Perspectives on Upper Extremity Injury

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

Educational Objectives

The goal of this program is to improve management of upper extremity injuries. After hearing and assimilating this program, the clinician will be better able to:

1.   Effectively evaluate the patient who presents with a metacarpal or phalangeal fracture and select appropriate treatment.

2.   Review the advantages and disadvantages of internal plate fixation of hand fractures.

3.   Recognize and manage infected fractures of the hand.

4.   Discuss the Oriental medicine concepts associated with acupuncture and cite evidence from Western medicine supporting its efficacy.

5.   Describe recommended techniques for managing common complications after total shoulder arthroplasty.

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 the planning committee re­ported nothing to disclose. In his lecture, Dr. von Schroeder presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Drs. Stern, von Schroeder, and Richards were recorded at 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.

Complications of Hand Fracture Fixation

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

Introductory remarks: hand fractures can be complicated by deformity resulting from no treatment, stiffness from overtreatment, or deformity and stiffness from poor treatment; complications following fractures categorized as ones over which physicians have little control or as controllable; case example  —  33-yr-old woman; presented 2 wk post closed fracture of proximal phalanx (P1) of small finger secondary to motor vehicle accident (MVA); treated nonoperatively (placed in figure-of-eight splint; regained full range of motion [ROM]; no scarring)

Patient evaluation: when managing phalangeal and metacarpal fractures, physical examination (PE) extremely im­portant in deciding on course of treatment; metacarpal block simple in phalangeal fractures; check for malrotation; if overlap present when patient makes fist, discuss correction of rotational alignment (difficult to do with splint alone); remember that treatment not necessarily based on radiographic findings; fracture management should start with either no treatment or cast or splint, and progress to more complicated forms of treatment

Disadvantages of internal fixation: include pin-track infections and technical failures; implants (eg, plates, screws) immortalize errors and can damage soft tissue; case example  —  patient with extremely displaced midshaft P1 frac­ture; treated with Burkhalter “clamdigger” splint; no incisions; immediate motion by buddy taping to adjacent fin­ger; at »8 wk, had virtually full ROM;

Plate fixation: advantages  —  stable; can provide anatomic restoration and maintain length; because of stability, pa­tient can be sent quickly to hand therapist for aggressive program of ROM exercises; disadvantages  —  plates bulky; screws must be put in correctly on first attempt; often have to be removed; implantation requires fair amount of dis­section (frequently causes adhesions and stiffness); in study of plate fixation of 66 metacarpal and 36 phalangeal fractures, »36% of patients had ³1 major complication; metacarpal fractures did fairly well; phalangeal fractures (especially open ones) had much poorer outcomes

Condylar fractures: most are unicondylar; in typical pattern, condyle displaces proximally and palmarly; results in development of angulatory deformity of finger and joint incongruence, possibly leading to arthritis and reduction of ROM; study identified 4 classes of fracture patterns; in majority of patients, nondisplaced fractures became dis­placed and required surgery; results suggest that after reduction, fracture should be fixed with combination of 2 pins and/or screws for best outcome

Infections: not common in hand injuries; seen in those with contaminated injuries, treatment delays, or systemic ill­ness; not much evidence-based literature on when to use antibiotics; speaker uses them for most open fractures, soft-tissue or vascular injuries, or when implanting hardware; management of infected fractures  —  must eliminate sepsis (debride soft tissues); usually need to remove implants; secure union in stages; place external fixator with or without polymethylmethacrylate antibiotic impregnated spacer; follow with bone graft using plate and internal fix­ation; finger will be stiff and may require tenolysis and capsulotomy to restore movement; if patient with osteomy­elitis has had >3 operations, chance of successful outcome with finger <15%; study of infections in tubular bones of hand identified »46 metacarpal and phalangeal fractures with osteomyelitis; infection in small bones of hand as­sociated with »40% overall amputation rate (75%-86% if infection >6-mo duration); with prolonged persistence, amputation often becomes best course for maintaining patient’s quality of life

Stiffness: risk for stiffness increases in combined injuries with open fracture and soft tissue component; much more common in flexor tendon zone II; also common in cases of intraarticular injury; serious problem if hand or fingers immobilized >4 wk; case example  —  patient with intraarticular fracture of proximal phalanx; treated with internal fixation; returned with “fairly stiff hand” (acceptable proximal IP [PIP] joint but stiffness in flexion); tenolysis per­formed dorsally under local sedation; final result improved

Errors related to screw fixation: if screws too long or prominent dorsally, can cause formation of adventitious bursa; screws placed dorsal to palmar in phalanges can rupture flexor tendons; too-proud screw head can impale ex­tensor tendon or cause bursa formation; case examples  —  patient who presented with extreme stiffness of DIP joint (screws went right through conjoined lateral bands; required screw removal and tenolysis); screws put in from dor­sal to palmar (particularly in flexor tendon zone II) must not be too long); even 8-mm screw can cause fraying of flexor tendons; on lateral x-rays, ridges on volar surface of proximal phalanx cause false impression that penetrat­ing screw is bicortical

Nonunion: extremely unusual; in most instances, fracture can be united (however, especially when dealing with com­bined bony and soft tissue injury or infection, prognosis should be guarded); case example  —  19-yr-old student with fractures of proximal phalanx treated with “distraction osteosynthesis” (surgeon inserted pins in distracted fashion); fracture healed, but patient clearly had atrophic nonunion; in such instances, speaker recommends com­plete resection of nonunion and placement of plate, followed by cortical or pure cancellous bone graft

Closing comments: remember that key determinant of success with hand fractures is soft tissues

Acupuncture in the Upper Extremity: Does it Work?

