Physio Charlie

I have a new website!!

 

http://physiocharlie.vpweb.co.uk

 

 

 

 

I had a patient today who I believe has got an undisplaced # of one of his scaphoid bones.

Scaphoid fractures and nonunions: diagnosis and treatment

http://www.springerlink.com/content/b9q118k2735wkp38/full...

I had a patient today who had sustained a fracture discloation of her 3rd PIP jt.  She has damaged the collateral ligaments of the joint and also has 20 degrees fixed flexion. 

http://en.wikipedia.org/wiki/Interphalangeal_articulation...

I needed recapping on my # timescales:

"Two to three weeks are given for the reparation of the majority of upper bodily fractures; anywhere above four weeks given for lower bodily injury.

http://en.wikipedia.org/wiki/Fracture_healing

http://www.bonefixator.com/bone_fracture/fractures_and_he...

I was wondering what the evidence was for Ultrasound and fracture detection as per the previous post on the foot.  So I did some research and found that there was a mixed opinion:

Ultrasound in the Diagnosis of Scaphoid Fractures, SHENOUDA and ENGLAND, Journal of Hand Surgery (British and European Volume) 1987; 12; 1  http://jhs.sagepub.com/cgi/reprint/12/1/1-c

"In a period of ten months, seventy-four patients presented at the Accident and Emergency Department. In sixty-nine patients (93%) the ultrasound test could be correlated with the X-ray appearances in the presence or absence of a fractured scaphoid. In twelve of these patients (27.9%) the fracture was diagnosed using the ultrasound before radiographic evidence was apparent".

"A continuous wave of ultrasound with an intensity of 3 watts/cm’ and a frequency of 3mHz was used in water at a distance of 2.5cms for 50 seconds.  Ultrasound had an accuracy of 93%, by 6-8 weeks the ultrasound test has become negative"
 

Ultrasonic assessment of fractures and its use in the diagnosis of the suspected scaphoid fracture, Bedford et al, (1982) Injury, 14: 180 -18

"Ultrasound in the therapeutic range was found to produce pain or severe tingling when applied to 80 of 87 fractures of all types less than 2 weeks old".

Ultrasound assessment of the suspected scaphoid fracture. DaCruz et al Arch Emerg Med. 1988 Jun;5(2):97-100.  http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=128...

"A prospective study of 111 patients thought to have sustained a recent scaphoid fracture on clinical grounds but who were radiologically negative was undertaken over a period of 7 months. All such patients were subjected to ultrasound scanning within a week of their injury under double blind conditions. All patients were re-X-rayed 2-3 weeks after their injury. The authors' results suggest that ultrasonic diagnosis of the possibly fractured scaphoid is unreliable". 

"Ultransonic diagnosis was carried out by a single senior physiotherapist using a Therasonic machine. In keeping with the experience of Bedford et al. (1982), ultrasonic energy at 0-5-1-5 W/cm2 and a frequency of 1 MHz was applied to the skin overlying the anatomical snuffbox. A water-based coupling medium was employed and the probe used had a diameter of 0-75 cm. Patients were asked to compare the sensation produced with that obtained on the same area of the opposite, un-injured limb. The test was deemed positive when pain or severe tingling was experienced on the injured side alone".

Ultrasound for Diagnosis of Scaphoid Fractures, Munk et al (2000) Journal of Hand Surgery (British and European Volume) 2000; 25; 369


"We decided to evaluate the diagnostic value of a true imaging ultrasonic technique (not the ultrasound we use) and the Doppler technique in the assessment of wrists with clinically suspected scaphoid fractures.... The accuracy of the ultrasound assessment was 84% and its specificity was 91%. However, its sensitivity was only 50%. We conclude that ultrasound examination is unreliable for the diagnosis of acute scaphoid fractures."

Diagnostic value of ultrasound in scaphoid fractures, CHRISTIANSEN et al, Injury. 1991 Sep;22(5):397-9

"We found that the ultrasound test, applied with a frequency of 1 MHz and intensity of 0.5 W/cm2 and 2.0 W/cm2 for 30s, had a sensitivity of 37 per cent and a specificity of 61 per cent. We thus conclude that ultrasound is not suitable for early diagnosis of scaphoid fracture".

