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Role of Bone SPECT/CT: Hand surgeon’s Perspective

Bo PovlsenConsultant Orthopaedic

Hand SurgeonGuy’s Hospital

Introduction

Life for a hand surgeon is easy we only treat 3 conditions:

1) Loss of function2) Loss of sensation

3)To much pain.

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How to diagnose the cause of Loss of function?

Use your eyes

SPECT Scan not needed to tell you what is wrong here

How to diagnose the cause of Loss of Sensation

Neuro-physiological studies can tell us:– if the peripheral nerves

are compressed

– &– where to operate

SPECT Scan not needed to tell you what is wrong here either

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How to diagnose the cause of Pain?

The simple Answer: With great difficulty

Why is the cause of pain difficult to diagnose?

No objective confirmation–Blood test, Biopsy or Scan

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What is the therapeutic dilemma with surgical pain treatment?

To anatomically pin point the invisible pain before treatment can be applied

How do I reach a diagnosis on the anatomical location of pain?

A distillation of information obtained from:

1. Taking a detailed “pain” history

2. Clinical inspection & palpation & examination

3. Relevant objective investigations (SPECT/CT ?)

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Taking a detailed “pain” history

When did the pain start? Do you have any medical conditions? Have the pain varied since then if so how? Do the pain vary during a 24 hour circle? Do the pain vary with activity? Do the pain co-inside with sensory symptoms? Can you pin-point the location of the pain? What makes the pain better or worse? Etc.

Clinical investigation to diagnose the location of the cause of Pain Inspection

– Swelling– Redness

Palpation – Tender– Warmth– Texture of swelling

Examination– Movement

– Active/passive– Pain association

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Relevant objective investigations the location of the cause of Pain

Non-invasive– X-ray

– Ultra sound scans

– CT-scans

– MRI scans

Invasive– Bone scans (wrist registration)

– SPECT /CT scan– LA test injection

– Biopsy

– Arthroscopy

Structures that I treat on a hand that can cause pain Skin Subcutaneous tissue Nerves Tendons Bone/fracture Ligaments Joint Capsule Articular surfaces/OA

What do I use SPEC/CT for?

–Fractures of bone– Articular surfaces/OA

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When do I use SPECT/CT Scan

Patient complain of pain but.....Clinical

examination?Standard x-ray

is normal

Wrist registration scan (WRS) of scapho-lunate joint arthritis

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Suspicion of scaphoid fracture, but WRS demonstrated trapezoid bruising

Pain after STT fusion, scan suggest union but ongoing inflammation

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Scaphoid fracture, delayed diagnosis but no suggestion of OA

Hook of hamate fracture but uptake in intact hamate – do not operate!!!!!

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? Scaphoid fracture. SPECT/CT: Capitate fracture – No need for OP

Pain after FOOH: Increased uptake; pisiform / triquetrum and triquetrum pseudarthrosis fragment => Excise

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Scaphoid / trapezium joint uptake, no fracture demonstrated => No OP

Ulnar sided wrist pain. SPECT/CT: Diagnosis DRU-J OA / abutment

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Multiple joint pain: Increased tracer several small joints in both hands

PAIN AFTER RADIO CARPAL FUSION. Non-union? SPECT/CT: OA CMC-J 3

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Wrist pain & Scaphoid bone cyst. SPECT/CT: No OA =>Excision+graft

Wrist pain & x-ray 1st row OA SPECT: 1st & 2nd row OA=>full fusion

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Ulnar sided pain: Ulnar abutment syndrome => TFCC debridement

Confirmation of correct diagnosis of anatomical location

when

LA injection removes pain instantly

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Treatment of pain from arthritic hand jointsInjection of steroidDebridementDenervationJoint fusionJoint replacements

Thank you for listening

Any questions?