Herbert von Schroeder, MD, Assistant Professor, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Faculty of Medicine, Toronto, ON

Acupuncture: ancient traditional Chinese medicine technique that involves inserting and manipulating very fine nee­dles in specific points on body; used to relieve pain and for various therapeutic purposes; first written reference dates to 300 BCE; interest in acupuncture in West increased in early 1970s, largely because of article by journalist who traveled with Nixon to China and wrote about successful treatment with acupuncture for pain and ileus follow­ing surgery for acute appendicitis; acupuncturists currently found throughout North America and Europe

Concept of acupuncture: prescientific paradigm with no biologic plausibility; based on concepts of balance between yin and yang in body (opposing interconnected forces) and “qi” (vital energy that flows through body; acupuncture said to regulate flow and establish balance); body treated as whole (based on concept of “zang-fu,” where body has “systems of function” named after specific organs, but may not have specific association with them); various merid­ians along and across body constitute well-defined pathways through which qi flows; most acupuncture points along meridians

Upper extremity: 3 yin channels on anterior of hand (labeled lung, pericardium, and heart, but not related to those organs); meridians start on chest and travel anteriorly down to hand and arm; 3 yang channels on back of hand go up dorsum to shoulder and head region; points on upper extremity not necessarily used to treat upper extremity problems (which may be treated with acupuncture elsewhere on body)

Comments: many styles of acupuncture; diagnosis and treatment individualized based on various philosophic con­structs, experience of acupuncturist, and subjective and intuitive impressions

Uses in upper extremity: acupuncture said to assist in pain and control of edema, and to enhance healing process; helpful for various muscle conditions, tremors, ticks, contractures, soft-tissue pain, most types of neuralgias, pares­thesias, and other conditions (eg, nausea, anxiety)

Acupuncture technique: needles pushed in to depth of 3 to 5 mm and twisted; patient feels twinging, tingling, ach­ing, and sometimes pain; needles sometimes stimulated (either manipulated directly, or heated or electric current passed through them); needles left in for various lengths of time

Effectiveness: issue from point of view of Western medicine is that meridians do not correspond to any known struc­tures; placebo effect suggested; Eastern concepts of yin and yang do correspond somewhat with gate control theory of pain (interplay between excitatory and inhibitory pain pathways); acupuncture shown to increase endogenous opiates which can be blocked by naloxone; regardless of tests used (eg, nerve conduction studies, magnetic reso­nance imaging), changes in activity noted with acupuncture (evidence of physiologic effect); acupoints themselves have higher blood flow, and acupuncture at these points increases blood flow in the region; acupuncture shown to work in animals and children (which disputes placebo explanation)

Data from evidence-based studies: Cochrane review concluded emerging clinical evidence suggests that acupunc­ture effective for some, but not all, conditions (approved its use for treatment of nausea and vomiting, neck pain, and fibromyalgia); World Health Organization (WHO) also supports its use for periarthritis of shoulder, postopera­tive pain, rheumatoid arthritis (RA), sprains, and lateral epicondylitis (tennis elbow; 5 studies have demonstrated efficacy); randomized controlled studies have also shown efficacy for stiffness of shoulder-hand syndrome, im­provement of muscle strength following stroke, fatigue, hand ischemia caused by vibration, and osteoarthritis (OA); National Institutes of Health (NIH) Consensus also approves its use

Comments: procedure extremely safe and number of complications “exceptionally low”; forgoing Western treatment methods considered greatest risk; acupuncture not useful for every condition (eg, cannot treat scaphoid nonunion), but can help great many patients; appropriate to set bar high for new techniques, but physicians should apply same standards to evaluate efficacy of their own treatment methods in terms of risks and how much they actually help pa­tients

Summary: acupuncture has real benefits; and highly effective and cost-effective; efficacy can be gauged quickly; drug-free alternative; Western scientific evidence and research techniques now being applied to acupuncture; regu­lation of practitioners needed

Complications of Total Shoulder Arthroplasty

Robin R. Richards, MD, Professor, Department of Surgery, University of Toronto Faculty of Medicine, and Head, Department of Surgery, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON

Rotator cuff problems: diagnosis after arthroplasty challenging; nonoperative treatment preferred, but if that proves ineffective, do not hesitate to perform rotator cuff surgery; most (if not all) of these patients have some acromiocla­vicular (AC) joint pathology; speaker usually excises AC joint, performs anteroinferior acromioplasty and bursec­tomy, and repairs tendon if torn