 Conclusion.

Good results are reported by: Bedford et al., 1982; Shenouda and England, 1987 and Moss et al 1983. However, Christiansen et al. (1991) and DaCruz et al. (1988) could not reproduce these good results.  The quality of the studies supporting the use of ultrasound as a diagnostic tool is poor with no double blinding, control or random allocation of subjects.

Added by: carledwards Posted: 22 February 2007 09:48 Hi, Here in Torbay we are continuing to review our hand service. At present we are looking into patient information sheets for common hand conditions, I would be grateful for any advice regarding this, especially if anyone has recently developed there own leaflets. Having looked through a variety of websites (ASH,e-hand etc) there are quite a few available however I would like to see what is being provided elsewhere. Many Thanks for any assistance, Carl           Replies: Use the filter below to re-order the replies. Filter by:           Title:  patient information sheets Added by:  craigy2s Posted:  23 February 2007 09:38 we use a variety of patient information sheets most of which are created in-house following the consultants protocol. We also use some of the ARC (arthritis research campaign) booklets for some of the common hand conditions and general OA, RhA. They're available free on-line at http://www.arc.org.uk/. Hope this is helpful T Title:	Hand information
Added by:	charliecotterill
Posted:	09 March 2007 10:16

I found this website recently which may be of use:

http://www.e-hand.com/hw/

My friend recently severed two of the extensor tendons of her right hand about 3 months ago.  She had surgery to repair the tendons and she has been having physio weekly since then.  She has been wearing a splint daily and now has been told to only use it when going out in case she bangs her hand.

She has recently c/o increased hair growth and sweating on her affected hand and a sharp shooting pain in her palm that travels proximally to her elbow.  The site of the injury was on the dorsum of her hand so this was a bit strange.  She says she has difficulty moving her wrist and fingers now as they "do not know how to move".  She has slight purply discolouration of her skin on the affected arm and her skin is very sensitive, so much so that she feels "sick" when it is touched.

This all rang alarm bells with me.  I had had a patient a few year ago with similar symptoms and she had RSD or Complex regional pain syndrome as it is sometimes called.  I told my friend that it was related to increased sympathetic nervous system activity and said TENs/contrast baths and normal movement would help it.  I am not treating her as she is having physio elsewhere but I decided to research RSD in a little more detail. 

What is RSD?  See this leaflet for an in-depth explanation:  rsdukleaflet.pdf, RSDguidelines.pdf

The RSD UK website is very good for information and support for patients:  http://www.rsd-crps.co.uk/

Yesterday I had a young woman come to see me with pain near her left radial styloid, exacerbated by typing and repetative gripping.  She attended A+E concerned about increased swelling around the area, they diagnosed her with RSI and sent her away with a wrist splint. 

O/E:  No swelling present.  Pain on resisted thumb Ext and Ab but FROM, pain @ EOR Flx/Ab.  Finklesteins test +ive on the left and pain on palpation of abductor pollicis longus (AP) and extensor pollicis brevis (EPB) tendons just distal to the radial styloid.

Rx:  Advice re: injury/ice/thumb spica (not wrist splint)/rest from aggravating activities/NSAIDs/st injection from GP

What is DeQuervain's Tenosynovitis?   The A+E department were correct in stating that it is an RSI, but specifically it is irritation of the tendons of the AP and EPB in their tendon sheath (they share the same sheath).  Excessive friction caused by repetative forceful use of the hands during gripping and wringing results in fibrous thickening of the sheath and stenosis of the osseofibrous tunnel.

Symptoms?   Pain over the thumb side of the wrist is the main symptom, it is also felt in the wrist and can travel up the forearm. The pain may appear either gradually or suddenly.  Swelling over the thumb side of the wrist is sometimes present and there may be a cyst in this region.  Irritation of the radial nerve lying on top of the tendon sheath may cause numbness of the thumb and back of the hand.

Patient information:  http://www.eatonhand.com/hw/hw008.htm

A good website for hands:  http://www.e-hand.com/hw/