Ward Rounds- A recently neglected part of inpatient care

 

More than two decades back when I did my house surgeoncy, I had tough time with the length of ward rounds. Ward rounds started at 7:45AM and it would continue beyond 12noon without a coffee break. My feet ached, mind was numb with hypoglycemia. In those moments I used to think why rounds can’t be faster and why it was taking so much of time. But later with a personal experience, that impression changed.

During my early PG days, my grandmother got admitted in the pay ward with a minor surgical problem in the busiest surgical unit. Each day I noticed that she was waiting for the time of rounds. One day, on the operation day of the unit; rounds was not taken till afternoon. My grandmother was unhappy and was wondering why no one has come so far for rounds. I tried to console her by informing her that it was the operation day. Initially she was comforted but soon she started grumbling. Soon it was a full blown tantrum and she refused lunch.

The time flew past the afternoon to evening, I did my best to comfort her without any response. I tried to contact the members of the concerned unit. They were held up in the OT. I gave up the hope of pacifying her and told her that probably there won’t be any rounds as it was already very late. She remained inconsolable. Then there was a knock on the door and the unit chief was standing outside the door. He peeped inside without even stepping in and asked “How are you grandmother? Are you better enough to go home? My grandmother was beaming and became an unrecognisably different person.

From that day I understood the psychological importance of ward rounds to the patient. But it is important for the treating team as well. It helps to establish a rapport with the patient, helps in early detection of complications and often saves one from embarrassment or even legal proceedings.

Over the years I have noticed that doctors as a community have become unaware of the importance of rounds. Rounds is often delegated to junior colleagues and many regard it as a nuisance. The patient is forgotten and more attention is given to the case sheets, investigation reports and the x-ray or MRI images. Some even think it is the best time to catch up with missed calls, emails, Facebook or Whatsapp messages.

To continue…..

https://learningorthopaedics.com/wardrounds/

Meniscus Lesions Tied to Neuropathic Pain in Knee OA

SOMEONE SOMEWHERE

Meniscal extrusion on MRI significantly associated with increasing pain scores in knee osteoarthritis.

Meniscus lesions, specifically extrusions, were a risk factor for neuropathic pain in patients with knee osteoarthritis (OA), results of a pilot study suggested.

The presence of meniscal extrusion on MRI, in both medial (P=0.006) and lateral (P=0.023) compartments, was significantly associated with increasing neuropathic pain (NP) pain scores in knee OA patients, according to Camille Roubille, MD, of the University of Montreal Hospital Research Center in Quebec, and colleagues.

The presence of meniscal tears in the lateral compartment (P=0.011) was also significantly associated with pain scores, they wrote online in Arthritis Research and Therapy.

“Our finding of an association between NP and lateral meniscal tear is somewhat unexpected as literature indicates that meniscal tears are not usually associated with symptoms,” the authors wrote.

The multicenter, cross-sectional, observational study included 50…

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Scapular dyskinesis

Definition

Scapular dyskinesia is defined as observable alterations in the static position of scapula or abnormal patterns of motion of scapula during coupled scapulohumeral movements in relation to the thorax.

Introduction

  • Due to inhibition or disorganization of activation patterns of scapular stabilizing muscles.
  •  Disrupts the normal rhythm of scapulohumeral motion and shoulder kinematics.
  •  Associated with various shoulder pathologies such as impingement, adhesive capsulitis, instability, SLAP lesions, rotator cuff injuries and acromioclavicular disorders.
  • May be the cause, effect or compensation. Exact role in shoulder dysfunction unknown.
  • It may exacerbate symptoms or adversely affect the outcomes of treatment.
  • Other causes are pectoralis minor contracture, Glenohumeral internal rotation deficit (posterior capsule of shoulder contracture), excessive thoracic kyphosis or excessive lumbar lordosis.
  • Frequently seen in athletes with shoulder injuries. It is also in asymptomatic individuals.
  • Treatment directed towards underlying cause and by kinetic chain based rehabilitation protocols to restore normal muscle activation protocols.

Functions of scapula

  • Provision of a stable but mobile foundation for humeral head during glenohumeral motion
  • Scapulothoracic motion
  • Elevation of acromion during abduction to prevent impingement of supraspinatus.
  • As a link in the kinematic chain for proximal-to-distal sequencing of velocity, forces and energy of shoulder function.

Scapular kinematics

  • Scapula, shoulder and humerus are either stabilized or moved during various activities to generate, absorb or transfer forces.
  • To optimize function, the scapula should move in coordination with the movements of humerus to maintain the instant centre of rotation and the alignment of glenohumeral joint. This has been likened to the balancing of a ball on seals nose.

