging from 23 Al. 1 as the simplest fracture (the ulnar styloid) through a mean of 23 B2.2 as a dorsal rim Barton fracture associated with lateral sagittal fracture to 23 C3.3 as the most severe wrist fracture (complete multifragmentary intra-articular fracture of radial articulation extending into the diaphysis). Although the authors regard the system as a prognostic grading, it is essentially based on radiological data and this takes no account of the associated soft tissue injuries which may play so large a part in ultimate disability. There seems to be an unduly large number of options available and classification of specific injuries may pose difficult choices as to the most appropriate code. One wonders whether the reproducibility and consistency of the coding would be satisfactory. Assessment of coding systems are plagued by the dilemma over the degree of detail sought. Simple systems are readily learnt and used. More complex systemsoffer far more detail but at the risk of poor compliance of coders with low data retrieval rates. This system will permit comparisons in fracture management between units and countries but a further evolution may be required to cover the soft tissue aspects before it reaches its full potential. Frank D. Burke ATLAS OF ORTHOPAEDIC SURGERY VOL. II-UPPER EXTREMITY Edited by C. A. Laurin, L. H. Riley, R. Roy-Camille. 438 pages. Masson, 1990.
This is the second volume in a three volume series, the first being general principles-spine, and the third being the lower extremity. There are 19 contributors, six of whom are from North America, and the remainder from France. It is described as an Atlas of Orthopaedic Surgery and deals with operative technique but does not set out to deal with the indications for surgery. It is designed to be available for the practising surgeon, VOL.
16B No. 2 MAY
1991
REVIEWS
indicating that it should be close to, or in, the operating theatre environment. The chapters are divided up anatomically, starting with surgery of the shoulder and working down through the upper arm, elbow, forearm, wrist and hand. An annexe includes recent surgical procedures of the spine. 185 pages of this 438 page book are devoted to surgery of the wrist and hand. The printed text is extremely clear and well-written. There are copious illustrations, all extremely well-drawn and well-labelled, and quite easy to follow. Each section is introduced by a chapter on the surgical exposure, then various operative procedures are described. However, it is extremely difficult in a text of this size to cover every operation; although they have been able to give a description of five different operations for anterior dislocation of the shoulder, it is regretted that there is only one paragraph on arthroplasty of the elbow. The only operation described for non-union of the scaphoid is the Matte-Russe graft. There is an excellent section on tendon injuries of the hand, as well as reconstruction for various nerve palsies. It is unfortunate that only nine pages could be devoted to surgery of the rheumatoid hand, but what is written is very clear and well presented. This book has a good international flavour, combining the North American and the European points of view; it is extremely easy to read and follow step-by-step drawings for many of the operations. One of the greatest problems in trying to write a text-book on operative procedures in orthopaedic surgery is how to include all the known operations. This book is excellent for the surgeon who is looking for a solution to a problem in the operating theatre and is an easy reference book both for the trainee as well as the practising hand or orthopaedic surgeon. I. J. Leslie OUTLINE OF ORTHOPAEDICS by John Crawford Adams and David L. Hamblen, 11th Edition, Churchill Livingstone 1990. pp. 433. 371 Illustrations. ISBN 0 443 04094 X.
f14.95.
In this edition Crawford Adams has been joined by Professor Hamblen from Glasgow as co-author. Previous editions have established the book as the principal source of information and education on orthopaedics for students, general practitioners, nurses and therapists, and clearly this edition continues that tradition. Sections relevant to the upper limb, including neurological disorders, total 60 pages, and are well-written and succinct. Inevitably in a book of this nature there are many omissions; some are serious, including the lack of any description of physical examination in nerve injuries, notably the ulnar nerve, and yet half a page is devoted to nerve conduction studies. The authors have clearly seen the need to be selective, but the choice of which conditions to give prominence to is surprising. For example, De Quervain’s tenovaginitis has considerable exposure, but no mention is made of the hazards to the superficial branch of the radial nerve inherent in steroid injection and surgery. Kienbock’s disease is discussed but length-adjusting procedures not mentioned, although this is probably the most promising line of treatment. Some of the advice is questionable. Few hand surgeonswould choose to leave a divided F.D.P. tendon unrepaired routinely, and three weeks is never long enough to splint a mallet finger. I was surprised to read that two-stage tendon grafting is a recent 229
BOOK
REVIEWS-LETTERS
modification-it started to become popular at about the time of the 8th edition of this book, now in its 1 lth! The anatomy of hand infection is well described, and the section would be excellent but for the unsatisfactory incisions for draining deep palmar space infections; they are too close to the webs, especially the first. These criticisms may seem petty, but this chapter may be the first information on hand surgery to hit impressionable minds, and will mould attitudes and actions in many A & E departments. When there is limited space it is vital that what appears is relevant and correct, and sometimes unfortunately it isn’t. As a whole, however, the book remains an excellent text for its intended readership. It reads well and is clearly illustrated and presented and the references collected at the back under section headings are particularly valuable.
