Upper Extremity Update: Part 1

From the University of Toronto Faculty of Medicine’s 25th Annual Upper Extremity Update

Educational Objectives

The goal of this program is to improve diagnosis of psychiatric disorders in patients with injuries to the upper extrem­ities, classification of acromioclavicular joint dislocations, and treatment of scaphoid nonunions (SNUs). After hear­ing and assimilating this program, the clinician will be better able to:

1.   Distinguish between malingering, somatoform disorders, factitious disorders and real injuries in patients who present with upper extremity injuries.

2.   Review the classification and diagnosis of acromioclavicular joint dislocations and determine which disloca­tions require fixation.

3.   Discuss fixation techniques for acromioclavicular joint dislocations.

4.   Assess patients with nonunion of scaphoid fractures and appropriately assign them to reconstruction or salvage procedures.

5.   Describe techniques for reconstruction of scaphoid nonunions using vascularized bone grafts.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgments

Drs. Stern, McKee, and Axelrod were recorded at the University of Toronto Faculty of Medicine’s 25th Annual Upper Extremity Update, sponsored by the University of Toronto Faculty of Medicine, and held April 3, 2009, at the Univer­sity of Toronto, ON. The Audio-Digest Foundation thanks the speakers and the University of Toronto Faculty of Med­icine for their cooperation in the production of this program.

Psychiatric Disorders in Patients with Upper Extremity Injuries

Peter J. Stern, MD, Professor and Chair, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH

Malingering

Overview: secondary gain present (not psychiatric diagnosis); problem with malingering  —  violates trust between physician and patient

Malingering in hand patients: check grip strength using dynamometer  —  in 5 positions; normally bell-shaped curve peaks at 2 or 3 position (flat-line curve suggests no previous injury); grip strength increases within 1 sec, peaks, and tapers; in rapid, alternating grip strength exercise, common to have “herky-jerky” curve; other approach  —  video surveillance after physical examination (PE)

Somatoform Disorders

Overview: group of disorders with unexplained physical symptoms; conversion reaction; case example  —  woman with minor injury to wrist; over several weeks, complete loss of upper extremity function; no objective findings

Somatoform disorders vs complex regional pain syndrome (CRPS): type I  —  reflex sympathetic dystrophy; fol­lows noxious event; type II  —  follows nerve injury such as transection or injury to median nerve at wrist

Diagnosing CRPS: not quantifiable; patients often misdiagnosed; broad criteria  —  1) pain (often described as burn­ing); does not usually follow nerve distribution; 2) trophic changes (initially seen as edema but ultimately stiff­ness and atrophy); 3) autonomic dysfunction (vasomotor hypo- or hyperactivity, eg, hyperhidrosis)

Factitious Disorders

Overview: self-injury for psychologic reason; motivation  —  assume sick role; lack of external incentives (eg, money, position, power); case example  —  woman 25 yr of age; “loose bodies” removed from wrist; additional surgeries and postoperative infections; extensive work-up reveals nothing (except for increase in soft tissue uptake on bone scan)

Indications: history of medical intervention (patient called “accident prone”); inconsistency in reports; patient feels victimized by medical system (many health care workers); remarkable number of tests, consults, and hospitaliza­tions, most to no avail; tests often contradict information given by patient; frequent consent to surgical procedures; use of flattery or unusual requests

Factitious lymphedema: case example  —  female librarian with distinct lymphedematous extremity (from rubber tourniquet); fully functional in workplace; work-up  —  chest x-ray and shoulder film to rule out Pancoast tumor; blood coagulation studies; liver function tests; venography; lymphangiography; magnetic resonance imaging (MRI) (shows soft tissue changes); can make diagnosis but treatment difficult

Secrétan’s disease: dorsal peritendinous fibrosis; woody swelling over dorsum of hand, possibly self-induced (can­not prove); not surgical; swelling described as “hard, elastic cushion”; possibly not malingering (many patients re­covered); speaker makes diagnosis once every 2 yr (in busy practice); patients could be striking their hands (some MRIs show stress micro-fractures); treatments  —  “studious neglect”; excision studies show poor results and slow recovery

Clenched fist syndrome: nonphysiologic posture of hand; sometimes all 4 fingers flexed; most use only thumb and index finger in daily activities; most patients have minor inciting episode, so probably conversion reaction rather than factitious disorder; speaker sees many nurses aides with disorder; findings  —paradoxical stiffness; resist at­tempts to straighten fingers; can develop maceration; (speaker has treated by fusing proximal interphalangeal joints in functional position); electromyography (EMG) studies  —  flexors show voluntary units with passive extension; nerve conduction velocities  —normal; x-ray  —  no osteopenia (suggests patients sometimes unclench fists); treatment  —  psychiatrist; use cast that keeps wrist and fingers extended for 6 wk; supportive and suggestive conver­sation with family sometimes effective; do not assume factitious disorder

