This post explains how to do a cemented Exeter Total Hip Replacement Arthroplasty in detail. Rather than re-write the Total Hip Replacement procedure, I have included a PDF version from the manufacturer – this can be read by clicking on the below link.
Exeter Total Hip Replacement
Exeter V40 Total Hip Replacement Arthroplasty procedure
Trigger Finger
What is Trigger Finger?
A trigger finger/thumb is caused by a nodule in the tendon catching it as it passes through a tunnel at the base of the finger /thumb.
The commonest symptom is clicking or locking of the finger / thumb when it bends associated with pain. It may be difficult or impossible to fully straighten the finger/thumb and require forcefully pulling straight. It may feel like the joint is dislocating. There is commonly a painful area at the base of the finger /thumb and you may notice a nodule and clicking sensation if you feel the tender area.
The cause of the nodule is usually unknown although it occurs more frequently in diabetics and patients with rheumatoid arthritis.
In the vast majority of cases there is no arthritis and the joints are not affected or damaged by this condition.
• Some trigger fingers/ thumbs do not require treatment, but persistent symptoms and pain may require treatment.
• The most simple treatment is to inject a small amount of cortisone (steroid) around the nodule. This can be done in the out-patients and although slightly uncomfortable at the time, can get rid of the problem in about 70-80% of cases. You can use the hand normally after the injection but it can take a few weeks to respond to the injection.
• Surgery may be required if the injection(s) are not successful.
The operation usually uses local anaesthetic to ‘freeze” the skin at the bottom of the finger/thumb. During the operation the area where the nodule is catching is released. You should only feel a small amount of pushing and touching but no pain. The skin takes 10-14 days to heal.
You will have a bandage on your hand, which will be reduced in size in 3-7 days, but you should not wet your bandage. You will be encouraged to use your hand gently within the limits of your bandage avoiding pressure over the front of the wrist.
* The scar is over a sensitive area at the front of the hand and you should try to avoid pressure over this area as well as strenuous manual activities, such as gardening and DIY for about 2 weeks.
* You will be able to drive after 14 to 20 days.
The risk from cortisone injection is extremely small.
In those cases requiring surgery, there is also some risk of damage to other tissues around the operation site, particularly the nerves to the finger although this is also very rare.
* There will be a scar, which may be sore for a few weeks.
* Infection in the wound can occur but is usually simple to treat with antibiotics. Recurrence of symptoms after surgery is very rare.
Back Pain
The back is built like a column of several bones (vertebrae) stacked one on top of the other like a stack of coins separated by spongy cartilaginous structure called as discs. The spinal column extends from the base of the skull till the pelvis. The spinal vertebrae are connected to one another at the back by special joints called as facet joints. This unique structure gives the spine its flexibility. The nerves in the spinal cord run through a hollow canal at the back carrying signals from the brain to the rest of body. Strong bands of tissues called as ligaments and strong muscles hold this structure in place.
Back pain can usually be seen due to mechanical imbalances on this unique structure of the spine. Anything that causes these ligaments to sprain or pull these muscles can lead to a painful back. This triggers a muscular spasm worsening the pain. Decreased use of the spine on that part leads to the muscle becoming progressively weaker. If low back pain radiates all the way down to one side of the leg usually till the leg or ankle then it may be due to sciatica. For details on Sciatica please read the following article on Sciatica – Causes, Symptoms & Treatment.
The common causes of back pain are:
* Mechanical back pain (commonest)
* Spondylosis: It refers to degenerative disc disease commonly seen in the neck and back.
* Spinal Stenosis: Refers to narrowing of the spinal canal at a particular level.
* Bone tumours
* Disc Prolapse
* Infections and abscesses in the vertebrae.
* Osteoporosis:(thinning of bones) leading to vertebral collase
* Inflammatory diseases like ankylosing spondylitis.
Mechanical back pain is usually caused by abnormal or improper use of the spine.
