By: Brett Levine, MD, MS

Total knee arthroplasty (TKA) is one of the most successful operations performed by orthopaedists with an incidence that is rising with each passing year.  In 1998, it was estimated that 259,000 TKAs were performed and that number increased to 441,000 in 2004.⁷ This represents an average yearly increase of 9.4%.  Despite well-documented long-term results with TKA, there has been a current trend in the United States towards an increasing demand for partial (uni- and bi- compartmental) knee replacements.  Riddle et al estimated an increase in unicompartmental knee arthroplasties (UKAs) from 6,570 to 44,990 during the eight year period between 1998 and 2005 an average yearly increase of 32.5%.⁷ Improved surgical techniques and implant designs are thought to be responsible for this surge in the popularity of UKA.

Unicompartmental Knee Arthroplasty (UKA)

UKA is a surgery that has fallen in and out of favor over the past 30 years of joint replacement history.  Refinements in patient selection, improved long-term outcome data, surgical technique and implant designs have fueled the renewed interest in this procedure (Figure 1).  In properly selected patients UKA is an attractive alternative to osteotomy or TKA for isolated medial or lateral arthritic changes.  Favorable initial and long-term results have been found with UKA compared to high tibial osteotomy.² Similarly Berger et al found 98% 10-year survivorship with revision or loosening as endpoints in 62 modular, cemented UKAs.¹ Stringent selection criteria is important for the long-term success of a UKA and in the ideal patient would include: noninflammatory osteoarthritis with a mechanical axis deviation of less 5 degrees of valgus or 10 degrees of varus from neutral; intact cructiate ligaments; a range of motion greater than 90 degrees; a flexion contracture no greater than 10 degrees; and body weight less than 90kg.

A typical UKA involves resurfacing of the medial or lateral compartments with preservation of the patellofemoral compartments (Figure 2).  Small-incision and minimally invasive options are available for UKA patients with several centers performing the surgery as an outpatient.  The recovery rate for UKA has been reported to be three times faster than that of TKA.³ Blending rapid rehabilitation and peri-operative pain management protocols has led to excellent early functional outcomes for UKA patients.  However, it is important to recognize that patellofemoral and lateral compartment disease progression is not uncommon during the second-decade after implantation.  Conversion from UKA to TKA can be performed with relative ease and good success when disease progression does occur.

Patellofemoral Joint Arthroplasty (PFJ)

Patellofemoral arthroplasty is another form of partial knee replacement in which the patella and the underlying trochlea groove are resurfaced (Figure 3).  In patients with osteoarthritis of the knee, up to 10% of men and 24% of women will have isolated patellofemoral compartment involvement.⁶ In such appropriately indicated patients, long-term success has been reported at 15 years follow-up.⁴ If patella maltracking is addressed prior to PFJ, then progression of tibiofemoral arthritis is most often the limiting factor and can lead to failure in approximately 25% of cases.⁵

The overall conservative nature of a PFJ (preservation of the anterior and posterior cruciate ligaments, medial and lateral menisci and tibiofemoral articulation) affords a rapid recovery in a properly indicated patient population.  Modern implant designs and sound surgical technique allow this procedure to be an excellent intermediate stage for those young patients with isolated patellofemoral arthritic changes prior to TKA.⁵ Contraindications for PFJ include inflammatory arthritis, patella maltracking, chondrocalcinosis, and tibiofemoral disorders

Bi-compartmental Knee Arthroplasty

Until recently UKA, PFJ and TKA were the only monolithic option for treating degenerative joint disease of the knee.  A new bi-compartmental knee arthroplasty has been introduced to treat the relatively common findings of medial and patellofemoral compartment arthritic changes.  The Journey Deuce (Smith and Nephew, Memphis, TN) allows for resurfacing of the medial and patellofemoral compartments, leaving the lateral compartment and anterior cruciate ligament intact (Figure 4).  By limiting the amount of bone and ligament resection, it is believed this new device will afford a more rapid, complete return to function.  Previously two separate implants (a patellofemoral replacement and a UKA) were required to treat bi-compartmental degenerative joint disease, or more traditionally, a TKA was performed.  Rolston et al reported that 73 out of 100 consecutive patients being seen for arthritic knee pain were noted to have well-preserved lateral compartments in the setting of advanced medial and patellofemoral degenerative changes, thus supporting the need for a bi-compartmental device.⁸

By preserving the anterior and posterior cruciate ligaments, normal kinematics and proprioception about the knee is maintained, allowing a return to function akin to that of UKA.  Similarly, preservation of bone stock and landmarks should allow for a relatively simple revision to a TKA when necessary.  It is believed that just as there has been a rise in UKA utilization recently, a similar trend will occur as surgeons gain more experience with bi-compartmental knee arthroplasty.  In a recent report, Rolston et al reported excellent early (33 month follow-up) results using the Journey Deuce bi-compartmental arthroplasty in 95 patients.⁸ The authors found less blood loss than TKA, an average range of motion of 117 degrees, and a high level of early function and patient satisfaction.  Contraindications for this procedure include lateral compartment arthritic changes, rheumatoid (inflammatory) arthritis, severe deformities, ACL deficient knees, and fixed flexion contractures.

Conclusion

Partial knee replacements are an excellent means for managing isolated degenerative joint disease of the knee.  In appropriately indicated patients, a relatively fast and more complete recovery can anticipated than with TKA.  International registries have shown UKAs represent 10-15% of knee arthroplasties each year.  In the United States, this number has risen from 2.5% to 7.7% over eight years, 1998-2005.  In the era of less invasive surgery and rapid rehabilitation protocols, it is likely we will continue to see a rise in the number of uni- and bi- compartmental replacements being performed annually.

