University Orthopaedics, professionals/GP...University Orthopaedics, Hand and Reconstructive...
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A quarterly publication of GP Liaison Centre, National University Hospital. MCI (P) 122/03/2016
médico
and ReconstructiveMicrosurgery Cluster
University
R.I.C.E. is Not Enough
IN THIS ISSUE+NUH Orthogeriatric Hip Fracture Service
Knee Osteoarthritis: 5W’s + H
Adolescent Idiopathic Scoliosis
Wrist Pain – The Lower Back Pain of the Upper Limb
Orthopaedics,Hand
APR - JUN 2016
(UOHC)
02 médico APR -JUN 2016
WHAT’SINSIDE
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A Publication of NUH GP Liaison Centre (GPLC)
Advisor Editors Editorial MemberA/ProfGohLeeGan AmarantaLim YvonneLin KarinLim
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Copyright(2016).NationalUniversityHospital,Singapore
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03 R.I.C.EisNotEnough:AMulti-DisciplinaryApproachtoTreatingSportsInjuries
07 NUHOrthogeriatricHipFractureService –AHolisticApproach
11 KneeOsteoarthritis:5W’s+H
15 AdolescentIdiopathicScoliosis–APrimer
20 WristPain–TheLowerBackPainoftheUpperLimb
24 SpecialistinFocus–DrMarkPuhaindran
26 Happenings@NUH
The NUHS group
15
20
MorepeopleinSingaporeareengaginginphysicalexercise.Endurancesportsinparticulararebecomingmorepopular.TheannualStandardCharteredSingaporeMarathonhasseenanexponentialincreaseinthenumberofrunnersfromjust6,000in2002tomorethan53,000in2014.OtherenduranceeventssuchastheOCBCCyclealsodemonstratedrisingparticipationovertheyears,fromabout5,000in2009toalmost12,000in2014.GymworkoutsarealsopopularamongstSingaporeansregardlessofagegroupandgender,asshownbydatafromtheNationalSportsParticipationSurveyin2011.Suchtrendsareencouragingandinlinewiththecommonunderstandingthatforhealthbenefits,oneneedstoengageinbothaerobicactivityandmuscle-strengtheningexercises.
R.I.C.E is Not Enough:A Multi-disciplinary Approach to Treating Sports Injuries
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 03
04 médico APR -JUN 2016
R.I.C.E is Not Enough: A Multi-disciplinary Approach to Treating Sports Injuries
Toensureoptimalrecoveryfromsportinginjuries,itisimportanttoadoptamulti-disciplinaryapproach.
Eachmemberoftheteambringstothetablehisorherownexpertiseandresources,complementingtheskillsetsofothermemberstoensurethatthepatientisholisticallycaredfor.
Usingapatientwithasports-relatedoveruseinjuryofthelowerlimbsasanexample,weillustratethedynamicsofamulti-disciplinarysportsmedicineteam.Thepatient,havingbeensymptomaticformanymonthsandhavingfailedself-therapy,presentstoaprimarycaredoctor,suchashisfamilyphysician.Beingthepatient’sfirstcontactpointinthemulti-disciplinaryset-up,familyphysiciansplayanimportantroleinassessingforredflagswhichcanmasqueradeasmusculo-skeletalsymptoms.Anexamplewouldbevascularinsufficiencyofthelowerlimbswhichmaypresentasclaudicationpain.Thefamilyphysicianmayalsoorderx-raystolookforfracturesorbonetumours.
Oncetheredflagsareruledoutandthefamilyphysicianissatisfiedwiththediagnosisofanoveruseinjury,hemayprescribeanti-inflammatoriesorteachthepatientsimplestretchingexerciseswhichtargetthesymptomaticregionorbodypart.Steroidinjections,commonlyknownas“HandL”,mayalsobegiventositeslikethesub-acromialregioninrotatorcufftendinopathyandlateralepicondyleofthehumerusintenniselbow.Thefamilyphysicianwilloftenrecognisethatthepatientneedsmorethanjustsymptomaticrelief,andareferraltoasportsphysicianiswarrantedtoaddresstherootcausesofthepatient’ssymptoms.