Commonly implicated reasons are:
* Poor and prolonged posture while sitting or driving
* Abnormal bending of the spine while lifting things from the floor or bending the spine instead of the knees.
* Being grossly overweight
* Sleeping on very soft mattresses.
Lifestyle changes needed are:
* Gradual weight loss reducing pressure on the spine
* Learning proper posture and bending techniques while sitting, bending and lifting stuff from the floor.
* Avoid lifting heavy weights.
* Regular exercises to improve mobility and strengthen muscles affected.
* Stress and smoking are known to worsen back pain hence tackling both these issues should be a part of any effective programme to treat back pain.
* If involved in lifting heavy weights as part of daily profession then avoiding such activities or considering an alternative profession may be desirable.
* Mobilising as comfort allows.
* Bed rest for back pain is a strict no-no and tends to worsen the pain by weakening the muscle further.
Most patients present with a history of back pain subsequently leading to altered or diminished sensations into either or both of their legs. This may be felt as numbness on the skin along the groin or along the area supplied by the affected nerve. There may also be weakness in moving limbs affecting ankle, knee or hip joints in isolation or as a combination. There may be a history of incontinence from the front or back passage, including loss of sensation while passing water or opening bowels.
The treatment options are:
* A gradual weight loss programme
* Mobilising as pain allows
* Adequate painkillers which could be a mixture of non-steroidal analgesics, paracetamol and codeine based painkillers, small doses of muscle relaxants like diazepam. These help in relieving the symptoms for a fixed amount of time enabling patients to do exercises to strengthen their back muscles.
* By far the most useful treatment lies in doing proper spinal exercises. These help by strengthening the muscles and getting rid of the spasm that accompanies it.
* Physiotherapy: A physiotherapist could be helpful in supervising and explaining the various exercises helpful in treating back pain.
Exercises for back pain can be divided into:
* Stretching exercises: These are done for the spine, hip and legs.
* Strength building exercise:
* General fitness exercises: these are done to put you back into shape and start mobilising. They include swimming, cycling or even plain walking.
Back Pain
Sciatica refers to lower back pain radiating down till the leg or ankle. It is generally due to pressure on the nerves coming out from the spinal canal at that level. These symptoms are carried along the distribution of the Sciatic nerve where it runs along the back of the thigh and leg.
More details on Backpain can be read on the article on Back Pain – Causes, Symptoms, Lifestyle Changes, Treatment and Exercises.
Most patients present with a history of back pain subsequently leading to altered or diminished sensations into either or both of their legs. This may be felt as numbness on the skin in the groin or along the area supplied by the affected nerve. There may also be weakness in moving limbs affecting ankle, knee or hip joints in isolation or as a combination. There may be a history of incontinence from the front or back passage, including loss of sensation while passing water or opening bowels.
Sciatica develops due to excess pressure on the nerve roots coming out of the spinal canal at the level of the lower spinal canal. This is usually seen at the level of the third lumbar vertebrae downwards. It is termed ‘Sciatica’ as the symptoms are seen along the distribution of the sciatic nerve.
They are:
* Lower back pain radiating till the leg or ankle on the affected side.
* Occasional numbness or altered sensation along the distribution of the affected nerve root.
* Occasionally weakness may be felt in moving the ankle or knee on the affected side. This could be due to hesitation on moving them or pressure on the nerve root generating pain.
Treatment revolves around:
* A gradual weight loss programme, if needed
* Mobilising as pain allows
* Adequate painkillers which could be a mixture of non-steroidal analgesics, paracetamol and codeine based painkillers, small doses of muscle relaxants like diazepam. These help in relieving the symptoms for a fixed amount of time enabling patients to do exercises to strengthen their back muscles.
* By far the most useful treatment lies in doing proper spinal exercises. These help by strengthening the muscles and getting rid of the spasm that accompanies it.
* Physiotherapy or Physical Therapist: A physiotherapist could be helpful in supervising and explaining the various exercises helpful in treating back pain and building up muscle strength.
Types of Hip Fractures
What is the anatomy of the hip joint?