1.                  Berger RA, Meneghini RM, Jacobs JJ, Sheinkop MB, Della Valle CJ, Rosenberg AG, Galante JO. Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up. J Bone Joint Surg Am. 2005;87(5):999-1006.

2.                  Broughton NS, Newman JH, Baily RA. Unicompartmental replacement and high tibial osteotomy for osteoarthritis of the knee. A comparative study after 5-10 years’ follow-up. J Bone Joint Surg Br. 1986;68(3):447-452.

3.                  Deshmukh RV, Scott RD. Unicompartmental Knee Arthroplasty: Long-term Results. Rosemont, IL: AAOS; 2006.

4.                  Kooijman HJ, Driessen AP, van Horn JR. Long-term results of patellofemoral arthroplasty. A report of 56 arthroplasties with 17 years of follow-up. J Bone Joint Surg Br. 2003;85(6):836-840.

5.                  Lonner JH. Patellofemoral arthroplasty. J Am Acad Orthop Surg. 2007;15(8):495-506.

6.                  McAlindon TE, Snow S, Cooper C, Dieppe PA. Radiographic patterns of osteoarthritis of the knee joint in the community: the importance of the patellofemoral joint. Ann Rheum Dis. 1992;51(7):844-849.

7.                  Riddle DL, Jiranek WA, McGlynn FJ. Yearly incidence of unicompartmental knee arthroplasty in the United States. J Arthroplasty. 2008;23(3):408-412.

8.                  Rolston L, Bresch J, Engh G, Franz A, Kreuzer S, Nadaud M, Puri L, Wood D. Bicompartmental knee arthroplasty: a bone-sparing, ligament-sparing, and minimally invasive alternative for active patients. Orthopedics. 2007;30(8 Suppl):70-73.

Figures:

Figure 1.  High-flex uni-compartmental knee replacement.  Courtesy of Zimmer (Warsaw, IN) – Not Shown

Figure 2.  (A) Pre-operative AP radiograph with medial compartment arthritic changes.  (B) Post-operative radiograph after a medial unicompartmental arthroplasty.

Figure 3.  Patellofemoral arthroplasty component.   Courtesy of Zimmer (Warsaw, IN) – Not Shown

Figure 4.  (A) Picture of the Deuce™, bi-compartmental knee arthroplasty.  (B) AP radiograph showing an implanted bi-compartmental knee arthroplasty.  Courtesy of Smith and Nephew (Memphis, TN)

(Article courtesy of Midwest Orthopaedics at Rush)

By: Kern Singh, MD

Introduction

Spinal fusion is a versatile and effective option in the management of instabilities, deformities, and painful spinal conditions. An increasing body of biomechanical and clinical evidence suggests that the relative immobility of fused spinal segments alters stress transfer leading to adjacent level degeneration. The development of non-fusion spinal prostheses has been driven by increasing concerns of these arthrodesis-related morbidities including graft-site harvest, pseudarthrosis and adjacent level degeneration (ALD). Motion-sparing implants offer some theoretical advantages over fusion; however, judicious use of these products with careful patient selection is warranted until outcome studies can demonstrate their efficacy.

Total Disc Replacement

Intervertebral disc replacements may be indicated for patients with degenerative disc disease at one or two levels of the spine. In order to avoid complications that may arise from artificial disc replacement surgery, careful patient selection by the treating surgeon is paramount.

Cervical Disc Replacement

Although fusion at single or multiple levels of the cervical spine allows for decompression of neural structures and restoration of disc height, it has been shown to alter the normal biomechanics of the cervical spine potentially leading to adjacent-segment degeneration. Cervical total disc replacement has emerged as a promising alternative for the management of disc herniations.  The primary goals of cervical TDR are to remove the offending disc while restoring disc height and segmental motion.

Current metal-on-metal designs include the Prestige Disc (Medtronic Sofamor Danek, Memphis, TN). The Prestige uses a stainless steel metal-on-metal configuration.  Although metal-on-metal designs are associated with the potential for debris and increased systemic concentrations of metal ions, the purpose of this design is to avoid the increased particulate debris found in metal-polymer designs.

Lumbar Disc Replacements

The ideal lumbar TDR would function as a physiologic replacement for the human intervertebral disc. It would assume the role of the nucleus pulposus and anulus fibrosis complex. In preserving the lumbar spine’s range of motion, the lumbar TDR would also need to transmit and absorb loads across the disc space between the vertebral bodies.

Indications for lumbar disc arthroplasty include back pain from degenerative disc disease in patients who have failed a protracted course of nonsurgical treatment. Spine-specific contraindications include spondylolysis, spondylolisthesis, posterior element disease, central or lateral recess stenosis, fixed deformity, osteoporosis, or infection.

Posterior Stabilization Devices

Posteriorly implanted, motion-limiting devices that reduce but do not eliminate movement have been widely investigated in Europe for the treatment of mechanical back pain and spinal stenosis. In contrast to the principles of TDR, whereby painful disc tissues are ablated or unloaded directly by the implant, posterior stabilization devices leave the pain-generating disc tissues in situ but restrict certain types of motion and alter load transfer through the functional spinal unit. Posteriorly-based, dynamic devices include pedicle systems with tethers between the intra-pedicular anchors and interspinous process devices.

Pedicle-Based Systems

A dynamic stabilizing device ideally establishes pain-free segmental motion and withstands the physiologic static and dynamic loads of the spine.  These devices work because they restrict movement to a zone or range where normal or near-normal loading may occur.