To read more

https://learningorthopaedics.com/scapular-dyskinesis/

Ulnar nerve palsy

Anatomy

  • Ulnar nerve is a branch of medial cord of brachial plexus which arises from C8 and T1 ventral rami.
  • It lies between the axillary artery and vein.
  • It lies posteromedial to the brachial artery.
  • In the arm at the level of coracobrachialis insertion, it pierces the medial intermuscular septum to enter the extensor compartment where it lies anterior to the medial head of triceps.
  • At the elbow it lies in the retrocondylar groove behind the medial epicondyle.
  • It enters the cubital tunnel between the 2 heads of flexor carpi ulnaris to reach the flexor compartment where it lies on the anterior surface of flexor digitorum profundus. It supplies the FCU and the medial half of FDP.
  • 7 cm proximal to the wrist it gives off the dorsal branch which supplies sensation to the ulnar part of dorsum f hand up to the proximal interphalangeal joints.
  • 5 cm above the wrist it gives off the palmar branch which supply the ulnar side of palm.
  • Nerve passes superficial to the flexor retinaculum, medial to the ulnar artery and radial to the FCU through the Guyon’s canal which lies between the pisiform medially and the hook of hamate laterally.
  • In the Guyon’s canal it divides into superficial and deep branches.
  • Superficial branch supplies the palmaris brevis and provides sensation to medial one and a half fingers.
  • Deep branch passes along with the deep branch of ulnar artery between the FDM and ADM. It pierces the ODM to reach the deep surface of flexor tendons.
  • Along with deep palmar arch it passes transversely.
  • Deep branch supplies hypothenar muscles, interossei, medial two lumbricals and ends by supplying adductor pollicis, deep head of flexor pollicis brevis and first dorsal interossei.
  • Ulnar nerves supplies
    • FCU
    • Medial half of FDP
    • Hypothenar muscles
    • Interossei
    • Medial 2 lumbricals
    • Adductor pollicis
    • Deep head of flexor pollicis brevis

Pathoanatomy

  • Martin-Gruber anastomosis
    • Seen in 15%
    • Between ulnar and either median or AIN in the forearm.
    • Carry motor fibres from median to ulnar for intrinsic muscles.
    • May result in intact intrinsic function in proximal ulnar lesions.
    • 4 Patterns
      • Type I 60%- Motor from median to ulnar to supply median innervated muscles
      • Type II 35%- Motor branch from median to supply ulnar
      • Type III 3%- Motor from ulnar to median to supply ulnar innervated muscles
      • Type IV- Motor from ulnar to median to supply median innervated muscles
  • RichieCannieu anastomosis
    • Between deep branch of ulnar and recurrent branch of median nerve.
    • Ulnar to median
    • May result in intact thenar muscle function in presence of median nerve injury.
  • Sites of nerve entrapment
    • At the elbow
      • Arcade of Struthers- Myofascial band extending from medial intermuscular septum to the medial head of triceps, 8 cm above medial epicondyle
      • Medial intermuscular septum where it pierces
      • Medial head of triceps
      • Medial epicondyle
      • Epicondylar groove
      • Cubital tunnel between 2 heads of FCU which are connected by aponeurotic Osborne’s ligament
      • Flexor pronator aponeurosis between FDP and FDS.
    • At the Guyon’s canal
      • Zone I- Proximal to bifurcation
      • Zone II- Distal to bifurcation. Contains deep branch.
      • Zone III- Contains the superficial branch
  • Functional losses in ulnar nerve injury
    • Loss of key pinch due to paralysis of adductor pollicis and first dorsal Interossei.
    • Clawing due to paralysis of Interossei and lumbricals in presence of functioning extrinsic extensors leading to MCPJ hyperextension and functioning long flexors leading to flexion of IPJ.
    • Loss of forward flexion of mobile fourth and fifth carpometacarpal joints lead to loss of transverse palmar arch manifested as inability to cup the hand to hold water.
    • Loss of normal integrated MCPJ and IPJ flexion. Normal finger flexion starts at MCPJ followed by IPJ. In ulnar nerve palsy IPJ flexes first followed by MCPJ. This rolling motion will lead to inability to grasp objects.
    • Loss of FDP function of medial 2 digits in high ulnar nerve palsy leads to diminished grip strength.

Clinical Features

  • Duchenne sign- Clawing
  • Cross finger test- Inability to cross index and middle finger over each other.
  • Pitres Testut sign- Inability to abduct middle finger to either side.
  • Wartenberg sign- Abduction of little finger.
  • Loss of normal sequence of finger flexion- Normally MCPJ flexes then the IPJ flexes. In ulnar nerve palsy MCPJ flexes last.
  • Loss of key pinch
  • Jeannes sign- MCPJ of thumb hyperextended during key pinch.
  • Masse sign- Loss of hypothenar eminence and flattened palmar metacarpal arch.
  • Pollock sign- Inability to flex DIPJ of little and ring fingers.
  • Froments sign- Substitution of adductor pollicis by FPL during key pinch.
  • Bouvier manoeuvre- Correct the hyperextension of MCPJ and ask the patient to extend IPJ. If IPJ extension is improved then Bouvier test is positive and claw and is termed simple claw hand. If IPJ extension doesn’t improve then test is negative and clawing is called complex claw hand.
  • Associated sensory loss over medial aspect of arm and forearm indicate medial cord lesion.
  • Systemic conditions mimicking ulnar palsy
    • Charcot Marie Tooth disease
    • Syringomyelia
    • Leprosy
    • Klumpke’s paralysis
    • Pancoast tumour
    • Cervical IVDP