It is a ball and socket joint between the socket in the pelvis called acetabulum and the head of the femur bone.
It is covered from all around by a thick fibrous tissue called capsule which increases the stability of the joint. The blood supply is from the medial and lateral branches of the profunda femoris artery.
The femoral nerve runs in front of the hip joint and the sciatic nerve behind it.
What is a hip fracture?
A hip fracture is a commonly encountered fracture usually seen in the elderly as a result of direct fall onto the hip. This is usually complicated by a number of coexisting medical problems. Treatment depends on the type of fracture, age, general health and mobility levels of the patient. Hip fractures are broadly divided into two categories.
1. Intra-capsular Hip Fracture: fracture sustained within the capsular attachment of the hip. This is prone to develop avascular necrosis (avascular necrosis refers to death of previously healthy bone) as the there is high chance for the blood supply to the head of femur to get compromised.
Intra-capsular fractures are of two types.
a.) Undisplaced: There is minimal or no displacement between the broken bit and the main bone.)
b.) Displaced: There is significant displacement between the fractured bone and the main bone.
2. Extra-capsular Hip Fracture: fracture sustained outside the capsular attachment of the hip.
There are four types of extra-capsular fractures.
a.) Basi-cervical fractures: They are seen at the base of the femoral neck. Because of their border line position they are considered with extra-capsular fractures.
b.) Inter-Trochanteric fractures: The fracture line runs through the area between the greater and the lesser trochanter. They are usually seen in the older age group. The current treatment of choice is a Dynamic Hip Screw (DHS).
c.) Greater Trochanter fractures: Greater trochanter fractures are rare in isolation. Treatment is usually non operative except in young patients where they are better fixed.
d.) Lesser Trochanter fractures: They are rare and can be often pathological or in young patients can be due to avulsion effect of the strong pull of the tendons attached to it.
There are many ways of surgically fixing hip fractures depending on the classification mentioned above.
The patient may complain of pain in the hip or the groin after a fall or trauma.
There may be tenderness and painful, restricted hip movements in an undisplaced fracture or a shortened, externally rotated leg if the fracture is displaced.
Lifting leg straight up into the air is painful and usually impossible. There may be bruising or abrasions around the hip.
What are the investigations for a hip fracture?
Usually two views of the hip joint, one from the front to back and the other from the side are enough to diagnose it. In doubtful cases an MRI or CT scan may be helpful. If a patient persistently complains of pain in the hip with normal initial x-rays then repeat x-rays may be needed after a few days to rule out an impacted fracture which may have been missed initially.
Treatment depends on the type of fracture, age, general health and mobility levels of the patient.
* Undisplaced intra-capsular hip fractures: Here the choice of treatment does not depend on the age of the patient.
* Internal fixation using three cannulated screws or pins is the treatment of choice. Better results are obtained with surgery.Some surgeons also use a Dynamic Hip Screw instead of cannulated screws, for reasons of increased rotational stability.
* Non operative treatment is used if the patient presents late with evidence that the fracture is uniting.
* Displaced intra-capsular fractures:
* Patients less than 65 years of age are classified as young. In them internal fixation using pins or screws (Dynamic Hip Screw) is the preferred treatment as they are more likely to recover from the fracture and have a lower risk of developing avascular necrosis.
* Younger patients require follow up to see if they develop avascular necrosis of the femoral head.
Patients over 65 years can be treated with:
1. Unipolar Hemi-Arthroplasty: The prosthesis has a metallic head that articulates with the acetabulum (socket in the pelvis) directly. The whole prosthesis is a single unit. It is mainly used for pain relief. Patient group most likely to benefit is the severely elderly who is home bound, demented, has multiple medical problems and doesn’t mobilize much independently except bed to chair transfers.
2. Bipolar Hemi Arthroplasty: The prosthesis has a larger head on top of a smaller head. The small head sits on the prosthesis while the larger head articulates with the acetabulum. This arrangement improves function and gives a better range of movement. It is used for elderly patients who are reasonably ambulant and manage their daily activities of life independently.
