Introduction
Upper limb injuries are common in ED y 50% has fractures Distal radius, elbow and shoulder fractures: usually not be missed European Journal of Emergency Medicine 18: 186-191 BUT! How about the HAND?
報告者: R2游姿寧 指導者:F2吳亮廷 1000816
Four hand injuries not to miss Ulnar collateral ligament injury
Ulnar collateral ligament injury Thumb: Base of metacarpal: Bennett’s fracture y Pinching, grasping Volar plate avulsion fracture y 50% of hand function y Stabilized by radial collateral ligament and Flexor digitorum profundus avulsion ulnar collateral ligament (UCL)
Ulnar collateral ligament injury
UCL: y More frequently injured ○ Sudden forced abduction of the thumb ○ Trauma, contact sports y 2 portions: proper ligament and accessory ligament Skier’s thumb: acute injury Gamekeeper’s thumb: chronic laxity Diagnosis of UCL injury Diagnosis of UCL injury
History: Complete v.s. incomplete y sporting injury rupture y Pain at the base of the thumb y Complete rupture: PE: ○ Both accessory and proper y Reduced ROM at MCP joint collateral ligaments rupture y Maximal tenderness over the ulnar aspect ○ Often associated with Stener y Stress examination: lesion (50%) ○ Lateral (valgus) stress: angulation >35o, or ○ Need surgery >15o than the uninjured side Æ complete y Incomplete rupture: rupture ○ immobilization ○ Flexion: proper collateral ligament rupture ○ Extension: accessory collateral ligament
Diagnosis of UCL injury For UCL injury
X-ray: NOT diagnostic for UCL injury History and PE! y Should be obtained Before stress tests All suspected UCL injuries: y To exclude nearby bone fracture immobilization y True lateral radiography: dorsal capsular Untreated UCL injuries Æ affect hand and collateral ligament tear Æ palmar function, decrease power of hand, early subluxation Æ need surgery OA
Base of metacarpal: Bennett’s fracture Bennett’s fracture 2 part, oblique intra- Even a 1 mm malunion can result in articular fracture residual symptoms: early OA, pain, subluxation of base of stiffness thumb metacarpal Best treated with surgery Falls Æ axial load on a flexed thumb metacarpal The most common first metacarpal fracture Diagnosis of Bennett’s fracture Volar plate avulsion fracture
PE: Proximal interphalangeal (PIP) joint: y Pain and swelling to the thumb base y A hinge joint y Exam the UCL and scaphoid injury y The largest ROM in the hand (0-110o) X-ray: y Stabilized by several important structure: including the volar (palmar) plate
Diagnosis of volar plate X-ray for volar plate fracture avulsion fracture V sign History: Avulsion y Forced hyperextension fracture is y Deformity characteristic! y Common in athletes, ball sports PE: y Pain, bruising, swelling, reduced ROM in PIP joint
Treatment for volar plate injury Flexor digitorum profundus avulsion
Dorsal or palmar dislocation: should be Flexor digitorum profundus (FDP) reduced, and repeat X-ray is obtained y Flexion of DIP A volar plate injury with small fracture, y Origin: forearm, insertion: palmar base of the no joint subluxation: conservative Tx distal phalanx y Avulsion at insertion: >40% articular surface involved Æ need surgery ○ Often normal X-ray ○ The finger is able to actively flexion at PIP and Or: early OA, stiffness, loss of function MCP, but not at DIP ○ Commonly misdiagnosed!! FDP Diagnosis of FDP injury
History: y Injury when sporting, Sudden extension of an actively flexed DIP joint y Most common in the ring finger y Avulsion in insertion y Rugby jersey finger PE: y Swollen, bruised distal digit y To exam FDP function
X-ray for FDP injury Treatment for FDP injury
Useful, but not diagnostic No any role for conservative treatment! The tendon would retract! Primary repair is impossible after 7-10 days
Conclusion
In thumb injuries, to exam RCL and UCL in Both hands In PIP joint injuries: need true lateral X- ray American Journal of Emergency Medicine (2011) 29: 361-366 FDP avulsion: clinical diagnosis; all need surgery Bennett’s fracture: usually need surgery All fracture need 2 projections Background Treatment of cutaneous abscess
Patients with cutaneous abscess Conventional treatment: doubles over the last decade y Incision and drainage (I&D) + secondary Community-acquired methicillin-resistant healing Staphylococcus aureus (CA-MRSA) How about the primary closure?? also increased y Ellis (1951): heal faster, few complication How to treat the cutaneous abscess? y Some studies in Europe, Africa, Asia and Australia ever mentioned about it ○ Speed healing ○ Reduce pain ○ Improve scarring
Goal of this paper Methods
Primary closure V.S. secondary healing Search MEDLINE (PubMed), EMBASE, Speed of healing and rate of recurrence Cochrane Library Keywords: primary closure, abscess, incision and drainage, soft tissue infection Exclusion: review articles, retrospective analyses, noncomparative studies, abstracts
Results Jadad score for RCT
543 articles y 33 articles: primary closure after I&D, total 2000 patients ○ 7 RCT
Jadad score ≥ 3 Æ high quality Use of pre-OP anti, RCT in the meta-analysis analgesia/anesthesia and method of primary closure
Outcomes by treatment method Conclusion
Primary closure after I&D: y faster healing y Low rates of abscess recurrences y Not associated with any significant adverse events Using antibiotic? Controversial Who does the I&D? y Mostly: by general or colorectal surgeons under GA ○ Complete drainage of abscess and curettage of its walls Æ successful primary closure!
Results Conclusion
After primary closure, all patients shoulb Primary closure of I&D results in faster be seen within 48 to 72 hours healing and similar low abscess y Recurrence or spread: remove the suture recurrence rate and drain the abscess For CA-MRSA y Not in any of the 7 RCT y Some study favor I&D + secondary closure