Thesportsphysicianwillreassessthepatientandcomeupwithamoredefinitiveanatomicaldiagnosis.Forexample,inapatientwithpersistentposterior
Withenthusiasticparticipationinphysicalexercise,onewillmostlikelysufferinjuriesatsomepoint.Whilstsomeinjuriesareduetoacutetrauma,mostareusuallyduetooveruseandrepetitivestrain.Symptomsofoveruseinjuriesareusuallyofgradualonsetandmaylastforweekstomonths.Examplesincludearunnerwhoserunningdistanceislimitedbygraduallyworseningheelpainoverafewmonths,oragym-goerwhopresentswithmanyweeksofshoulderpainwhichseemstooccurwheneverhedoesoverheadexercises.Mostarerecreationalathleteswhodonotseekmedicalattentionwhensymptomsfirstoccur.ManyofthemareawareofR.I.C.E.therapy(Rest,Ice,Compress,Elevate)andarecompetentinself-treatment.Somemayalsoobtainover-the-countertopicalororalanalgesiatoaidinsymptomrelief.AssymptomsprogressdespiteinstitutingR.I.C.E.therapy,theseathletesmayseekmedicalattentionatprimarycareclinics.Theymayevenpresenttotheemergencydepartmentattheoutsetifthecauseoftheinjurywasduetoacutetrauma,orifthesymptomsaresevereordebilitating.
Physiciansintheprimarycareclinicsorintheemergencydepartmentswhoseepatientswithsportsinjuriesfindthatmostinjuriesaresprainsorstrains,andcanbeconservativelymanaged.Asmallnumberofpatientsmayrequirespecialistreferralandsurgicalmanagement,suchasthosewhosustainedfracturesfromacutetrauma.Usingtheearlierexamples,therunnerwithheelpainmaybediagnosedashavingplantarfasciitis;andthegym-goerwithshoulderpainmaybelabelledashavingrotatorcufftendinopathy.Thephysicianwilloftenadvisesuchpatientstorestandtoavoidaggravatingactivity.Thisissimilartowhatthepatienthadalreadydonebefore,i.e.R.I.C.E.therapy.Thephysicianmayprescribeanti-inflammatoriesandalsoteachthepatientsimplestretchesorrange-of-movementexercisestoaidinrecovery.
Mostpatientsexperienceanimprovementinsymptomswithrest.However,theirpainwillmostlikelyrecurwhentheyreturntotheirsportingactivity.Itisnotenoughtodiagnosetheproblemandtreatsymptomatically.Thecauseoftheinjurymustbeidentifiedandcorrectedaswell.Thecausemaybereadilyapparent,suchasasuddenincreaseintrainingvolumeorfrequency.However,itisoftenmulti-factorial.Usingtheearlierexamples,plantarfasciitismaybecausedbyabnormalbiomechanics,inappropriatefootwearorchangeinintensityoftraining;rotatorcufftendinopathymaybeduetopoorweightliftingtechniquesorweakrotatorcuffandscapularmuscles.Itisnear-impossibleforaphysiciantoassessforandcorrectalltherootcausesoftheinjuryonhisorherown.
Sports injuries are ideally managed by a sports medicine team comprising the following practitioners:
Familyphysician
Sportsphysician
Physiotherapist
Podiatrist
Radiologist
Orthopaedicsurgeon
SportsNurse
Acupuncturist
Dietician
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 05
kneepain,thefamilyphysicianmayhavediagnosedahamstringstrain.Thesportsphysicianwillbeabletodelineatethepathologyfurther,diagnosingabicepsfemorisinsertionaltendinopathywithaconcomitantpopliteusinjury.Accuratediagnosisisimportanttoallowfortargetedandsuccessfultreatment.Imagingmodalitiessuchasultrasound,CTandMRImaybedoneincaseswhereapreciseanatomicaldiagnosisisindoubt.Interpretationoftheimagesisdonewiththehelpofamusculoskeletalradiologist.