To continue

https://learningorthopaedics.com/ulnar-nerve-palsy/

Examination of knee

INTRODUCTION

It is important to have a systemic plan for the examination of knee arrive at the correct diagnosis, to identify its impact on the patient, to understand the patients’ needs and concerns and then to formulate a treatment plan that is individualized for the particular patient. A thorough knowledge of the normal anatomy, biomechanics of knee and the pathology of various knee disorders is a must for proper examination of knee and for the interpretation of physical findings.
First listen to the patient carefully to understand his concerns and needs and also to gain his confidence.
The involved and the normal knee should be adequately exposed to examine the knee. Always examine the spine and the hip to rule out conditions that lead to referred pain in the knee and any associated hip and spine disorders.
Always compare with the uninvolved side as wide range of anatomic and functional variations exist.
Examination should be gentle and as painless as possible to avoid worsening of injury and to ensure a cooperative patient.
The function of the knee is assessed by the patient’s ability to weight bear, walk, ability to squat, sit cross-legged, run, stair climb and the level of restriction of activities of daily living and the occupational and recreational activities.

 

To continue

https://learningorthopaedics.com/examination-of-the-knee-joint/

 

Acromioclavicular joint injuries

Anatomy

    •The average dimension of Acromioclavicular joint is 9mm superoinferiorly and 19mm anteroposteriorly. Joint is straight and vertical in 30% of population and in 70% the joint is oblique downwards and medially.

    •Articular cartilage of clavicle end becomes fibrocartilaginous after 17 years of age and the acromial end becomes fibrocartilaginous at 23 years.

    •A fibrocartilaginous disk of variable size and shape attached to the superior capsule is present between the articular surfaces. The fibrocartilaginous disk is partial and meniscus like in 50%, remnant like in 30%, absent in 20% and complete in less than 2%.

    Biomechanics

•Anteroposterior stability of ACJ is provided by the ACJ capsule and ligaments. The superior and anterior capsule and ligaments are the strongest.

•Superoinferior stability is provided by the coracoclavicular ligaments. Coracoclavicular ligaments have trapezoid and conoid parts. They are confluent at the coracoid and separate at the clavicle side. They form the primary suspensory complex of the upper limb.

•Conoid ligament is conical and is attached to the posterior-medial aspect of coracoid process. Trapezoid ligament is quadrangular and attaches to coracoid shaft. Trapezoid ligament is attached 2.5cm from the lateral end of clavicle to the trapezoid ridge and the conoid portion is attached 4.5 cm from the lateral end of clavicle to the conoid tubercle. This is important for anatomical reconstruction of coracoclavicular ligaments.

•Conoid footprint is posterior and measures 25-30mm. Conoid portion provides 60% of the superoinferior stability.

•Deltoid inserts to the superior capsule and anterior surface of lateral 1/3rd of clavicle. Trapezius inserts to the superior capsule and dorsal surface of lateral end of clavicle. Their attachments are also detached in higher grades of ACJ injury.

•Joint allows axial rotation of clavicle and anteroposterior and superoinferior sliding of acromion.

Mechanism of injury

    •Acromioclavicular joint injuries occur due to direct trauma over the acromion with the arm in the adducted position.

    •Once the ligaments are ruptured, the acromion is pulled down by the weight of the upper limb and the lateral end of clavicle is pulled up by the sternocleidomastoid and the trapezius.


    Investigations

•Zanca view showing both Acromioclavicular joints is the best view for diagnosis. Measure and compare the coracoclavicular distance on either side.

•Zanca view taken in the standing position. Should show both ACJ. It is a true AP view with 10-150 cephalic tilt.

•Axillary view is needed for diagnosis of posterior displacement in type IV injury. Axillary view taken in 70-900 abduction with the beam directed cranially.

•Normal distance from superior border of coracoid to inferior border of clavicle ranges 1.1cm to 1.3 cm. Side to side difference of > 25% diagnostic of injury.

•Stress x-rays taken with 10-15 pounds hanging from the forearm with the shoulder muscles relaxed. But it is impractical in acute cases due to pain.

•Associated injuries to the glenohumeral joint especially SLAP lesions are common. Hence MRI scans may be necessary in higher grades of injury.

Rockwood & Young classification

    1.Acromioclavicular sprain.

    2.Acromioclavicular ligaments ruptured and coracoclavicular ligaments intact. Joint displaced to a third of the width of clavicle.

    3.Acromioclavicular and coracoclavicular ligaments ruptured with 25-100% displacement.

    4.Acromion displaced posteriorly into the trapezius.

    5.100-300% dislocated.

    6.Acromion displaced below the coracoid.

    To continue click the following link

    https://learningorthopaedics.com/acromio-clvicular-joint-injuries/