DID I MISS THAT?

MISSED HAND INJURIES &

EFFECTIVE SPLINTING

HERB VON SCHROEDER, MD

HAND AND WRIST SURGEON, UNIVERSITY HAND PROGRAM

ASSOCIATE PROFESSOR, UNIVERSITY OF TORONTO

MEDICAL DIRECTOR, HAND & UE, ALTUM HEALTH

DISCLOSURE: INTEGRA

THE WELL-KNOWN

LIST OF THE MISSED: 10% OF HAND INJURIES

FRACTURES & DISLOCATIONS 80% SOFT TISSUE INJURIES (20%)

SCAPHOID # TENDON AVULSIONS

SCAPHOLUNATE LIG / PERILUNATE NERVE INJURIES

CMC JOINTS, esp. 5th FLEXOR TENOSYNOVITIS

HOOK HAMATE AVASCULAR DIGIT

DISTAL RADIOULNAR JOINT

SKIER’S THUMB • But Why?

• Tips

• Splinting

HEURISTICALLY

1. I don’t know what I don’t know

2. I do know, but I didn’t see it

3. I saw it, but made the wrong Dx

1. I DON’T KNOW WHAT I DON’T KNOW!

• e.g.

• COMPLETE TEAR SL LIG: WITH NORMAL X-RAYS,

• PARTIAL SL TEAR,

• MC STYLOID #.... .. DRUJ SUBLUXATION…ETC.

• IT’S COMPLICATED, BUT DOES GET BETTER WITH EXPERIENCE*

*Acta Orthropaedica 2018 52:32

What to do?

1. I DO KNOW:

• Any bone can be broken, any joint subluxed (and relocated)

• So, assume an injury, not a sprain, esp. young men

• Max tenderness -> Dx

• Check films again (system) and call a friend (radiologist)

2. I DIDN’T SEE AN INJURY!

• I’M NOT LOOKING AT THE PATIENT (MULTI-TRAUMA, UNCONSCIOUS, TIME, BIAS)

• X-RAYS NOT ORDERED OR NEVER CHECKED (15% OF ERRORS)

• X-RAYS ARE “NORMAL”, AND YES, THEY CAN BE DESPITE SERIOUS INJURY

What to do?

2. BUT I CAN SEE/DO THIS:

• Check your patient: Max tenderness -> Dx

• Extra views, extra imaging (CT, MRI*)

• Check films again (system) and call a friend (radiologist)

• Arrange follow-up

*Bone Joint J. 2019 101B:984. NB not in Gen Practice

3. WOOPS WRONG DIAGNOSIS

• ….BETTER THAN NO DX, OR “SPRAIN” DX!

• “BONE CHIP”… TRIQUETRAL #?

• EXISTING INJURY/OA: ESTABLISHED PSEUDARTHROSIS OR BROKEN OSTEOPHYTE

What to do?

-- the fix

THE FIX FOR MISSING

1. The Suspicion

2. The Hx and PE

3. The Imaging

4. The Dx(s)

5. The Tx (Splint)

6. The communication (FU)

1. SUSPICION

Older

Young

Scaphoid #

SL Lig

Perilunate

Boxer`s #

OA

SNAC

SLAC

Radius #

OA Thumb

Tendonitis

RSIssues

Hypermobility

MCI

Dorsal wrist

Ganglia

Female Male

1. SUSPICION

Older

Young

Scaphoid #

SL Lig

Perilunate

Boxer`s #

Work injury

OA

SNAC

SLAC

Radius #

OA Thumb

Tendonitis

RSIssues

Hypermobility

MC Instability

Dorsal wrist

Ganglia

Female Male

2. HX & PE:

• Hx: Injury or Issue?

• PE: squeeze testing

• PE: press bony prominences and soft spots (not just the snuff box)

3. THE IMAGING - ORDERING

• X-rays: 4 views not 3

• Extra views: e.g. Scaphoid view, Clenched fist, Carpal tunnel view, etc.

• CT or MRI

• (not US)

3. CHECKING THE X-RAYS

• Spaces and Edges (consistent & round); Happy faces

*Gilula’s Lines

3. CHECKING THE X-RAYS

• Happy faces

3. CHECKING THE X-RAYS

• Happy faces

3. CHECKING THE X-RAYS

• Happy faces

• And call radiologist…!

4. THE DX

• It’s an injury and it’s significant.

• It is not a sprain. There was a lot of force to the…[list here]

• Although it’s only partially seen on the X-rays, we know….it’s

significant

5. THE TX

• NO TENSOR! … it’s significant….

• Splint: aluminum (small) or plaster slab

“FAT-FREE”

•FOR CARPAL AND DISTAL RADIUS

INJURIES

•“FINGERS AND THUMB FREE”

•NOTHING TIGHT CIRCUMFERENTIAL

6. COMMUNICATION

“… it’s a significant injury ….” Follow-up:

2nd X-ray (+)ve

Prevent the honey-moon phase

Prevent falling through cracks

Prevent long term issues: stiffness, OA

THE SUMMARY:

1. The Suspicion: Young males

2. The Hx and PE: Squeeze

3. The Imaging: Check it, 2 , Add views, Add extra

4. The Dx(s): Not a sprain

5. The Tx (Splint): Not a tensor

6. The communication: It’s a significant injury -> FU

MISSED 18 YRS AGO

Dx was “SPRAIN”

OA –SLAC SNAC

Herb.vonSchroeder@uhn.ca

THANK-YOU