Thenextstepinmanagementisusuallypainrelief.Forthispurpose,thesportsphysiotherapistisabletoadministeravarietyofmodalitiessuchasultrasound,transcutaneouselectricnervestimulation(TENS)andcryotherapy.Acupuncturetreatmentmayalsobebeneficial.Gentlestretchingandrange-of-movementexercisesoftheaffectedmusculotendinousunitsarealsotaughttothepatient.Aspainimproves,thesportsphysiotherapistortrainerwillstartthepatientonaprogressiveandspecificstrengthandconditioningexercisestopreventfutureinjury.Iftheinjuryisanenthesiopathy,suchasAchillesorpatellatendinopathy,andisnotrespondingwelltomonthsofconservativetherapy,thesportsphysicianmayadministerextracorporealshockwavetherapy(ESWT)toaidinhealing.
Asmentionedearlier,managementdoesnotendwithsymptomrelieforthehealingofaninjury.Thesportsphysicianconcomitantlyassessesthepatientforpre-disposingfactorstotheinjuryandaddressesthem.Inpatellofemoralpainsyndrome,acommonly-encounteredoveruseinjury,thesportsphysicianusuallyidentifiesvariousbiomechanicalfactorswhichhavecontributedtotheinjury.Factorsincludeexcessivelateralpatellatiltduetoatightiliotibialbandandweakvastusmedialis.Thephysiotherapistcanaidincorrectionofthosebiomechanicalabnormalitiesbyteachingthepatientvariousstretchingexercisesfortheiliotibialband,aswellasstrengtheningexerciseswhichtargetthevastusmedialis.Thepatientmayalsohaveexcessivepronationofthefoot,whichcanpredisposetoconditionslikepatellofemoralpainsyndromeandplantarfasciitis.Asportspodiatristwillbeabletoassessthepatient’sgaitandfit
customisedorthoticstohelpcorrecttheexcessivepronation.Noteverysymptomisrelatedtothemusculoskeletalsystemorbiomechanicalabnormalities.Apatientwhoparticipatesinendurancesportsmaycomplainoftirednessandpoorperformanceduringraces.Thesportsphysiciancanenlistthehelpofadieticiantoassessthepatient’snutritionalstatusandidentifyspecificdeficiencies.Recommendationsondietarychangesaremade,andnutritionalsupplementscanbeprescribedtohelpenhancethepatient’sperformanceinhissport.
Theroleofthesportsorthopaedicsurgeonisimportantassurgerymaybeneededinthemanagementofsports-relatedoveruseinjuries.ApatientwithrecurrentanklesprainsandinstabilitydespiteundergoingphysiotherapymayundergoaBostromrepairoftheanteriortalo-fibularligament.Apatientwithpersistentanklepainfromanosteochondrallesionofthetalardomedespiteimmobilisationandrestrictedweightbearingmayundergoarthroscopicdebridementandmicrofracturetoaidhealing.Thesportsnursecomplementsthesportsorthopaedicsurgeonbyservingasanimportantsourceofcounsellingandeducationforthepatientinthepreandpost-operativeperiod.Pre-operativecounsellingisdonetoexplaintheprocedure,andwhattoexpectoncethesurgeryiscompleted.Thesportsnursewillcontinuetoseethepatientpost-surgeryandeducatehimorheronwoundcareandoptimisingwoundhealing.Thesportsphysiotherapistalsohasanimportantroletoplayinpost-operativerehabilitationtohelpthepatientregainhisfunctionalstatusandpreventre-injury.
Itisvitalforallmembersinthesportsmedicineteamtobeawareoftheirownstrengthsanddeficiencieswhenitcomestomanagingthepatient.Theymustknowwhichotherteammembers
R.I.C.E is Not Enough: A Multi-disciplinary Approach to Treating Sports Injuries
06 médico APR - JUN 2016
Family PhysicianNUH Sports CentreUniversity Orthopaedics, Hand and Reconstructive Microsurgery cluster
DrWangMingchangisafamilyphysicianandsportsmedicineregistrarwhopracticesatNationalUniversityHealthSystemNUHanditsaffiliatedpolyclinics.Hehasakeeninterestinpromotingphysicalactivityinthecommunity-at-large,especiallyinpatientswithchronicdiseaseorspecialneeds.