The DYNESYS (Zimmer, Warsaw, IN) is similar to the Graf system, with the addition of compression-resistant polycarbonate urethane sleeves around the prosthetic ligaments. The motion segment can be stabilized in a more neutral alignment instead of lordosis.  The prosthetic ligaments provide restraint to flexion, whereas the sleeves prevent excessive lordosis, bear compressive loads, and unload the disc when the patient’s musculature exerts a net lordotic moment on the functional spinal unit.  Three potential problems are introduced by the DYNESYS system. First, the compressive sleeves limit the amount of lordosis that can be achieved, and if placed with excessive distraction, the implant becomes kyphogenic.  Second, compressive loads on the sleeves produce bending moments on the pedicle screws that could lead to breakage or loosening. Lastly, the introduction of compression sleeves significantly increases the rigidity of the construct thereby questioning its role in preventing adjacent level degeneration.

Interspinous Process Devices

The first-generation interspinous process implant for non-rigid, lumbar stabilization was developed in 1986. Over the past twenty years, several designs of interspinous process devices have been developed; however, the clinical indications for their use remain poorly defined.  The clinical results with these devices have been reported only in anecdotal case reports with varied indications and incomplete patient follow-up making meaningful interpretation difficult.

Conclusion

The ability of the intact spine to provide mobility and stability over an extended period of time while withstanding repetitive loading is a remarkable feat.  In many patients, however, degenerative diseases of the spine eventually cause significant pain and disability.  Fusion remains one of the must useful and versatile tools in the spine surgeon’s armentarium.  The emergence of nonfusion implants that can relieve pain, restore motion, and endure repetitive loads may provide an attractive option to arthrodesis.  Optimally designing these motion-sparing prostheses requires an understanding of the complex pathophysiology, anatomy and kinematics associated with altered spinal biomechanics and pain syndromes. Judicious use of these implants is warranted until further clinical studies can validate their safety and efficacy.

Figure Legend

Figure 1: A lateral radiograph demonstrating a Charite disc replacement in situ.

Figure 2: A disassembled Charite disc demonstrating the two metal alloy end-plates and the inner UHMWPE core (Picture courtesy of Depuy Spine, Raynam, MA)

Figure 3: Schematic of a Charite disc demonstrating biconcave nature of the metal end-plates. (Picture courtesy of Depuy Spine, Raynam, MA)

Figure 4: A picture of the PDN (Raymedical Inc., Bloomington, MN). The device is composed of a hydrogel pellet that is surrounded by a polyethylene layer. (Picture courtesy of Raymedical Inc., Bloomington, MN)

Figure 5: A. Axial image of a cadaveric specimen with the NuCore injectable nuclear material. B. Lateral image of a cadaveric specimen with the NuCore injectable nuclear material. (Pictures courtesy of Spine Wave, Shelton, CT)

Figure 6: Picture of the DIAM inserted into the proper interspinous location. (Picture Medtronic Sofamor Danek, Memph

Editor’s comment: One of our national clients advised of a recent trend—drug compounding and repackaging to make the simple pharmaceutical process much more expensive. In follow-up to our first article, we note in recent years, compound drugs and drug repackaging have gone hand-in-glove as ways in which WC claims handlers often have no idea what they are paying in handling Illinois workers’ compensation claims. As we have advised on numerous occasions, it is amazing Illinois has a medical fee schedule without a prescription fee schedule. This change won’t happen until Illinois business demands it.

Compounded drugs are hand-made rather than mass-produced, and supposedly tailored to the needs of individual patients. These practices are mainly regulated by the states instead of the federal Food and Drug Administration. The disparities resulting from 50 sets of rules and levels of technical and inspection prowess shouldn’t be allowed to continue. Repackaged drugs are prescription or over-the-counter drugs taken from initial drug producers and repackaged and repriced, usually by physician/clinic dispensers. The cost is from two times higher to twelve times higher. In one study, repackaged drugs accounted for less than a third of all prescriptions but over half of all dollars paid. The concept is especially troubling when one considers the overwhelming majority of the top 20 drugs are generic.

As has been the case for the last several years, the average prescription cost of “compound drugs” is well over the national average. A growing percentage of the providers dispensing compound drugs submit via paper, and many payers have had limited capabilities with adjudicating these bills at the appropriate or allowable rates. While the number of the compound drug paper bills is currently a small percentage of most national payers’ overall prescription volume, the dollars associated with these transactions and the potential savings can be high.

With many states’ workers’ compensation laws, the rules vary regarding how a payer can adjudicate prescription charges. For example, California’s billing regulations require the providers (pharmacies, compound drug companies, physicians, etc.) to submit a detailed list of the individual ingredients in each compound prescription. In addition to significantly overpaying, payers encounter other drug treatment and billing-related shortcomings and challenges when managing compound drugs.

Some of the issues include:

• Double billing–compound drugs are not required to have nor do they use standard national drug code (NDC) numbers, and therefore it is difficult to identify when multiple fills for the same prescription are being provided. In addition, some times the compound pharmacy companies also use different third-party biller names, further complicating a payer’s ability to identify this type of situation.
• Drug interactions–since individual ingredients of the compound drug are not captured as part of the prescription transaction within the claimant/patient profile, there is a high risk for potential drug interactions (adverse effects) or overdoses when other drugs in a patient’s overall drug regimen are being combined with these compound prescriptions. In addition, the lack of NDC-level detail does not allow for drug utilization edits to occur on these transactions. The only way to solve this issue is to record and adjudicate each individual ingredient within the same pharmacy management system, using the same patient profile and applying the same clinical review edits and rules.
• Overbilling–occasionally compound drugs will include the use of higher priced brand name drug ingredients regardless of whether there is a generic alternative available. The lack of NDC detail within a pharmacy management system will not identify these types of issues. There is also a frequency of overbilling compared to the allowable compound production time billing rate.
• Therapeutic duplication with different dosage forms–dispensing the same drug in oral and topical form and avoiding the appropriate drug utilization edits since they aren’t using standard NDC numbers.