3. Total Hip Replacement: In this procedure both the parts of the hip joint namely the upper part of femur and the acetabulum are replaced. This has the best functional outcomes of the three procedures and restores mobility to almost normal levels. It is recommended for patients who are fit and active.
They are
1. Avascular Necrosis: It refers to the condition when a part of the bone dies as its blood supply gets compromised due to variety of factors. It can occur after hip fractures. It presents with a persistently painful hip in absence of trauma or infection. An MRI is needed to confirm it.
2. Infection: If infection happens after metalwork has been fixed in the hip joint then it may lead to septic arthritis. Treatment lies in long term intravenous antibiotics or removal of metalwork if no significant progress is made even after a few weeks. A second operation may be needed to remove the infected tissues and wash the joint again to get rid of the bugs.
3. Non union: Non union or failure of fixation can be treated by Arthroplasty.
4. Re-fracture: A further fall can cause re-fracture at the same site or near by. It can be seen at the tip of the plate or screw or plate.
5. Death: A hip fracture increases the chances of death within the first one to one and a half years after the event after which the chances go back to what is expected for that age. This is due to generally reduced mobility levels and increasing co-morbidities.
Dupuytren Contracture
What is Dupyutren’s Contracture?
Dupyutren’s Disease is a contracture ( i.e bending) of the normal fibrous layer of tissue in the palm. It frequently runs in families (Congenital) and there is higher incidence in people who suffer from epilepsy, diabetes and alcoholic liver cirrhosis.
What are the features of Dupyutren’s Contracture?
The disease usually starts as firm nodules in the palm of the hand which progress to form hard and thickened bands or cords which are likely to extend from the palm to the fingers, leading to deformity and difficulty in straightening the fingers. It is not usually painful.
Does it affect all the fingers?
The disease can affect any of the fingers of either hand but the most common to be involved are the little and ring fingers. The disease affects both hands in about 60 percent of cases and the thumbs are occasionally involved.
Can I prevent the disease from progressing?
No. However, keep the skin of the palm and fingers supple by massaging the skin with lanolin cream or a skin lubricant.
Can this disease be related to my work?
There is no evidence that suggests Dupyutren’s Contracture is work related.
What are the treatment options for Dupyutren’s Contracture release ?
Hand Post Dupuytren Operation with Stiches and healed
1. Steroid injections – this is indicated for painful nodules in the palm of the hand in the early stages without associated deformities.
2. Fasciotomy – an operation performed under anaesthetic to divide the tight bands which cause flexion or bending of the knuckle joints.
3. Fasciectomy with or without skin grafting – this entails surgical excision of the thickened bands from the palm and the affected digits. It is indicated for more severe finger contractures which have been present for 2 years or more.
4. The 2-stage technique- in advanced cases with severe deformity, the digit can be stretched using a special external fixator followed 2 months later by fasciectomy and skin grafting (as above).
A hand surgeon will choose the best option for you after examining you.
For how long will I be unable to use my hand after surgery?
1. Following injection, perhaps a day or two
2. Following division of the band (fasciotomy): you will have a bandage on your hand for about five days.
3. After surgical excision and skin grafting (fasciectomy): three to four weeks. During this period you should not drive or do any manual activity that is likely to cause pressure or friction on the bandage.
Will I need any other treatment?
Following surgical excision and skin grafting (fasciectomy) you will require exercises from a hand therapist and possible splinting for about 6 months. You will require review until the finger(s) fully heal.
Can the operation do me any harm?
Anaesthetic: Rarely problems can occur related to your general health. The potential problems should be picked up at the pre-assessment clinic. Your anaesthetist will be able to discuss this further with you.
Wound healing: This usually takes between 2-4 weeks and requires dressings until the wound has fully healed but may take longer.
Nerve injury: The nerves to the fingers can be trapped within the Dupuytren’s bands and can be damaged during removal of these bands. This is usually a temporary numbness in the finger(s), but can rarely be permanent.