DrWangMingchang
Director and Senior ConsultantNUH Sports CentreUniversity Orthopaedics, Hand and Reconstructive Microsurgery cluster
DrLingarajKrishnaistheDirectoroftheNationalUniversityHospital(NUH)SportsCentre-amulti-disciplinary,research-oriented,tertiary-levelcentreforsportsmedicineandsurgeryinSingapore.DrLingarajisalsoanorthopaedicsurgeon,whodealswiththeentirespectrumofkneeandhipconditions,rangingfromsportsinjuries,degenerativeconditions,rheumatologicdisordersandtraumaticinjuries.Hisparticularinterestsareinsports-relatedkneesurgeryandkneeligamentreconstructionsurgery,aswellashipandkneejointreplacementsurgery,andrevisionjointsurgery.
DrLingarajKrishna
areabletoofferthenecessaryexpertisetobesttreatthepatient.Foroptimaltreatmentoutcomes,acombinationofdifferenttypesoftreatmentfromdifferentpractitionersintheteamisneeded.Thismayseemlikesubjectingthepatienttofragmentedcare,butatthecentrecoordinatingthecareofthepatientwillbethesportsphysician,whoservesasthepatient’sprimarycontactpoint.Membersoftheteammeetregularlyinaphysician-led“multi-disciplinarymeeting”todiscusscasesandalignmanagementplanstoensureoptimaloutcomesforthepatient.
Thesportsphysicianwhocoordinatesmanagementisawarethattreatmentdependsonthepatient’ssituationandnotjusttheanatomicaldiagnosis.Everypatientisauniqueindividualwithuniqueneeds.Acompetitivegolferwithlowerbackpainmayneedtwice-dailytreatmentinordertoparticipateinanupcomingcompetition;abusinessmanwithasimilarinjuryfromrecreationalgolfmayonlyrequireweeklyphysiotherapy.
Insummary,treatmentofsportsinjuriesinvolvestwocomponents:treatmentofthepresentingsymptomsandtreatmenttocorrectthecause.Amulti-disciplinaryapproachtailoredtothepatient’scontextisneededforoptimaloutcomes.
R.I.C.E is Not Enough: A Multi-disciplinary Approach to Treating Sports Injuries
NUH ORTHOGERIATRIC HIP FRACTURE SERvICE– a Holistic approach
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 07
Recently,Iheardadefinitionfora“holisticorthopedicsurgeon”.“Theydon’tjustcareforafracture;theycareforthewholebone!”However,takingcareofthefractureisnolongersufficient.Ourworldandpopulationareageing.ThenumberofSingaporeansaged65yearsandaboveisexpectedtotripleto900,000by2030.Optimisingbonehealth,reducingtheriskoffuturefractureandsuccessfullyreintroducingthepatientbackintothecommunityareequallyimportantasfractureunion.TheWorldHealthOrganisationreportedthatin2010,anestimated524millionpeoplewereaged65yearsorolder,representing8%oftheworld’spopulation.By2050,thisnumberisexpectedtotripletoabout1.5billion,representing16%oftheworld’spopulation.Singaporeisnotsparedfromthis‘greytsunami’.
08 médico APR -JUN 2016
From2000to2011,theproportionofelderlySingaporeanresidentsincreasedfrom7.2to9.3%.Theproportionoftheveryold,aged85yearsandover,grewfrom0.2%oftheresidentpopulationin1980to0.7%inthemid-2000s(Figure1).
Thispopulationhasanincreasedpredispositiontofallsowingtoamyriadofreasons,includingmultipleco-morbidities,polypharmacy,posturalhypotensionandcognitiveimpairment.Fallsandrelatedinjuriesareamajorhealthproblem,withfracturesorotherseriousinjuriesin5%leadingtosignificantconsequencesontheperson,familyandthehealthsystem.Thelargestmorbidityoccursamongtheelderlyaged65yearsandover,withhipfracturesaccountingformostoftheinjuries.Thenumberofhipfracturesworldwideisestimatedtorisefrom1.7millionin1990to6.3millionby2050(Figure2),withosteoporosisastheprimaryriskfactorandwomensufferingthemajority(80%)ofhipfractures.Onlyhalfofhipfracturespatientsregainpre-fracturemobilityandtheoneyearmortalityratefollowinghipfractureis25%.