On the closely related repackaging issue, it is difficult for WC payers to receive accurate prices for repackaged medications, which, by definition, mean a pharmaceutical product is removed from the original container with an original NDC and put into a new container with new quantities, therefore requiring a new NDC, with a new repackaging company label and price for the medication. By its nature, the process can result in inaccurate and overpriced medications. Some states other than Illinois have been attempting to help payers manage the process better, after they have begun to understand the cost-control issues.

We hope to see such prescription and over-the-counter drug abuses end and urge our administrators to get involved to help Illinois business counterattack abuse.

Post Provided by Gene Keefe of Keefe, Campbell & Associates, LLC. The firm was started by 
Eugene F. Keefe, Michael J. Danielewicz, John P. 
Campbell, Joseph R. Needham and Shawn R. Biery with 
the goal of providing high-quality and cost-effective 
civil litigation services for the defense of 
self-insured employers and insurance carriers.

Editor’s comment: Everyone in the claims industry knows who they are but what can we do about them? Please understand we cannot name names in an article such as this—to do so would result in an immediate and expensive libel action from each and every doctor and clinic we named. When you run an ongoing medical scam, you are generally very sensitive about “defending your good name” and most of these joints and scamming physicians/chiropractors in Illinois are ready, willing and able to sue at a moment’s notice.

Our favorite story about medical provider abuse came from a Petitioner’s attorney who told us of a clinic in the central part of Chicago—they were sending a bus out to pick up a patient in a distant suburb and bringing him to town for care. The clinic was billing over (or overbilling) $5,000 per long-distance visit. How do we stop this sort of shenanigans?

What as a start–what defines Unstoppable Medical Fraud Machines? Well, every doctor and healthcare giver across the state knows who they are. Some day, we look forward to actually having a doctor on the IWCC advisory boards who will take steps to identify and stop the abuse. Every veteran Illinois WC claims manager rolls their eyes to hear the names of any of the Unstoppable Medical Fraud providers. When a newbie WC claims handler who is unfamiliar with our strange ways in this state sees a bill from one of them, bingo—you note:

• Most times chiropractors are involved at the beginning or middle of the process;
• Lots of times, claimant lawyers are “secretly” involved in referrals
• The treatment is never-ending;
• These providers’ medium bills are about five-ten-fifty times higher than reputable providers;
• The clinics and doctors are relatively immune to utilization review and IME’s;
• All of it looks like fraud.

Why are chiropractors involved? From our perspective, the role of chiropractors in this form of medical care is in the larger personal injury setting, prone to overtreatment and overbilling. If you find a chiro that doesn’t do so, save their name and number and send them business. We feel chiropractors have a bona fide role in medical care but, in our view, is should not be an endless one. It is a rare chiropractor we see in the Illinois WC process who believes in a beginning, middle and end to what they provide. And sadly, lots of chiropractors seem prone to medical abuse when they are taking advantage of the strange situation in which they are fronting the cost of care to then try to scam or wedge out payment from a carrier and not the patient.

Why are lawyers involved in too-much-treatment and clear instances of medical fraud? Well, Plaintiff lawyers started doing so on the general liability side to increase what are called “special damages.” Then they seem to miss the fact it usually doesn’t help to have overtreatment on the much more structured WC side—claimants don’t get more money for a soft-tissue strain when there are $50K in medical bills; it creates a headache no one wants.

The problem is many of the overtreating doctors look for Plaintiff lawyers to trade clients—you send me folks who will overtreat and I will send you clients. In the wildly competitive world of Plaintiff personal injury work, it is hard to turn down new business for newbie lawyers, regardless of the problems present. The old-timer lawyers know the math and don’t want to represent clients of overtreaters but the process had been going on for years and won’t stop any time soon.

How do we stop Unstoppable Medical Fraud Machines from the perspective of defense WC claims handlers? Well, officially you can use utilization review and independent medical exams and our clunky medical fee schedule to counterattack. All of those techniques have strengths and weaknesses. We assure all of you the current Illinois WC Commission does generally cut the medical bills of overbillers and kudos to them for doing so. The problems our clients note is you have to then fight and litigate to win and stop the abuses.

We were asked by a client whether you can pay-off a claimant to get them away from an overtreater/overbiller? The answer is there is nothing in the Act or Rules that prohibits it and whatever isn’t illegal is therefore legal. This is a new one for us and we would love to hear your thoughts and comments on it.

Our vote is to get administrators and WC advisory boards that have brains, guts, talent and care about business in Illinois—we hope to some day see someone consider implementing a blacklist for overtreaters and overbillers to stop clear and obvious instances of repeated medical abuse. Until we start to get serious about identifying and stopping overbillers and medical fee abuse, it will not stop and it is a major pain at every level of WC claims handling.

Post Provided by Gene Keefe of Keefe, Campbell & Associates, LLC. The firm was started by 
Eugene F. Keefe, Michael J. Danielewicz, John P. 
Campbell, Joseph R. Needham and Shawn R. Biery with 
the goal of providing high-quality and cost-effective 
civil litigation services for the defense of 
self-insured employers and insurance carriers.

