Orthopaedic Surgery

Introduction: Hand injuries account for a significant proportion of emergency department attendance. We investigated the diagnostic accuracy of clinical examination in patients with simple hand lacerations undergoing surgical exploration at our unit. Methods: One hundred and sixty-five consecutive patients were identified as undergoing exploration of the hand. Case notes of these patients were reviewed. The clinical findings, made by emergency department doctors (ED) and hand surgeons (HS), were compared with the operative findings. Results: A total of 101 patients were included following exclusion criteria. Both ED and HS correctly identified 68.2% of flexor tendon injuries. Overall, the ED diagnosed accurately significantly fewer extensor tendon injuries (ED 65.6% vs HS 75.0%, p < 0.001). Similarly, HS diagnosed nerve injuries more accurately than ED (ED 54.5% vs HS 78.8%, p < 0.005). Discussion: Clinical examination forms an important part of the patient assessment, provides the surgeon with an idea of which structures are potentially injured, and its value should never be underestimated. Formal exploration, however, should be undertaken since both ED and HS missed about 30% injuries.

Background: Segmental or multi-fragmentary phalangeal fractures causing bone loss are rare but difficult injuries to treat. Aims: This report evaluates a tricortical graft from the proximal ulna for both suitability of use and donor site morbidity. Methods: The proximal part of the subcutaneous border of ulna was exposed in two cadavers and a 1 cm graft chamfered at either ends was harvested. Thus, a crater measuring 2 cm was created in the proximal ulna. The proximal phalanx of one finger (different for each cadaver) was exposed by a dorsal tendon splitting approach. A segment of the midshaft of the proximal phalanx measuring 1 cm was removed and the graft taken from proximal ulna was interposed and checked for size and fit. The ulna was then disarticulated at the elbow and osteotomised proximal to the wrist. Opposite intact ulna was also harvested in the same manner. The ulna were mounted on a materials testing machine (Instron) and subjected to four-point loading to failure. Results: The shape of the tricortical graft was suitable to bridge the segmental defects in all the phalanges except the thumb phalanx, where it left a step in the dorsoventral plane. In all other phalanges the cortex allowed the flexor and extensor tendons to glide smoothly. The mean load to failure of the intact ulna was 1138.35 N (range 1025.7-1251, SD ¼ 112:65) and the donor ulna failed at an average of 519 N (range 408.25-629.75, SD ¼ 110:75). Thus the donor ulna had 46% strength compared to the intact ulnar. Discussion: Ulnar tricortical graft provides a good anatomical match for segmental defects of proximal phalanges of fingers. The donor bone retains almost half the original strength. This contrasts with studies on the radius for mandibular reconstruction where 82% of the strength was lost resulting in frequent fracture. However, care may need to be taken to protect the donor site. Conclusion: The ulnar is a useful and accessible donor for tricortical graft for use in proximal phalanx reconstruction.

The management of intra-articular fractures of the hand represents a challenge. Large articular fragments require reduction and operative fixation. A number of surgical techniques have been described in literature, with variable results. Distal interphalangeal joint fractures have been fixed by various methods including screw, plate and suture techniques. Generally operative fixation is indicated when more than 30% of the articular surface is involved with or without subluxation of the joint. The aim of surgery is to reduce the fracture fragments anatomically whilst providing osseous stability, and to commence early active movement of the joint to prevent stiffness. In this review we aim to summarise the main management options for intra-articular distal interphalangeal fractures, placing particular emphasis on surgical treatment.

The management of intra-articular fractures of the hand represents a challenge. Large articular fragments require reduction and operative fixation. A number of surgical techniques have been described in literature, with variable results. Distal interphalangeal joint fractures have been fixed by various methods including screw, plate and suture techniques. Generally operative fixation is indicated when more than 30% of the articular surface is involved with or without subluxation of the joint. The aim of surgery is to reduce the fracture fragments anatomically whilst providing osseous stability, and to commence early active movement of the joint to prevent stiffness. In this review we aim to summarise the main management options for intra-articular distal interphalangeal fractures, placing particular emphasis on surgical treatment.

spr in trauma and orthopaedics West Midlands, S Edwards, MSc, MIMI, Mr V Rajaratnam, Consultant Hand Surgeon, FRCS(Ed), Dip Hand Surgery (Eur) Procedure based assessments (PBA) are part of the orthopaedic assessment and curriculum project (OCAP) 1 where trainees work through procedures with their trainers using the structured templates provided. Previous research has shown that the operative competence of a trainee can be reliably assessed using structured checklists 2 ; however evaluation of surgical competency should include assessment apart of knowledge and judgment, technical skill which has been difficult to document adequately and transparently. There is now evidence demonstrating that surgeons can discriminate between the video recordings of a competent and non-competent trainee. 3 and video recordings have become requirements for the assessment and recording of consulting skills module of the MRCGP examination and surgical skill modules for the post FRCS hand diploma examina...