Ourcareforelderlyhipfracturepatientshasbeenevolvingoverthepastdecade.Previously,lessthan60%ofelderlypatientswithhipfractureunderwentsurgery.Itwasnotuncommontobetoldthatapatientdeclinedsurgerybecausetheywere“tooold”.However,studieshaveconsistentlyshownbetterfunctionaloutcomes,shorterhospitalstays,shorterrehabilitationandquickerreturntoindependenceinpatientswhoundergosurgeryforhipfractures.Surgeryreducespainandfacilitates
rehabilitation,reducingtherisksofcomplicationsassociatedwithprolongedimmobility.Nowadays,approximately90%ofallpatientswithhipfractureattendingourhospitalwillundergosurgery.Agealonedoesnotprecludeoperativetreatment.
How does the Orthogeriatric Hip Fracture Service function in NUH?
TheNUHOrthogeriatricHipFractureService(OGHFS)commencedin2015andusesevidence-basedbestpracticetoimprovecareandoutcomesforelderlypatientswithhipfracturesinNUH.
TheOGHFSconsistsofamulti-disciplinaryteamwithacommongoalofprovidinghighstandardsofholisticcareinlinewithinternationalguidelines.Duringadmission,patientsareassessedbyateamoforthopaedicsurgeons,geriatricians,carecoordinators,nurses,andtherapists.Clearroleswithagreedmanagementandcarepathwayshavebeencreated,withthegoalofoptimisingpre-operativeconditions,reducingtimetosurgery,reducingcomplications,andimprovinglongtermfunctionandqualityoflife.Weaimtohavepatientsoperatedonwithin48hoursofdiagnosis,providedthepatientisfit.Morethan90%ofpatientswillbemobilised,fullyweightbearing,within48hoursofoperation.Fallriskfactors,bonehealthandcognitionarereviewedandintervenedtoreducefuturefallsandfractures.Thisholisticapproach,accountingforaperson’smedical,surgical,functionalandsocialneeds,isthecornerstoneofourpatientmanagement.Evidencehasshownthatpatientsbenefitfromstructuredrehabilitation,andthiscareshouldcontinuemonthsbeyondthetimeofsurgery.ThedevelopmentofanOGHFSallowsfortheseamlesstransferofpatientsfromtheacutecarehospitaltoastep-downcommunity
Figure1:IncreaseinelderlypopulationinSingapore.
Figure2:Estimatednumberofhipfractures(1,000s).Adapted from Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a worldwide projection.
8 6 4 2 0 2 4 6 8
Percentages
85+80-8475-7970-7465-6960-6455-5950-5445-4940-4435-3930-3425-2920-2415-1910-14
5-90-4
Singapore 1980
Males Females
8 6 4 2 0 2 4 6 8
Percentages
85+80-8475-7970-7465-6960-6455-5950-5445-4940-4435-3930-3425-2920-2415-1910-14
5-90-4
Singapore 2009
Males Females
Estimated number of hip fractures (1000s)
NUH Orthogeriatric Hip Fracture Service – A Holistic Approach
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 09
hospitaltominimiseinterruptiontotheirrehabilitationandoptimisepatient’sfunctionaloutcome.A“fast-track”pathwayhasbeencreatedbetweenNUHandStLuke’sHospital(SLH)toprovideasmoothtransitiontoitshipfracturerehabilitationprogramforolderpatients.Fromthere,patientsareoffereddayrehabforcommunityintegration,andtocontinuefunctionalimprovements.