Introduction

The wrist has often been described by surgeons as a “black box”, in that for a long period of time in hand surgery the pathology and mechanics were not well understood. In fact, most of these injuries were treated by surgeons who did not have specialized training in wrist conditions.  It is only recently that it has come to be appreciated that the wrist should be considered in concert and as part of the hand and requires a hand surgeon who has extensively studied and trained in this part of the upper extremity.

Before addressing specific wrist injuries and pathology it is important to have at least a basic understanding about the function of the wrist, its anatomy, mechanisms of injury, as well as, initial evaluation and treatment.  These building blocks serve as the basis for more in-depth study.

This month’s Hand Surgery Update will serve as an introduction to a series of articles which will be presented over the following months on specific wrist injuries and conditions.  Please be patient are there are numerous areas to discuss as books have been written which focused exclusively on wrist conditions, some of which have extended to two volumes.

As always we welcome your feedback and suggestions for future topics in hand and wrist surgery.  Please share this article with friends and colleagues as we are certain that this is and will be a topic that garners great interest.

Background

The wrist is the critical link between the arm and fingers that permits fine adjustments to the position of the hand in space.  This ability to precisely position the hand allows us to accomplish a variety of manual tasks with skill and ease.  Injuries to the wrist disrupt the link and lead to decreased hand function.  Proper evaluation and management of wrist injuries is essential in order to optimize recovery and minimize loss of hand function.

Anatomy

The wrist is a complex structure formed by eight carpal bones, the radius, the ulna, and an intricate network of ligaments.  The carpal bones are divided into two rows.  The proximal carpal row includes the scaphoid, lunate, triquetrum, and pisiform.  The distal carpal row includes the trapezium, trapezoid, capitate, and hamate.

The network of ligaments in the wrist includes both intrinsic and extrinsic ligaments.  Intrinsic ligaments connect the carpal bones to each other.  Extrinsic ligaments connect the carpal bones to the radius, ulna, or metacarpal bones.  One of the most important intrinsic ligaments is the scapholunate ligament that connects the scaphoid to the lunate bone.  Another important ligament is the triangular fibrocartilage complex or TFCC.  Both the scapholunate ligament and the TFCC are critical to proper wrist function.

Function

The first critical function of the wrist is motion.
Wrist movements include:

• Flexion
• Extension
• Radial deviation
• Ulnar deviation
• Pronation (turning the hand palm down)
• Supination (turning the hand palm up)

The second critical function of the wrist is load bearing.  Forces are transmitted across the wrist joint during a variety of tasks.  For example, formation of a tight fist during gripping activities transmits high forces across the wrist joint.

Mechanism of Injury

Perhaps the most common mechanism for wrist injury is a fall onto an outstretched hand or FOOSH.  However other mechanisms include loaded twisting, hyperextension, and direct blows to the wrist.

Evaluation

Physical examination and radiographic evaluation are two essential components of the work-up of a patient with an acute wrist injury.

Physical exam begins with inspection for swelling, bruising, or deformity.  Next, the wrist and hand are palpated to elicit tenderness.  Tenderness to palpation or pain with provocative maneuvers can localize the injury to a specific anatomic structure.

Radiographic examination at the time of injury is indicated for patients with any deformity, significant soft tissue swelling, or pain that localizes to a specific anatomic area.  A three view wrist x-ray series of the wrist includes the PA, lateral, and oblique views.  Plain x-rays properly obtained will detect most fractures and dislocations, but do not provide information about soft tissue injuries.  If plain radiographs are negative and the patient has significant localized pain, MRI may be appropriate in the acute or chronic setting.

Treatment

The treatment of wrist injuries is tailored to the severity and type of injury.

Wrist sprains are among the most common wrist injuries.  A wrist sprain is a stretching or tearing of the ligaments of the wrist.  Initial management consists of rest, ice, compression, elevation, and immobilization.  Many wrist sprains will resolve within 1-3 weeks without any further intervention.  However, a wrist sprain can result in severe damage that requires prolonged splinting, a trial of corticosteroid injection or eventual  surgical intervention.  If a patient with a wrist sprain has persistent symptoms 4 weeks after injury or pain that localizes to a specific area, referral to a wrist specialist is indicated.

Fractures of the carpal bones, distal ulna, and distal radius are treated with immobilization or operative fixation as indicated.  Immobilization typically will be for a period of six to eight weeks.  Hand therapy is an essential component of treating wrist injuries.  The purpose is the acute setting is to reduce edema and maintain digital (finger) motion and is typically initiated within the first several weeks.  Wrist motion is initiated after fracture healing is achieved.

Treatment protocols must be individualized and outcomes vary according the severity and location of the fracture.  In our opinion treatment by a hand surgeon who has specialized in wrist surgery results in a more satisfactory outcome.

Conclusion

As we said, this article serves as only an introduction to the topic of wrist injuries.  We hope you find the coming updates educational and informative.

Information provided by: Hand & Plastic Surgery Associates, Ltd. – The physicians of HPSA treat the most challenging and complicated hand and wrist problems as well as minor conditions and injuries. They believe that seeing a physician who specializes in surgery of the hand yields the best results. When caring for injured workers, HPSA takes a proactive role to insure that these individuals are returned to work as soon as medically possible. They assist employers and case managers in determining appropriate job placement. Their physicians are also available for independent medical evaluations and second opinions. Visit their website at www.handplastic.com to learn more about HPSA.

Frostbite

During the winter season with extremely cold temperatures, frostbite becomes a real danger. While initially a problem for soldiers in the military, frostbite now occurs in civilians with prolonged exposure to the elements. Frostbite can occur during work as well as during recreation.  Males, ages 30-49, are most commonly affected.

