For all of you that work in urgent care, emergency medicine, after hours clinics and new to orthopaedics, this blog is dedicated to helping you understand the initial evaluation and management of metacarpal fractures. This Review on the Management of Metacarpal/Hand Fractures is a 3 part series. The first focused on an overview of initial evaluation considerations and description of radiographs, the second will addressed initial treatment and splinting techniques and this, the final installment, will discuss the indications for surgical correction vs. conservative management of metacarpal fractures.
This is the 3rd blog in our three-part series on management of metacarpal fractures. To learn more about the initial evaluation considerations and description of radiographs see our blog post from 03/27/2013, for a review of the initial treatment and splinting techniques see our blog post from 04/03/2013.
For all of you that work in urgent care, emergency medicine, after hours clinics and for those who are new to orthopaedics, this blog is dedicated to helping you understand the initial evaluation and management of metacarpal fractures. This Review on the Management of Metacarpal/Hand Fractures is a three-part series. The first, that we posted last week, focused on an overview of initial evaluation considerations and description of radiographs; this one, the second, will address initial treatment and splinting techniques; and the final installment will discuss the indications for surgical correction vs. conservative management of metacarpal fractures.
This is the second installment in this three-part series. For more information regarding the overview of initial evaluation considerations and description of radiographs please see last week's blog post.
For all of you that work in urgent care, emergency medicine, after hours clinics and those who are new to orthopaedics, this blog is dedicated to helping you understand the initial evaluation and management of metacarpal fractures. This Review on the Management of Metacarpal/Hand Fractures will be a three-part series. The first will focus on an overview of initial evaluation considerations and description of radiographs; the second will address initial treatment and splinting techniques; and the final installment will discuss the indications for surgical correction vs. conservative management of metacarpal fractures.
The thumb is a unique structure of the hand and allows us to perform many tasks daily. Injury to the collateral ligaments will prohibit apposition and opposition of the thumb with the ulnar four (4) fingers. Injuries to the ulnar collateral ligament can occur acutely (Skier's thumb) or from repetitive actions (Gamekeeper's thumb). My blog today will discuss the differences between skier's and gamekeeper's thumb injuries.
General Anatomy Review
The thumb Metacarpal Phalangeal (MCP) is a diarthrodial joint with a primary function is to allow flexion and extension. The MCP joint support structures are divided into static (ligament) and dynamic (muscle/tendon) stabilizers. The static stabilizers are comprised of the collateral ligaments (radial/ulnar), accessory collateral ligaments, the volar plate (aka: palmer plate) and the dorsal capsular ligament. The collateral ligaments restrict in flexion, accessory collateral ligaments restrict in extension, the volar plate limits extension and the dorsal capsular ligament limits in flexion. The ulnar collateral ligament originates at the metacarpal head and inserts at the base of the proximal phalanx. Dynamic stabilizers of the MCP joint include the extensor hood, intrinsic/extrinsic muscles of the thumb and the adductor musculature of the thumb. Remember, that the adductor tendons will attach at the level of the ulnar collateral ligament. The dorsal sensory branch of the radial nerve traverses near the ulnar aspect of the thumb.
Why does it appear that a majority of PA's are opposed to a CAQ (or sub-specialty training) to enhance their skills and knowledge? Would we, as a profession, be less resistant to gaining additional knowledge and skills if we called it something else other than a CAQ? Would we all be more accepting if it was less costly and time consuming? Or, would we be happier if the NCCPA had not instituted the CAQ process? I understand that we are primary care trained and that gives us our "freedom" to move about various disciplines of medicine in order to obtain a job. I get that rationale; no one (including me) wants to get "legislated" out of a job. For those folks who have the belief that we will get closed out of a job, please explain this in more detail to me. More specifically, tell me how or why you lost a job because you had advanced knowledge and skills. In my career, I have never lost a job because I had additional knowledge and skills. In fact, it helped me to become a top candidate in every job I ever applied for (and won!!!). Like many of you, I grew up as a PA by the "on-the-job-training" method. I worked hard, studied a lot, read many articles and made myself available any time to learn from whatever opportunity presented itself. However, in the very near future (if it has not already occurred) PA's (and NPs) are going to be asked to handle a larger burden in treating patients. Information coming out of many physician medical organizations indicates that there are not going to be enough new physicians trained to meet future demands nor will there be any additional government funds to support expanding physician residency programs. A natural solution to these problems would be to employ PA's (and NP's) to help meet the demand for medical care in the future. Physician Assistant educational programs are a mirror of the physician medical school training programs. It would seem natural for PA's who are looking to work in sub-specialty medicine environments to want to possess additional training/ skills.
Providers who treat children who present with “sprains” of the finger or thumb should be suspicious of Salter-Harris fractures involving the growth plates. It is not uncommon for children to injure the growth plate but yet their clinical evaluation makes it appear that they have a ligamentous injury. Healthcare providers should be proficient in their interpretation of extremity radiographs, especially those involving the hand.
Falls on a flexed knee can present as a variety of injuries like contusions, sprains, patellar/quad tendon ruptures and fractures. A patient who demonstrates an inability to bear weight should increase the providers concern for fracture.