Incomplete correction of deformity: In more severe or longstanding deformity, full correction of the deformity is unlikely you will be advised of the likely degree in your case.
Recurrence: This is very common whatever procedure is performed, but less likely if skin grafting is used. It may affect the same finger or other fingers in the hand.
This article is written by Dr. Abhinav , Dr. Y Chee
Wrist Splint
Carpal Tunnel Syndrome patients are often advised to try out night splints to get a non-surgical relief from the symptoms of carpal tunnel syndrome. The use of splints and braces, when used at night, can give relief to mild and moderate compression caused at the carpal tunnel.
These Carpal Tunnel splints and braces, when used specifically for carpal tunnel syndrome, can be an effective non surgical alternative or cure. Many patients, in our practise, benefit from the use of these night splints.
Why are the Carpal Tunnel Symptoms worse at night?
As the name suggests, these are night splints, so are to be worn during the night. This is because the symptoms are maximal at night and because, the natural position of the wrist at night is a flexed (bent) position. The splints prevent such a bent position.
When the wrist is in a bent (flexed) position the surface area within the carpal tunnel is reduced, thereby pinching the Median Nerve and therefore, the symptoms are worse at night, as explained above.
Non Surgical Treatment of Carpal Tunnel Syndrome
The treatment modalities for non surgical cure are:-
* Night Splints
* Use of warm water bath or soaks – some patients find it helpful
* Steroid Injections into the Carpal Tunnel
The above cures for Carpal Tunnel Syndrome are temporary and the only permanent cure is surgery or Carpal Tunnel Decompression! Though many patients get transient relief, many have to have surgery.
Carpal Tunnel Syndrome
What is Carpal Tunnel Syndrome?
Carpal Tunnel Syndrome refers to the condition of the hand in which one of the nerves of the hand (median nerve) becomes compressed between the carpal ligament and other structures within the carpal tunnel causing pain, tingling of the hands.
Carpal tunnel is a narrow tunnel-like structure in the wrist where the median nerve runs through together with other muscle tendons. The carpal tunnel is covered by a ligament on its roof, called the TCL- Transverse Carpal Ligament – this is cut during the surgery to make the tunnel bigger & hence relieving the pressure.
Causes of Carpal Tunnel Syndrome?
It is seen when the contents of the tunnel increase in size causing pressure on the nerve. Some known causes are:
* Pregnancy
* Repetitive use of hands and injuries of the wrist
* Rheumatoid arthritis
* Myxedema
* Hyperparathyroidism
* Sarcoidosis
* Idiopathic – that means the cause is not found. This is the most common cause of CTS.
What are the symptoms of Carpal Tunnel Syndrome?
Carpal tunnel syndrome can present with
* pain,
* burning and tingling sensations on the palm of the hand.
* Patients tend to drop things as their grip becomes affected.
The symptoms typically extend from the thumb till the ring finger, in the Median Nerve distribution. This pain may radiate towards the forearm or shoulder. Pain can increase by manual activity and at night. In advanced stages muscle wasting may be seen at the base of the thumb.
How is carpal tunnel syndrome diagnosed?
Diagnosis includes physical examination of the wrist joint by the clinician and investigations like nerve conduction studies or MRI.
What is the treatment for Carpal Tunnel Syndrome?
* Treatment is aimed to reduce the pressure on the median nerve. This is done by finding the specific cause of increasing the pressure on the nerve and appropriate treatment.
* Adequate pain relief in the form of analgesia and wrist splints for Carpal Tunnel Syndrome are advised.
* If symptoms persist, the next step could be an injection of steroid within the carpal tunnel or surgical decompression.
* Surgery involves cutting the Transverse Carpal Ligament that covers the carpal tunnel through a short incision of around 2-3 cm along the length of the wrist, on the side of the palm. This usually cures the symptoms and is performed as a day case surgery.
What is the anatomy of the hip joint?
* It is a ball and socket joint between the socket in the pelvis called acetabulum and the head of the femur bone.