Frostbite occurs when tissue freezes. There can be direct cell injury with intracellular or extracellular crystal formation. More commonly a vascular insult or ischemia occurs. During very cold temperatures, blood vessels to the extremities constrict, sending more blood to the heart and brain.  This leads to frostbite injury occurring most commonly in the tip of the nose, ears, finger and toes.

The severity of the frostbite is directly related to the duration of exposure to below freezing temperatures and wind chill. Frostbite can occur in as few as 10 minutes, if skin is exposed to temperatures less than 20 degrees Celsius, in the face of 40 mile per hour winds.

Risk factors for frostbite include:

• Intoxication
• Dehydration
• Wind exposure
• Underlying vascular disease
• Smoking
• Fatigue

Classification of frostbite:

1st Degree: Superficial skin injury with erythema, edema, and hyperemia
2nd Degree: Full thickness skin injury with erythema and blistering
3rd Degree: Full thickness skin and subcutaneous injury with edema and bluish discoloration
4th Degree: Full skin necrosis, with necrosis to even deeper structures

Symptoms of frostbite are related to the depth of injury.

Superficial frostbite causes numbness, tingling and a cold sensation. The patient may complain of a whitish, pale digit.
Deeper damage can lead to decreased sensation followed by a loss of sensation. Swelling, blood filled blisters and eventually a purplish blue waxy appearance can occur if damage is severe enough.

Treatment

• Get inside to a warm room and remove all wet clothes immediately.
• Immerse the hand or foot in warm water for 30-45 minutes in water at 40-42 degrees Celsius. If the water is too warm the treatment can be painful.
• Avoid dry heat, as this can burn skin. For example avoid use of a heating pad, sun lamp or radiators.
• After rewarming, elevate the extremity and dress the wound with antibiotic ointment such as Silvadene.
• No systemic antibiotics are indicated in most cases.
• Blisters are not debrided unless they have ruptured.
• Begin range of motion exercises if motion is noted to be limited. Hand therapy can also be helpful to decrease edema and sensitivity.
• No surgery should be performed for at least 2 months to allow tissue to demarcate. Occasionally, excision of necrotic tissue with either direct closure or flap closure is required. Infrequently, release of joint or intrinsic muscle contractures is needed

Long term consequences of frostbite injury include persistent burning or tingling pain, sweating, ulceration and cold sensitivity.

Prevention

• Avoid prolonged exposure to extremely cold and windy days
• Wear warm clothing. The outside layer should block the wind as wind chill can lower the skin temperature.
• Deeper layers should provide wicking to keep skin dry.
• Wear a hat to prevent heat loss.

If there is any doubt about the care and treatment of frostbite digits, do not hesitate to refer to the appropriate specialist. Hand surgeons and plastic surgeons see these injuries frequently in the winter. They can best provide local wound care, surgery if needed and guide hand therapy when appropriate.

Information provided by: Hand & Plastic Surgery Associates, Ltd. – The physicians of HPSA treat the most challenging and complicated hand and wrist problems as well as minor conditions and injuries. They believe that seeing a physician who specializes in surgery of the hand yields the best results. When caring for injured workers, HPSA takes a proactive role to insure that these individuals are returned to work as soon as medically possible. They assist employers and case managers in determining appropriate job placement. Their physicians are also available for independent medical evaluations and second opinions. Visit their website at www.handplastic.com to learn more about HPSA.

Snow blowers have certainly made our lives easier during the winter months.  However, they are a potentially dangerous piece of machinery.

According to the US Consumer Safety Commission, as many as 5,300 hospital and emergency room visits each year are secondary to snow blower injuries.  Since 1992 at least 19 deaths have occurred. Two deaths were secondary to people being caught in the machine and 5 were secondary to carbon monoxide poisoning when the snow blower was left running in an enclosed space.

According to the American Society for Surgery of the Hand, injuries most commonly occur in men in their mid 40′s.  Two-thirds of injuries involve the fingers. The dominant hand is involved in 90 % of accidents, with the long finger most frequently amputated. Of the 5,300 injuries sustained over the study period, 1000 involved some degree of digital amputation.

Accidents tend to occur in first time users of snow blowers or during the first use of a given winter. Weather conditions play a part as well. Heavy, wet snow can clog machines. More accidents occur with snow falls greater than 6 inches.

Unfortunately nearly all lawnmower accidents are the result of human (operator) error.  The two most common reasons people give us when performing a detailed history of the injury is either “I was in a hurry” or “I forgot.”  Occasionally we see individuals who failed to read the operator manual and take appropriate action to prevent an injury, especially when performing repairs or maintenance on the device.  It is clear that recognizing potential hazards before they occur is paramount to preventing injury.  A fraction of a second and loss of concentration is all that is required.

From our experience most snow blower injuries are caused from heavy wet snow clogging the discharge chute of the snow blower.  The operators’ attempt to clear the chute with their hands leads to severe injury. The individual may believe the machine is off though the blades may still be moving. The blades may also forcefully swing around after the snow is cleared.  Injuries can also occur when using an appropriate technique to clear the snow with a broom handle or small shovel if the snow blower is not completely turned off prior to unclogging.  The handle is swung around causing a severe crush injury and multiple hand fractures. Finally, burns can also occur from touching a extremely hot motor and projectiles can also cause serious eye injuries.

In our practice we’ve seen a higher percentage of partial amputations requiring a revision amputation of the digit or the need for multiple staged reconstructive procedures as we described in the article “Management of Traumatic Digital Fingertip Amputations” (Volume 1, Issue 1).