Apatientwithahipfractureisco-managedbytheOGHFSteam.Thisisbestillustratedbyfollowingthetreatmentofarecentpatient,Mr C.Thiscentenarianwasalreadyinhis50’swhenSingaporegaineditsindependence.Hewasindependentinhisselfcareandenjoyedwalking,usingaquad-stick,tothenearby“Kopitiam”onweekends.Unfortunately,heslippedinhisbathroomathomeandsustainedahipfracture.Hisfamilybroughthimtoourhospital,whereheunderwentacomprehensiveassessmentbytheorthogeriatrichipfractureteam.Hewasfoundtohaveahistoryoffrequentfalls,hearingimpairment,vitaminB12andDdeficiencyandwascommencedonappropriatetreatment.Thedecisionregardingsurgeryinvolvedconsiderationofthepatient’spre-morbidfunctionandcondition,andweighingthisagainstlikelyoperativerisksandthemorbidity
ofprolongedimmobilisationfollowingconservativetreatment.Hispastmedicalhistorywasquitecolourful,asonemightexpectforamanofhis“youth”,andhewasreviewedbyanaesthesiology.Geriatricteamoptimisedhimduringthepre-operativestayasitwascomplicatedbyhyperactivedelirium,arrhythmiasandpneumoniarequiringintravenousantibioticsandfluids,chestphysiotherapy,regularbowelclearanceandpainrelief.Hismedicationswerereviewedtoreducepolypharmacyandcomplications,whileoptimisingpainrelief.DailyreorientationwasstartedbythenursingstaffandMentaltestandConfusionAssessmentMethod(CAM)scoreswereperiodicallytakentomonitorforworseningdelirium.Withhismedicalconditionsoptimised,thiscentenarianunderwentsurgery,performedbyanexperiencedanddedicatedorthopaedicteam.Hewassittingoutofbedonpost-operativeday2andfullyweight-bearingwithassistance.Hewasfollowedupforpotentialcomplicationsbythegeriatriciansandcarecoordinators.Therapistsreviewedhisfunctionandsocialsupport.HesubsequentlyunderwentfurtherrehabilitationinSLHtoreintegratethepatientbackintothecommunity.PostdischargefromSLH,hewillbeoffereddayrehab,withfollow-upbythecarecoordinator,andappropriaterightsittingofcareforhisvariousmedicalandsurgicalconditions.
Mr Cisnotanexception.Wereviewedtheresultsofhipfractures(intracapsularorintertrochanteric)overa10-yearperiodinournonagenarianpopulation.ThesecasesalloccurredpriortotheestablishmentofOGHFS.Therewereatotalof58patients,50ofwhomwerefemaleandtheyhadameanageof92.4years(range90–99years).Asexpected,theseelderlypatientshadamultitudeofco-morbidities,themostcommon
NUH Orthogeriatric Hip Fracture Service – A Holistic Approach
10 médico APR -JUN 2016
Deputy HeadDivision of Muscoloskeletal TraumaSenior ConsultantDepartment of Orthopaedic SurgeryUniversity Orthopaedics, Hand and Reconstructive Microsurgery Cluster
DrMurphyisaSeniorConsultantattheNationalUniversityHospitalandaVisitingConsultanttoStLuke’sHospital.HecompletedhisundergraduateandhigherspecialistorthopaedictraininginIrelandbeforejoiningNUH.Hisspecialistinterestsincludefragilityfracturesintheelderly,bonelossfollowingopenfracturesandhip/kneearthroplasty.
DrDiarmuidMurphy
ConsultantDivision of Advanced Internal Medicine (Geriatric Medicine), Department of University Medicine ClusterDrSanthoshdidhisundergraduatetraininginIndiaandcompletedhishigherspecialisttraininginUK.HeworkedintheUKasaConsultantinelderlycarewithspecialinterestinstrokebeforemovingtoSingapore.Hisspecialinterestsareinmanagingfallsandbalanceissuesontheelderly,orthogeriatrics,functionalageing,useoftechnologyingeriatricsandmedicaleducation.
DrSanthoshKumarSeetharaman
DrTongisaConsultant,GeriatricMedicineinStLuke’sHospitalandaVisitingConsultanttotheNationalUniversityHospital.ShegraduatedandworkedintheUnitedKingdombeforecompletinghertraininginSingapore.Herinterestarefalls,ortho-geriatricsandintermediateandlongtermcareservicesfortheelderly.