* It is covered from all around by the capsule increasing the stability of the joint. The blood supply is from the medial and lateral branches of the profunda femoris artery.
* The femoral nerve runs in front of the hip joint and the sciatic nerve behind it.
What is a hip fracture?
A hip fracture is a commonly encountered fracture usually seen in the elderly as a result of direct fall onto the hip. Hip fractures are broadly divided into two categories.
1. Intra-capsular hip fracture sustained within the capsular attachment of the hip. This is prone to develop avascular necrosis as the there is high chance for the blood supply to the head of femur to get compromised.
2. Extra-capsular hip fracture sustained outside the capsular attachment of the hip. Mostly, Dynamic Hip Screw is used for its treatment.
There are many ways of surgically fixing hip fractures; bipolar hemi-arthroplasty is one of them.
What is Bipolar Hemi-Arthroplasty of Hip?
It refers to surgically treating hip fractures using half a hip replacement. It is performed on elderly patients who have sustained an intra-capsular (fracture sustained within the capsular attachment of the hip) fracture of the hip and have a reasonably good mobility.
The word bipolar means that there are two heads one within the other on top of the neck of the prosthesis, providing good range of hip movements. The bipolar prosthesis is intermediate in between a Total Hip Replacement and an Austin Moore’s or Thompson’s Hemi arthroplasty.
What are the components of a Bipolar prosthesis?
* It consists of a metallic acetabular cup, and
* a polyethylene liner with a snap- fit socket to be used with a femoral prosthesis made of 22 mm or 32 mm diameter head.
Logic Behind the Bi- Polar Hemi Arthroplasty Design
The logic behind this particular design is that the erosion and protrusion of the acetabulum (acetabulum is the weight bearing area in the pelvis which forms part of the hip joint) would be reduced because motion is present between the Metal head and the polyethylene socket (inner bearing), as well as between the metallic cup and the acetabulum (outer bearing).
The bipolar prosthesis is designed making the axis of the metallic and polyethylene cups eccentric so loading off the hip causes the metallic cup to rotate outwards instead of inwards, avoiding fracture of the polyethylene insert and dislocation.
What are the steps of Bipolar Hemi-arthroplasty of Hip?
* The surgical steps of Bipolar Hemi-Arthroplasty consist of placing the patient on to the normal side on the operation table after appropriate anaesthetic.
* The patient is suitably prepped and draped using appropriate aseptic precautions.
* A 6 to 10 cm long incision is made on the side of the upper part of thigh. This exposes the subcutaneous fat tissues.
* Further dissection is carried out in between the various muscular layers. This exposes the capsule of the hip joint.
* A further incision is made to gain access to the neck of the femur bone.
* Using a power saw the fractured head is cut and removed.
* The next step consists of reaming the shaft of the femur bone to an appropriate depth, allowing implantation of the prosthesis.
* The shaft part of the prosthesis is fixed using special biocompatible anti-biotic (usually Gentamycin) mixed cement as the anchoring substance.
* Once the cement sets, the prosthesis is reduced back into the hip joint, after the smaller head is attached to the neck of the prosthesis and in the next step the larger head is fixed on top of the smaller head.
* The wound is closed in layers using stitches. A dressing is applied on top, which is removed in a few days time.
* Usually, the patient is allowed to start weight-bearing in the next few days as tolerated.
What are the complications of Bipolar Hemi Arthroplasty?
Complications are:-
1. Blood clots in the leg’s or lungs (called as DVT or P.E). These happen due to prolonged immobilization, stress of surgery and dehydration. These conditions tend to produce reduced blood flow causing it to clot where it gets pooled within the vein.
2. Infection: Each time there is a cut made to the surface of the skin there is a chance of infection. The surgery is usually done in a clean sterile environment, but still, the chances of infection remain. In case of infection treatment lies in intravenous antibiotics for a few days to a few weeks and in extreme cases by removal of the prosthesis.