Self-induced burning and cutting (Phelps [1977]; Journal of Hand Surgery): if self-injury suspected, apply fluo­rescent dye to ulcer and cover with occlusive dressing; tell patient not to remove dressing; after 3 days  —  reinspect hands using Wood’s lamp; check for fluorescence on fingernails of opposite hand

Munchausen syndrome: original patient description  —  travels widely and has dramatic but plausible stories; can be evasive; leaves against medical advice; various motives (eg, attention, grudge against physicians, drug seeking); recognition considered more important than treatment; additional features  —antisocial behavior; history of sex­ual or physical abuse; more common in men; multiple scars; equanimity for invasive procedures; multiple hospi­talizations; case example  —  woman with swelling and crepitation in first web space; showed no discomfort in hyperbaric chamber; re-examination revealed no swelling, minor crepitus, and full range of motion; treatment  —usually refused; confrontation ineffective (avoid); may benefit from group psychotherapy;  prognosis poor

SHAFT syndrome: sad, hostile, anxious, frustrating, tenacious; variation of Munchausen; psychologic need ful­filled through surgery, eg, for chronic low back pain without objective findings; identify patients and avoid sur­gery; expanded SHAFT (Kasden, 1998;Journal of Hand Surgery)  —mostly female patients; 75% had no objective findings; see average of 4.5 physicians; worker’s compensation issues common (psychiatric disorder plus malingering)

Management of factitious disorders: psychotherapy; confrontation  —  limited success; hypnosis and biofeedback  —may help; use encouragement and optimism about treatment; pharmacotherapy  —  not helpful; other  —  talk to patient

Dislocations of the Acromioclavicular Joint

Michael McKee, MD, Associate Professor, Division of Orthopaedic Surgery, University of Toronto Faculty of Medicine, Toronto, ON

Overview of acromioclavicular joint (ACJ) dislocations: slings and devices  —  most common treatment; choices based on patient comfort; indications for surgery  —  controversial

Classification scheme: type I  —  simple sprains with no radiographic displacement; type V  —  extensive damage; clav­icle elevated through deltotrapezial fascia; type VI  —  rare; clavicle driven under coracoid process; usually result of major chest trauma; type II  —  tear ligaments and strain coracoclavicular (CC) ligaments; possible mild migration of clavicle; types I and II  —  decide when patient can return to activity; no easy answer, but usually when patient has full range of motion [ROM] and minimal pain; recognize high risk for reinjury

 Type III injuries: common; most controversial; no contact between distal clavicle and acromion (ie, complete dis­placement; CC and AC ligaments completely torn); common in clinic; data available to guide treatment; studies show operative treatment no better than nonoperative; many recommend against routine surgical treatment

Randomized trials on ACJ reconstruction: 18 papers published in 2 yr on chronic dislocations; some deficiencies in measuring outcomes; after surgery, average patient had shoulder score of 80 to 85 (not normal); challenges  —  identification of injury; standardization of x-rays (arm position matters); conclusions  —  conservative management acceptable for most, but certain patients (eg, those who do overhead work) benefit from fixation

Type IV and V injuries: type IV  —  difficult to diagnose (sometimes misdiagnosed as type III); clavicle elevated and pushed back; shoulder girdle moved forward  —  possible benefit from fixation; type V  —  100% displacement; “ear tickler” (ie, clavicle elevated); severe deformity and dysfunction; requires fixation

Polytrauma with ACJ injury: shoulder outcomes worse than those with ACJ injury alone; most x-rays taken with patient in supine position, so large displacement missed, and actual grade IV and V misdiagnosed as grade II or III

Fixation Techniques

Bosworth screw: gold standard; screw into coracoid helps reposition clavicle; high failure rate; failure results in complete loss of fixation

Endobutton fixation: new technique; top button in clavicle; button underneath coracoid; use coracoid as solid post against which to reduce clavicle; preliminary outcomes  —  definite failures (eg, button can pull through); places tre­mendous force across joint; case of distal clavicle fracture (ACJ equivalent)  —  endobutton pulled up into coracoid and down into clavicle with resulting re-displacement of clavicle fracture

Other strategies: fresh injury  —  push clavicle down into place and hope for scar formation; chronic injury  —  need bi­ologic transfer (ie, ligament substitution); transfer ligament from acromion to end of clavicle; can remove hardware later; can use >1 technique in patients: allograft  —  around coracoid; can use hamstring tendon; can combine with other approaches

Hook-plate fixation (HPF): speaker’s method of choice; depends on acromion rather than coracoid; plate fixes to distal clavicle; hook under acromion helps to hold clavicle down (prevents re-elevation of clavicle); allows phys­iologic motion; revision procedure, ie, effective after loss of fixation by other techniques (eg, loss of coracoid fix­ation), provided acromion intact

Retrospective reviews: Journal of Shoulder and Elbow Surgery study  —  HPF group 10 to 15 points better (despite having more severe injuries) than controls; German study  —similar finding; new Canadian study under way  —  acute ACJ dislocations in higher grades; patients randomized to sling or HPF with intensive 2-yr follow-up