One of the main problems with scaphoid fractures, real and suspected, is that we over-treat many patients in our anxiety to avoid under-treating the ones which are going to give trouble. What we need most is better prediction of the outcome and Mr Herbert’s classification is designed to provide this. The book will make every reader think afresh and is full of useful tips and observations. For those who, like me, are fascinated by this awkward little bone, this book is a must. Those who are not yet fascinated will be when they have read the book. Nicholas Barton
Letters to the Editor
David M. Evans THE FRACTURED SCAPHOID By Timothy J. Herbert. Quality Medical PubZishing,Inc., St.
Louis, Missouri, USA. 1990. f69. (Available in U.K. from Williams and Wilkins Ltd., Broadway House, 2-6 Fulham Broadway, London S W6 IAA). ISBN o-942219-06-6. 26.2 x 18.4 cm. xii+ 202pages. 255 illustrations, Index. 30 years ago, nobody gave much thought to fractures of the scaphoid. They were not considered to be a problem. In the 1960’s, Geoffrey Fisk awakened interest in the subject and in the last 15 years other workers have shown that much of what has been believed is, at best, unproved and, at worst, untrue. Tim Herbert has been in the vanguard of progress and has now gathered his knowledge and wisdom into a book. It is not an operative manual or a lengthy advertisement for the Herbert screw, but a thoughtful and stimulating survey of the whole problem. He has probably operated on more scaphoids than anybody ever has before, so his experience is unique and now we can to some extent share it. The book reviews the anatomy, diagnosis, natural history, classification and treatment of fresh fractures and non-union. There are also chapters on avascular necrosis, ma&union and rotary subluxation. It is one of those rare textbooks, like those by Watson, Jones and Flatt, which is a joy to read because it is written in clear simple straightforward English. It is also beautifully produced and illustrated. The publishers, an American firm whom I had not heard of before, have done a superb job and this reader appreciated their acceptance of the author’s preference for English spelling and usage. It is an almost-forgotten pleasure to read a textbook in which the lines go right across the page, like an ordinary book, instead of being in two columns. I wish that journals could go back to that! (The argument for columns is that the lines can be printed closer together and therefore more can be printed on one page.) I have heard it said that fractures of the scaphoid are intracapsular fractures, like sub-capital fractures of the femur, and should therefore always be treated in the same way: by open reduction and internal fixation. Mr Herbert does not go as far as this, though he does incline much more to operative intervention than is usual in Britain or, indeed, than would be practical in most British centres. He also advocates corrective osteotomy of the scaphoid for mal-union, but cautiously and admitting that good long-term results will be needed to justify the possible risks of this procedure. 230
Dear Sir, Nathan et al. (1988) found no association between occupational hand activity and slowing of sensory conduction of the median nerve at the carpal tunnel. Unfortunately, this study suffers from “exposure misclassification.” Re-analysis of the author’s data using a more logical classification system actually supports the association of occupational hand activity and slowing of sensory conduction of the median nerve at the carpal tunnel. In Nathan’s study “occupational hand activity”, or exposure, was evaluated using two major variables : “rate of repetition” and “amount of resistance [force]“. Rate of repetition was divided into the following 5 groups : low, moderate, moderately high, high, very high. Force was divided into the following 5 groups: very light, light, moderate, heavy, very heavy. In addition, an occupational classification grouping was generated according to the employee’s job title. Then, rather than comparing the exposure variables of repetition and force to the nerve conduction results, the authors compared the occupational classification grouping (based on job title only) to the nerve conduction results. Table 1 demonstrates the inadequacy of this grouping. Table l-Occupational and repetition
classification groups by exposure variable of force
Repetition 1
High
1
I
I
I
I
Moving from the upper left to the lower right of the table, jobs have more exposure to repetition and force; factors reported to cause upper extremity cumulative trauma disorders, one of which is carpal tunnel syndrome (Armstrong and Chaffin, THE
JOURNAL
OF HAND
SURGERY