Instability: reported in £4% of patients after arthroplasty; has extremely negative clinical impact on active patients; diagnosis usually straightforward (axillary view); if shoulder unstable, look at direction of instability, orientation of components (and whether well fixed), determine which soft tissues present or deficient, and look for possible pa­tient factors (eg, medical condition possibly contributing to instability); anterior instability  —  assess version of prosthesis and check its size if planning to do revision surgery (may need to downsize femoral head component); evaluate status of glenoid fossa and deltoid muscle; superior instability  —  associated with deficiency of rotator cuff tendon and/or coracoacromial arch; prevention preferable, as no effective surgical treatment available; posterior instability  —  can occur when prosthesis inserted correctly but shoulder slips out in early postoperative period (pos­sibly due to damage to posterior capsule); if detected early, speaker has had good experience with making posterior incision, tightening after reattaching posterior capsule, combining with anterior approach, and using thermoplastic orthosis to restabilize shoulder

Component dissociation: seen with use of modular components; again, prevention better than treatment; must be sure no fluid or debris present when assembling components, as they come apart quite easily

Loosening: most common complication (much more common at glenoid than humeral site); does not necessarily re­quire further surgery; take serial images to look for progressive loosening; role for arthroscopic assessment and treatment, and for revision surgery in patients severely symptomatic (ie, those with pain at night or with activities of daily living [ADL]); patients must understand that procedure will not restore normal motion or strength of shoul­der (goal is pain relief with ADL); when revising shoulder, not always possible to reimplant prosthesis (consider bone grafting or even fascial replacement in some cases)

Wear: universal in long-standing implants; serial imaging important to determine if patient sufficiently symptomatic to justify further surgery; simply explaining that wear expected and arranging further follow-up often enough to satisfy patient; wear commonly causes loosening; same criteria apply when considering whether to do revision sur­gery

Humeral fractures: can usually be fixed; classified as intraoperative or postoperative; intraoperative fractures (if rec­ognized) should be fixed during surgery; in speaker’s experience, most humeral fractures associated with shoulder arthroplasty displaced and require intervention; speaker uses cerclage cables for fixation; alternative method  —  long-stem prosthesis

Sepsis: when patient complains of pain after arthroplasty, always do blood work and bone scan as minimum; depend­ing on results, gallium scan and aspiration may be indicated; management options  —  include suppressive antibiot­ics; single-stage revision (another arthroplasty with antibiotic-impregnated cement); two-stage revision; excision; or arthrodesis; 2-stage revision  —  involves making spacer with antibiotic-impregnated cement; Mayo Clinic study concluded technique associated with high rate of unsatisfactory results, marginal success at eradicating infection, and high complication rate; resection arthroplasty  —  reasonable salvage option for poor candidates for prosthetic reimplantation (yields patients who can reliably perform basic ADL); if 2-stage reimplantation does not work, speaker chooses excision over arthrodesis

Suggested Reading

Bohsali KI et al: Complications of total shoulder arthroplasty. J Bone Joint Surg Am 88:2279, 2006; Chin PY et al: Compli­cations of total shoulder arthroplasty: are they fewer or different? J Shoulder Elbow Surg 1:19, 2006; Fink M et al: Chronic epicondylitis: effects of real and sham acupuncture treatment: a randomised controlled patient- and examiner-blinded long-term trial. Forsch Komplementarmed Klass Naturheilkd 9:210, 2002; Fusetti C et al: Complications of plate fixation in meta­carpal fractures. J Trauma 52:535, 2002; Green S et al: Acupuncture for lateral elbow pain. Cochrane Database Syst Rev (1):CD003527, 2002; Guerra J et al: Acupuncture for soft tissue shoulder disorders: a series of 201 cases. Acupunct Med 21:18, 2003; Guerra de Hoyos JA: Randomised trial of long term effect of acupuncture for shoulder pain. Pain 112(3):289, 2004; Harness NG et al: Extra-articular osteotomy for malunited unicondylar fractures of the proximal phalanx. J Hand Surg Am 30:566, 2005; Kurzen P: Complications after plate fixation of phalangeal fractures. J Trauma 60:841, 2006; Sperling JW et al: Avoidance and treatment of complications in shoulder arthroplasty. Instr Course Lect 58:459, 2009; Teoh LC et al: Cer­clage-wiring-assisted fixation of difficult hand fractures. J Hand Surg Br 31:637, 2006; Trinh KV et al: Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford) 43:1085, 2004; Tsui P, Leung MC: Com­parison of the effectiveness between manual acupuncture and electro-acupuncture on patients with tennis elbow. Acupunct Electrother Res 27:107, 2002; van de Sande MA et al: Indications, complications, and results of shoulder arthroplasty. Scand J Rheumatol 35:426, 2006; Weiss AP, Hastings H 2nd: Distal unicondylar fractures of the proximal phalanx. J Hand Surg Am 18:594, 1993.