Patterns of injury which are typically seen occur from direct contact with jammed or rotating blades. Avulsion injuries are those in which soft tissue is torn and separated including bones. Gross contamination can occur from contact with, leaves, grass and pathogens harbored in the soil.  All of these injuries require wound closure or reconstruction accompanied by appropriate debridement and antibiotic prophylaxis to reduce the risk of infection. Debridement may increase the amount of necessary tissue loss and lead to a more complicated reconstruction

The patient should be evaluated by a hand surgeon to see what reconstructive options are available. Skin defects can be treated with either skin grafts or flap coverage. Lacerated tendons and nerves can be repaired. Fractures can be treated as well, usually with k wire fixation. Unfortunately, in some cases due to the crushing mechanism, amputation may be the only option. Again, evaluation and management is best done by a hand surgeon who is familiar with the many reconstructive options.

Several Safety tips have been recommended by the ASSH to Prevent Hand Injuries:

• Always read instructions if unfamiliar with the machine.
• Never operate any machine intoxicated as concentration is needed.
• Never let children operate machinery.
• If the machine is jammed, turn it off first even if you think it is off.
• Always disengage the clutch. Always wait 5 or more seconds for the blade to stop.
• Beware of brief recall of motor and blades even after the machine is turned off.
• Take your time: the machine is more likely to jam if the job is rushed.
• Always use a large stick or broom to unclog the snow blower.
• Always keep hands and feet away from moving parts.
• Never disable the safety mechanisms.

Additional Recommendations include:

• Always wear slip resistant footwear to prevent slipping.
• Always wear protective eye shields to minimize projectile injuries.
• Always make sure the snow is directed to a space free of people, children and pets.
• Always know where the cord is at all times.
• Never leave the snow blower running in an enclosed area as carbon monoxide accumulates.

While no recommendations can eliminate all injuries, if one follows the above guidelines the risk of severe injury can be greatly reduced.

Have a fun and safe winter season!!

Information provided by: Hand & Plastic Surgery Associates, Ltd. – The physicians of HPSA treat the most challenging and complicated hand and wrist problems as well as minor conditions and injuries. They believe that seeing a physician who specializes in surgery of the hand yields the best results. When caring for injured workers, HPSA takes a proactive role to insure that these individuals are returned to work as soon as medically possible. They assist employers and case managers in determining appropriate job placement. Their physicians are also available for independent medical evaluations and second opinions. Visit their website at www.handplastic.com to learn more about HPSA.

The physicians and therapists of Hand and Plastic Surgery Associates, Ltd. (HPSA) continue to advocate the importance of timely and effective occupational therapy as a requirement to maximize the injured workers functional outcome.  While in subsequent articles I will focus on specific modalities which we utilize in occupational therapy I’d like to begin with a topic which gets little recognition and is often overlooked as an essential component of occupational therapy.  This deals with the role of communication in the patient’s care.

The following scenario is one that is commonly seen in our occupational hand therapy clinics due to the reconstructive nature of our physicians hand surgery practice:

I’m going through the charts and organizing myself for the upcoming day’s patients.  Today I will again be treating my current most challenging workers’ compensation patient.

The individual sustained a severe crush injury to their hand.  Initial intra-operative findings included several metacarpal and phalangeal shaft fractures, a digital nerve injury, multiple flexor and extensor tendon lacerations as well as, an injured blood vessel. The fractures required pin fixation and due to the multiplicity of injuries it took approximately 10 weeks for the fractures to heal adequately so that the pins could be removed and occupational therapy started.

The patient has undergone a total of three surgeries with subsequent procedures including split thickness skin grafts to reconstruct open wounds and finally extensor and flexor tenolysis, as well as, joint capsulectomies to allow for improved motion.

The patient has made substantial progress since their last surgery, but still has not been able to return to full duty at this time. It is clear that the patient will require additional occupational therapy for range of motion and strengthening despite nearly six months of treatment.  The physicians and therapists are anticipating an additional 2-3 months of occupational therapy for this individual. You know from the severity of the initial injury that this is not an uncommon scenario. Your goal is to have the patient make a full recovery and to return to full active duty but you also want to ensure that the care provided is targeted, effective, reasonable and medically necessary throughout the course of treatment.

How do I achieve this? What else can I do as an occupational therapist to ensure that the needs of my patient are being met in an efficient, timely, and cost effective manner to maximize my patient’s progress and ultimate functional result? What should the patient, case manager or adjustor expect from the occupational/hand therapy clinic and its practitioners?

The answer can be summed up in one word:  COMMUNICATION

An experienced and well designed hand therapy clinic will not only provide the highest quality of hand care but will also have a functional, systematized internal communication system in place that can easily be accessed by the patient’s case manager or adjustor. The process begins with a phone call to a designated communicator that can relay/fax/email any patient information requested within 8-48 hours of the request.  Documentation should be specific to the patient with clearly delineated goals. Therapeutic modalities being utilized should coordinate with the plan of care.  Ongoing documentation should include a section detailing which goals have been met, as well as, new goals to be achieved based on the level of progress.

There should be evidence of communication between the physician and therapist and between the therapist and the patient.  Speaking directly with the treating therapist should be as easy as picking up the phone or dropping into the clinic.   A case manager, adjustor or other professional should feel comfortable asking any specific questions of the therapist and should expect informed and accurate information in return.  This allows for the best coordination of care and minimizes any chances of interruption of treatment.  Therapists should also be accustomed to communicating with other professionals in order to coordinate the earliest possible return to work for the patient whether that includes a light duty restriction or full unrestricted activity.