Tong Pei-Yein, Soumen Das De, Dominic Power, Vaikunthan Rajaratnam: Using Instructional Design Principles In Developing Skill Acquisition Workshops In Hand Surgery- Our Experience. Poster presentation at the Edinburgh Royal College of Surgeons Trainers’ Conference, Birmingham 21st October 2013

In November 2003, a day case emergency hand surgery system was introduced to deal with hand trauma at University Hospital, Birmingham. The patients are assessed in the Accident Department by a Senior House Officer or Specialist Registrar on the day of referral, and strict criteria are used to assess eligibility for day case treatment. A Hand Coordinator liases with patients, surgeons and the ambulatory theatre department to organise treatment on consultant led dedicated daytime hand lists. Twelve lists per week serve the current referral load. An escalation policy exists in order to deal with excessive waiting times or large numbers of patients awaiting surgery. This is triggered when more than 8 patients are awaiting surgery or patients wait more than 3 days for surgery. Available lists and staff are sought and, when necessary, an additional theatre list will be organised on a weekend or an evening. The aim of this study was to assess the effect this reorganisation in terms of numb...

Our study aims to develop and evaluate the practicality, clinical merit, and usefulness of a hand clerking sheet for use in a clinical orthopedic surgical unit. We hypothesize that the cause and extent of damage to anatomical structures will be more accurately documented in concordance with intraoperative findings when evaluated with the clerking sheet. All patients admitted to a tertiary care institute for hand-related injuries requiring acute surgical intervention within a 1-year period were evaluated. Assessments made preoperatively without the clerking sheet were evaluated retrospectively. Data concerning cause and extent of damage to anatomical structures were recorded using the hand clerking sheet for all newly admitted cases. The number of injuries documented prior to surgery and intraoperatively was compared. Patients who were assessed without the use of a clerking sheet had their injuries diagnosed with 61% accuracy (96/157), while patients who were assessed with the use of...

The Declaration of Helsinki, statement of institutional review board approval, and clinical trial registration information are not applicable in this biomechanical laboratory study, as the authors only used cadaveric sheep models for the experiment.

Hand tumours are frequently encountered in clinical practice. A list of differential diagnoses of the most common hand tumours based on anatomical location would be helpful for clinicians. We aimed to determine the anatomical distribution of hand tumours seen at a hand surgery practice in Singapore. The medical records of 50 men and 65 women (mean age 41.7 [range 17-74] years) who underwent excision of hand tumours between 1 June 2010 and 31 December 2012 were reviewed. The histological diagnoses and anatomical locations of the tumours were analysed. The locations were divided into three main groups: (a) distal to the metacarpophalangeal joints (MCPJs); (b) between MCPJs and carpometacarpal joints (CMCJs); and (c) between CMCJs and the radiocarpal joint (RCJ). Overall, the most common tumours excised from the hand were ganglions (n = 66/116, 56.9%) and giant cell tumours of the tendon sheath (GCTTSs; n = 11/116, 9.5%). However, distal to the MCPJs, GCTTSs (n = 11/39, 28.2%) were mor...

IntroductionManaging healthcare service during pandemics and outbreaks is a challenging process. The aim is to keep patient safety as the priority, besides, continuing to provide essential healthcare services.MethodsSituational audit was performed for the services rendered before and during COVID-19 pandemic and the elevation of the disease alert status, and a retrospective analysis of the attendance and procedures performed in the service.ResultsWe present a methodology for performing a situational audit and generating service modification for hand and reconstructive microsurgery unit in a pandemic. There was no significant difference between the number of patients seen at outpatient clinics. However, there was a reduction in the numbers of total surgeries performed, with a 40% drop in the number of elective surgeries performed. There was also a reduction of cases seen in the emergency department hand clinic.DiscussionCOVID-19 pandemic is currently affecting not only the health ser...

, and whose medical notes were available were included in the audit. Results: Sixty-eight patients were available for analysis. They included 44 (65%) male and 24 (35%) female with mean age of 36 (2-101). There were varying grades of injury: 24% Gustillo and Anderson Grade I, 39% Grade II, 16% Grade IIIa, 18% IIIb and 3% IIIc. Only 3% of cases had documented evidence of appropriate wound care in A&E. Ninety-three percent of patients received IV antibiotics given at a mean time from injury of 2 h 37 min. Of the 44% of cases referred to plastics, only 13% (4/30) of referrals were made before the initial procedure. The mean time from injury to initial operative procedure was 9 h 34 min (median 5 h 22 min). Only 23% of cases were carried out with a consultant present. Ten of 62 cases (six lost to follow-up) were complicated by infection, 2 (3%) of which were deep. Two cases of compartment syndrome occurred requiring fasciotomy. All fractures united with a mean time to union of 39 weeks. The most striking problem was the poor quality of note keeping and hence difficulty in obtaining accurate data. Conclusions: The results show that in a number of crucial areas the guidelines are not adhered to. However, the complication rate in terms of nonunion and deep infection is respectable compared to current literature. One cannot read too much into this due to the problems with data collection. The department should examine its current protocol and perform a prospective audit thereby obtaining an accurate picture of its results. In the meantime emergent debridement of soft tissues, fracture stabilisation and early administration of intravenous antibiotics should be supported.