3. Anaesthetic problems. Sometimes the stress of surgery can give patients problems like heart attacks, chest pains, irregular heartbeat, stroke or mini stroke.
4. Excessive blood loss: Some patients tend to lose more blood during hip surgery than normally tolerated by the body. They may need blood transfusions to make up for the loss.
5. Dislocation of the prosthesis from the hip joint : Once the prosthesis has been implanted after surgery, any further fall onto the affected side can result in the prosthesis getting dislocated out of the hip joint. This dislocation might get reduced by simple traction under sedation in emergency departments or might need open surgery again.
Hallux Rigidus
What is Hallux Rigidus?
It is a painful degenerative condition involving the base of the great toe in the foot. It is due to wear and tear (‘arthritis’) in the first Meta-Tarso-Phalangeal joint (MTP joint). Osteo Arthritis of the Big Toe is called Hallux Rigidus. “Hallux” – means big toe & “Rigidus” means rigid or unable to move.
What are the symptoms of Hallux Rigidus?
They present with:
* Pain at the base of the great toe joint
* Stiffness and loss of movement at the great toe joint.
* Discomfort on wearing certain footwear like heels or standing on tip-toes.
What are the treatment options for Osteo-Arthritis of Big Toe?
The surgical options are:
* Cheilectomy:
This is an operation done if the wear and tear is only mild on diagnosis. The bony spurs( osteophytes or abnormal bone) is shaved off. Bone may be realigned rarely to improve results. It is a day case procedure.
* Arthrodesis or fusion of the 1st MTP Joint:
MTP fusion
This is done if the wear and tear is more advanced or the cheilectomy has failed. In this procedure the cartilage in between the joint is removed and the bony ends fused. Metalwork like screws, plates or wires may be needed to hold the bones together. This allows you to walk normally but not to run. The foot is kept in a plaster cast or a special foot splint or shoe for six weeks after surgery. If the bones don’t fuse together then further surgery may be needed.
* Joint Replacement:
Joint replacement of the 1st MTP joint, may be an option if movement at the base of the toe is to be preserved. It involves shaving off the ends of the joint at the base of the great toe and implanting a metallic prosthesis.
* Conservative Options are to grin and bear the pain and stiffness.
Mallet finger or Baseball Finger
Mallet Finger Injury Mechanism
Causes :-
Mallet finger is also called baseball finger. It is usually caused by an injury to the tendons ( tendons – are structures which connect muscle to bone and help in movement) which keep the last joint of the finger in a straight position. There are two opposing sets of tendons ( called the flexors and extensors) at the tip of each finger. The first set on the top of the finger helps in lifting the tip ( this movement is called extension and therefore this group of tendons are called extensors) and the second on the underside of the finger, help in lowering the tip of the finger ( this movement is called flexion and hence this group of tendons and muscles are called flexors). Hence injury to the tendon that helps in lifting the finger creates an imbalance of forces. This leads to drooping of the tip of the finger. These injuries can be seen with bony fragments.
What Investigations are needed to diagnose Mallet Finger?
This is usually a clinical diagnosis and x-ray is recommended to rule out any bony injury, which may have happened as a result of the tendon being pulled out at the site of insertion on the bone. In either situation, treatment remains the same.
What is the Treatment for Mallet Finger?
* Mallet Splint:- The treatment is to immobilize the tip of the affected finger in a special splint, called as the mallet splint.
Mallet Splint
The splint is made of plastic shaped like a well secured sleeve covering the tip of the finger including the last joint of the finger. It is secured by using tape. It is kept on for a period of six weeks in the first instance.
* Prolonged Immobilization for Delayed healing:- In case of the deformity persisting after six weeks of splintage, then splintage may be necessary for ten to twelve weeks.
The patient is advised to remove it only after having kept his hand flat on top of a table, avoiding any bending at the tip and asking an assistant to clean the splint and change the tape at the bottom. The patient is followed up by bone doctors ( orthopaedic doctors) in the clinic. Physiotherapy is usually needed to resolve stiffness.