My colleagues and I at HPSA recognize the benefits achieved in ultimate functional outcome when an aggressive return to work program is instituted by the practice.  We believe that the benefits extend to not only the patients functional outcome, since even light duty restrictions are viewed as therapeutic, but it also reinforces to the individual that they are expected to return to the workplace environment and continue as a productive and valued member of the company.

At Hand and Plastic Surgery Associates, Ltd. we feel that it is vitally important that our three occupational therapy clinics operate as a single and unified department which are linked by a set of common values, standards and goals. This allows us ensure the same level of quality and professionalism regardless of where our patients are treated.

Because our clinics are located on the same site as our physician offices frequent and timely communication with the treating physicians ensures that any change in the patient’s condition is dealt with immediately, whether this is to address an unforeseen complication or more commonly to increase the pace of therapeutic rehabilitation.  We are therefore able to design more individualized treatment plans for our patients as opposed to just following established protocols.  This also permits case managers and other individuals involved with the patient’s care to speak with the physician and the therapist at the same visit so that everyone is on the same page and all aspects of treatment are coordinated.

We believe that communication and coordination is an extension of the physician’s evaluation and surgical or non-operative treatment as the situation dictates.

What is the best way to manage your complicated patient?  Communicate!!

Talk it over with the treating therapist.  They should be happy to partner with you in an effort to maximize the patient’s recovery and functional outcome.

Should you have a difficult case which you are managing please contact our offices and one of our physicians will be happy to speak with you.

Angela Sarno, MS., OTR/L
Head, Department of Occupational Therapy
Hand and Plastic Surgery Associates, Ltd.

Information provided by: Hand & Plastic Surgery Associates, Ltd. – The physicians of HPSA treat the most challenging and complicated hand and wrist problems as well as minor conditions and injuries. They believe that seeing a physician who specializes in surgery of the hand yields the best results. When caring for injured workers, HPSA takes a proactive role to insure that these individuals are returned to work as soon as medically possible. They assist employers and case managers in determining appropriate job placement. Their physicians are also available for independent medical evaluations and second opinions. Visit their website at www.handplastic.com to learn more about HPSA.

First dorsal compartment tendonitis is also known as stenosing tenosynovitis of the first extensor compartment or more commonly as de Quervain’s tendonitis or tenosynovitis.  It is a condition producing pain in and around the dorsal and radial aspect of the radial styloid at the base of the thumb.  Patients typically present with pain and discomfort as well as swelling on the dorsal radial aspect of the base of the thumb and wrist.  The pain may appear gradually or suddenly.  The pain can be localized to that area or sometimes radiates down to the thumb or more proximally to the forearm.  The pain is often made worse by forceful grasping or twisting of the wrist as well as sometimes by excessive pinching of the thumb to the index finger.

Pathophysiology

The cause of the pain is thought to be secondary to irritation of the abductor muscle tendon within the first extensor compartment tunnel at the base of the thumb.  It is thought to be caused by repetitive activities albeit it is sometimes secondary to unusual positioning of the hand as well as hormonal fluctuations associated with pregnancies.  Wrist fractures can predispose the patient to de Quervain’s tendonitis.

Diagnosis

The diagnosis of de Quervain’s tenosynovitis is a clinical one with patients exhibiting tenderness directly over the first extensor compartment at the wrist.  Patients usually have a positive Finkelstein test where the patient exhibit worsening of the pain and discomfort with clasping the fingers and making a fist while the examiner is bending the wrist towards the little finger.  The patient’s skin exhibits some swelling and crepitus in and around the first compartment. A fullness in and around the area is often noted.

The differential diagnosis does include CMC (carpo-metacarpal) arthritis of the thumb, which is typically ruled out by a normal examination of the CMC joint of the thumb as well as routine X-rays of the hand and wrist.

Tenosynovitis of the second extensor compartments should also be ruled out. Those patients typically presents with tenderness 4 cm proximal to the second compartment on the dorsal and radial aspect of the forearm.  There is also some edema and crepitus in and around that site. Both de Quervain’s and second compartment tenosynovitis can coexist with patients presenting with somewhat less localized pain.

Treatment

Initial treatment of de Quervain’s tenosynovitis is geared towards avoiding activities that are causing or worsening the pain.  Resting the thumb by adding a splint can also be helpful.  Oral nonsteroidal anti-inflammatories can also be recommended.  If these measures fail after 2-3 weeks, a steroid injection in and around the first extensor compartment may be recommended.

When non-operative modalities fail, surgical release of the first compartment is indicated.  The surgery is typically done under either local anesthesia or local anesthesia with sedation ( MAC ) and as an outpatient surgery.  At surgery, the first extensor compartment is released so that normal tendon gliding ensues without any constriction. Patients are usually able to gently increase use of the involved hand 2-3 days after surgery and are often able to return to all their previous activities 6-8 weeks after the surgical release.  Occupational therapy is sometimes required for patients who are slow to improve. Complications of surgery are rare but do include scar hypertrophy as well as nerve injury.

Conclusion

In conclusion, first dorsal compartment tendonitis is a fairly common condition presenting as an aggravating ailment in the hand. Early recognition and treatment by a hand trained surgeon and well qualified hand therapist are essential to obtain a successful outcome.

Information provided by: Hand & Plastic Surgery Associates, Ltd. – The physicians of HPSA treat the most challenging and complicated hand and wrist problems as well as minor conditions and injuries. They believe that seeing a physician who specializes in surgery of the hand yields the best results. When caring for injured workers, HPSA takes a proactive role to insure that these individuals are returned to work as soon as medically possible. They assist employers and case managers in determining appropriate job placement. Their physicians are also available for independent medical evaluations and second opinions. Visit their website at www.handplastic.com to learn more about HPSA.