Current Treatment of Scaphoid Fractures and Nonunions

Terry Axelrod, MD, Professor, Division of Orthopaedic Surgery, University of Toronto Faculty of Medicine, Sunnybrook Health Sciences Center

Rationale for intervention for scaphoid nonunion (SNU): 1996 Japanese study  —  102 cases (symptomatic pa­tients); of those <5-yr duration, 22% had osteoarthritis (OA) at <5 yr; those of 5- to 9-yr duration, 75%; those of 10-yr duration, 100%; demonstrates that patients with symptomatic SNU develop OA; no correlation between pain and severity of OA or duration of nonunion; McCabe (1993); Journal of Hand Surgery  — natural history of SNU not as severe as literature indicates; studies focus on symptomatic patients; no longitudinal cohort studies of SNU; take-home messages  —  symptomatic patients develop OA (OA itself not always symptomatic); if asymptomatic, out­come unclear (but likely to develop OA)

SNU imaging: in addition to history and PE; plain x-rays  —scaphoid, upshot, and ulnar deviation views; computed tomography (CT)  —  gold standard; Sanders views  —  recommended for assessment of displacement, size of frag­ments, and inflection deformity (typical feature of SNU); magnetic resonance imaging (MRI)  —  useful for sus­pected SNU (when undetected using plain x-ray); detection of avascular necrosis

Managing SNUs: goals  —  union of scaphoid; correction of deformity, ie, restore scaphoid height, correct deflection deformity, and correct rotational malalignment (often, pronation of distal segment of bone present); prevent long-term complications; approach  —  x-rays, and CT; open surgery;  volar approach, through palmar exposure  (occa­sional dorsal exposure for proximal pole nonunion)

Diego Fernandez graft (1984 to 1990): excise nonunion site; obtain iliac crest bone graft (compression-resistant); trapezoidal sculpting of graft to correct deflection deformity; stable internal fixation (with K-wires or screws); pal­mar exposure incision can be longitudinal (between radial artery and flexor carpi radialis (FCR) or through FCR subsheath); volar capsulotomy; outcome  —  »85% success rate for primary midway SNU with iliac crest bone graft and internal fixation; fixation devices  —  type of hardware (eg, Herbert screw, headless compression screws) does not matter; technique used for restoring scaphoid (ie, how surgeon inserts screw and uses pins) matters

Vascularized bone grafts (VBGs): described in early 1990s; involves taking bone graft from distal radius along with vascular pedicle and rotating live bone into pseudoarthrosis site; applications  —  SNU involving proximal pole; failed previous operations; revascularization of other dead bone; 1,2  intercompartmental supraretinacular artery  — most commonly used; vessel on radiostyloid between first and second dorsal compartment; current branch of radial artery

VBG outcomes: Boyer and McKee 1995  —  6 of 10 patients followed 15 mo healed and revascularized; all patients with no previous surgery healed; of 5 or 6 with previous surgery, 4 failed; Journal of Bone and Joint Surgery study  —  68% success rate; Bishop (2002); Journal of the American Academy of Orthopaedic Surgeons  —  15 pa­tients (5 had previous failed surgery); all healed with same bone graft; new Bishop study  —  4 of 10 patients with VBG healed; follow-up possibly too short in Bishop 2002; take-home message  —  VBG effective for proximal pole fractures that frequently fail treatment with conventional iliac crest bone graft (70%-80% success in primary cases, »50% for reoperation); probably more effective than conventional graft for small proximal pole nonunion

Fixation vs Salvage

Overview: no definitive answers; consider reconstruction  —young patients with wrist worth salvaging; try to recon­struct scaphoid if possible; consider salvage  —  elderly or low-demand patients; multi-fragmentary tiny proximal pole; moderate to advanced OA in wrist

Reconstruction: case example  —  man 22 yr of age; scaphoid collapsed in NU site; graft alive but failed distally and proximally; treatment  —  volar exposure; removed NU site and replaced bone graft; used K-wires (8-10 wk); pa­tient healed and symptoms eliminated: take-home messages  —  adapt approach according to previous intervention; eg, if patient had local bone graft with inadequate fixation, reconstruct; some patients not amenable to reconstruc­tion and must have salvage

Salvage treatment: options  —  debride region (radial styloidectomy); resect osteophytes off scaphoid with or without wrist denervation; denervation alone; proximal row carpectomy; scaphoid excision and 4-cornered fusion; total wrist fusion; all reasonable options

Suggested Reading

Byard RW: "Munchausen syndrome by proxy": problems and possibilities. Forensic Sci Med Pathol 5:100, 2009; Docimo S Jr et al: Surgical treatment for acromioclavicular joint osteoarthritis: patient selection, surgical options, complications, and outcome. Curr Rev Musculoskelet Med