Mallet finger is an injury that involves the extensor tendon and occurs at the distal Interphalangeal Joint (DIP). This injury is caused by opposing forces exerted on the extensor tendon resulting in a rupture (or avulsion fracture) on the extensor tendon at its insertion point into the distal phalanx. The classic presentation is that a patient will have a drooping DIP joint and will be unable to actively or resistively keep the distal phalanx in a straight position. Treatment is placing the DIP joint in terminal extension to allow the ruptures tendon to heal. If the mallet finger injury involves a bony portion of the distal phalanx, surgery may be needed to correct this type of injury. Recovery time, regardless of treatment options, is usually 6-8 weeks.
Patients who presented with persistent thigh and knee pain may not always have knee pathology. Frequently, avascular necrosis (AVN) or osteoarthritis (OA) of the hip will present as thigh or knee pain.
Osteoarthritis (OA) is one of three (3) forms of arthritis that affects the knee. The other forms of arthritis frequently associated with the knee are Rheumatoid and Post-Traumatic arthritis. OA is a slowly progressive disease process that involves the articular joint cartilage. It can affect anyone with symptoms presenting in middle age. Post-traumatic arthritis develops as a result of an injury occurring to the knee joint. Injures are not just limited to the articular cartilage but can involve fractures to the joint, ligament injuries (ACL most common) or meniscus injuries. Any injury that can have an effect on the joint structures can potentially lead to the onset of osteoarthritis. Finally, Rheumatoid arthritis (RA) is an inflammatory arthritis that destroys articular cartilage and is not the result of trauma or activity. RA is an autoimmune process that not only affects the knee but can afflict all synovial joints. RA can occur in both juveniles and adults.
For the purpose of my blog this week, I will focus on osteoarthritis (activity related/post-traumatic). Stay tuned for a future blog on Rheumatoid arthritis.
Every once in a while you might come across a patient who experiences pain symptoms that are out of proportion to their injury. We all have had a post-op patient who is particularly uncomfortable because their dressing is too tight or the post-op/injury swelling is worse or the splint/cast is too tight. These are all plausible causes for your patients to have pain out of its usual proportions. However, when you run across a patient that complains of unrelenting pain, burning, redness, swelling, sweating that occurs after a small injury (sprained ankle, finger laceration, contusion), start thinking of Complex Regional Pain Syndromes (CRPS). CRPS is also commonly referred to as Reflex Sympathetic Dystrophy (RSD), Causalgia or Sudeck's atrophy. No matter the name, the onset of symptoms bears the full attention of healthcare providers. Early and accurate diagnosis and appropriate treatment are essential to recovery, yet many health care professionals and consumers are unaware of its signs and symptoms. Typically, people with CRPS report seeing an average of five physicians before being accurately diagnosed. This condition is not a psychological injury, but patients can develop emotional/psychological problems related to lack of support and understanding of their pain complaints. Treatment for CRPS may include; medications, physical/occupational therapy, psychological therapy, sympathetic nerve blocks, spinal cord stimulator and tincture of time.
Sever's disease (also called Calcaneal apophysitis) is a painful inflammatory condition of the heel. It is the most common cause of heal pain in adolescents and is termed a non-articular osteochondrosis. The heel pain frequently associated with Sever's disease results from repetitive shear forces applied to the calcaneal apophysis. This occurs due to the result from the pull of the Achilles tendon at its insertion point on the calcaneous. The Calcaneal apophysis develops as an independent center of ossification. Sever's disease can affect boys and girls equally, with the average age of symptom onset between 9-11 years of age. During puberty, the apophyseal line appears to be weakened due to rapid growth and this allows more stresses to occur at the apophysis.
I recently took the PANRE for the 4th time since I graduated from the Wake Forest University School of Medicine Physician Assistant program and became a physician assistant (PA). For those of you who have taken this test, all I can say is start early and hang on till the finish. Conventional wisdom might indicate that since I have been in the profession 15+ years and having taken the test before I would have developed some test taking skills. WRONG. I can't tell you the amount of anxiety that developed around this particular PANRE test. In the past, I would start studying 3 months before taking the test and usually would sit for the test in year 5 of the 6 year certification process. After changing jobs in 2010, living apart from my family for 6 months and moving to a new city, I did not have a good feeling about the whole recertification process. So I decided to change my tactics a little and take a review course early to help me better define my weak areas and start the studying process based on that information.
This is a unique case that involves injury to both knees from separate events that was missed during an initial evaluation. This case will help you expand your knowledge using plain x-ray to assist in to diagnosis musculoskeletal injuries.
This study looked at two (2) components of delivering relief for subacromial shoulder inflammation of the rotator cuff/bursae. Hong addresses the variability of the steroid product used for injection and the methods by which the injection was delivered. In the steroid product selection process it appears that the provider bases their selection solely on their medical experiences and not evidence based medicine. Commonly, providers will use Methylprednisone (Depo-Medrol), Triamcinolone (Kenalog, Aristospan) or Betamethasone (Celestone) as the corticosteroid for injection. This study also looked at the differences in the therapeutic effects of the medication delivered via injection when the needle is positioned in the joint, either through ultrasound guidance or by physical examination. Hong reported that there was a significant benefit in guiding and confirming that the needle was in the subacromial space prior to the delivery of the corticosteroid when compared to the physical exam guided subacromial injection.
Low Dose Corticosteroid Effective in Treatment of Shoulder Pain
Hong JY et al, Ajou University School of Medicine, Republic of Korea
Archives of Physical Medicine & Rehabilitation, Published online October 28, 2011