* Surgical Repair of Mallet Finger:- is usually not advised as it doesn’t usually yield good results. Surgical Repair is rarely needed in younger patients or if the bony chunk is huge.
* Mallet Thumb is treated in the same way as a mallet finger.
What are the Complications of Mallet Finger?
They include:
1. Loss of extension
2. Temporary skin problems
3. Difficult patient compliance
4. Refractory bony mallet ( where there is a significant chunk of bone that has come off with the tendon) cases not responding to conservative management are treated by open surgery if needed.
Tendo Achilles Rupture & Repair
What is Achilles Tendon?
This is an important tendon found at the base of the heel at the end of the foot. It is very helpful in keeping the foot flat, and to walk. It is a thick fibrous structure, shaped like a rope formed by the tendons of the calf muscles namely gastrocnemius and soleus.
What are the symptoms of Achilles tendon rupture?
Achilles tendon usually ruptures during physical exertion or exercise but spontaneous rupture can also be seen in the elderly. Games of squash, basketball, sprinting or running are commonly implicated, as they require sudden starts and stops.
A sudden sharp pain is felt at the base of the foot like a kick on the heel. {atients describe it as if someone has kicked them in the leg. Patients find it difficult to weight bear after rupturing the tendon. It is almost impossible to stand on tiptoes. There may be a visible gap in the tendon and it may not feel firm to touch as compared to the other ankle. There can be full or partial rupture.
What conditions can predispose to Achilles Tendon rupture?
* It can be seen in people who take regular steroids or suffer with inflammation of the tendon, although it can be seen in normal population.
* Local steroid injections increase chances of rupture.
* Previous tendon rupture in the past increases the risk of re-rupture.
* It is seen in people usually leading a sedentary lifestyle who suddenly become very active and do vigorous sports.
* Spontaneous rupture of this tendon especially in the elderly while walking is not uncommon.
What are the investigations to diagnose Achilles Tendon Rupture?
* It is usually a clinical diagnosis but in doubtful cases an ultrasound may help.
* Some useful tests are inabilities to stand on tip toes and no movement of the foot on squeezing the calf (calf squeeze test) while the patient lies on a bed chest down, knee bent and leg pointing to the roof or when the leg hangs down freely with the patients sitting.
What is the treatment for Achilles tendon rupture?
Treatment is divided into two categories
* Conservative management of Achilles Tendon Rupture.
It revolves around keeping the foot in a position where it brings the ruptured ends near to each other to promote healing. This position is called “Equinus position”.
The patient is put in a Plaster of Paris cast for a total duration of ten to twelve weeks. (the duration can be anywhere between 6 to 8 weeks, as well – depending on place to place). This cast is regularly changed at intervals of 4 weeks. In the first four weeks the heel is kept raised and the toes point downwards with the patient mobilizing non-weight bearing on that side using crutches.
In the next four weeks, the plaster is applied midway between a flatfoot and the position mentioned above.
In the last four weeks foot is put in plaster in the flat position allowing him to walk normally. The patients shoe is fitted with a heel raise for the next four weeks.
They are advised to stay off any contact sports or active exercise for another two months. This method is suitable for the elderly or people at a high risk of complications from the anaesthetic.
* Surgical management of Achilles Tendon Rupture
Young patients who lead an active lifestyle or professional sportsmen find better results after surgical fixation. They usually benefit from surgery to fix these ruptured ends of the tendon by stitches. A plaster cast or a specialist boot, is applied in the same manner as for conservative management.
* It causes better approximation of the ruptured ends leading to a stronger recovery.
* The benefits of the surgical treatment are lower re rupture rates, but can get complicated by infection, rarely.
What are the Complications of Achilles Tendon Rupture?
The complications are:
1. Re-rupture
2. Weak muscle response while bending the ankle downwards.
3. Ankle stiffness
4. Increased incidence of blood clots – Deep Vein Thrombosis or Pulmonary Embolism.
5. Postoperative infection.