DrKamunTong
beinghypertension,diabetesmellitus,hyperlipidemia,ischemicheartdisease,congestivecardiacfailure,cardiacarrhythmias,cerebrovasculardisease,chronicobstructivepulmonarydisease,chronickidneydisease,previoushistoryofmalignancyanddeepveinthrombosis.Allpatientswereoperatedwithamedianintervaltimetosurgeryoffourdays(range1–14days).Themedianlengthofhospitalstaywas11days(range3–48days).Therewere27(46.6%)patientswithimmediatepost-operativecomplications.Atfirstyearpostsurgery,38patients(65.5%)fromthecohortstillmaintainedtheirambulationstatus,albeitnotattheirpre-injurylevel.13(22.4%)werenon-ambulant,butpainfree,atoneyearpost-operatively.Onepatientdiedwithin30daysoftheiroperationandafurthersixpatientsdiedwithinoneyearoftheirinjury.Ourreviewshowedthatnonagenarianswhounderwenthipfracturesurgeryhadgoodresultsintermsofclinicaloutcomesandfunctionalstatus.SincetheintroductionoftheHipFractureService,overall30daymortalityhasreducedforthosewhounderwentoperationfrom6.9%to1.3%.Thepercentageofpatientswhohadtowaitmorethan48hoursforsurgeryhasalsobeenhalvedfrom54.7%to27.7%.WearecurrentlyauditingtheratesofUTI,pneumoniaanddeliriumpost-surgerytodeterminetheeffectthatOGHFShasinreducingthesemedicalcomplications.
Insummary,fallsandhipfracturesbearasignificantimpactonourincreasingageingpopulation.Alwaysdemandingthebeststandardsforourpatients,NUH’sorthogeriatriccollaborationhasembracedrecommended,evidence-basedguidelinestoprovidemulti-disciplinarycare.Thisiswiththesoleaimofimprovingourelderlypatientscarepathwayfromadmissiontohomeandbackintothecommunity,improvinglongtermoutcomeandfunction,whilstreducingcurrentandfuturecomplications…atrulyholisticapproach!
NUH Orthogeriatric Hip Fracture Service – A Holistic Approach
KNEE OSTEOARTHRITIS:5W’S + H
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 11
12 médico APR -JUN 2016
The knee is the archetypal example of a joint that undergoes degenerative changes with increasing age, due to its weight-bearing status throughout life, propensity to injury in sports and accidents, joint morphology and inherent lack of mechanical stability, and high degree of mobility leading to increased contact stresses. When the typical, and often naturally irreversible, features of joint damage occur, knee osteoarthritis ensues.
The approach to knee osteoarthritis may be encapsulated in the common mnemonic 5W’s +H: What, Where, Who, When, Why and How.
WHAT CONSTITUTES KNEE OSTEOARTHRITIS?Biologically,kneeosteoarthritisoccurswhenthearticularcartilagehasbecomedegenerateoversignificantareas,associatedwithchangesintheunderlyingsubchondralbone.Thisisdistinctfromacuteorepisodicinjuriestolimitedareasofcartilage(chondraldefects)orcartilageand
underlyingbone(osteochondralinjuries),whichinyoungerindividualsmaystillhavethe
possibleoutcomelimitationandhealing.Inosteoarthritis,thedamageistoomuchortooextensiveforthehealingpotentialtocopewith.Progressivejointdegenerationensues,leadingtoextensivelossofarticularcartilage,formationofosteophytes,andknee
deformitiesinsomecases.Clinically,thisresultsinmechanicalkneepainand
functionalimpairment.
Intheambulatoryclinicalsetting,itisnotpossibletoseethetissuesofthekneejointdirectly,andsox-raysareconvenientlyemployedtovisualisethebonystructuresofthejoint.Thespecificfeaturesthatindicateosteoarthritisarelistedbelow:
Associatedradiologicalfeaturesthatmaybepresentincludekneejointdeformity,mostoftenvarusbutsometimesvalgus,andinseverecases,jointincongruityandsubluxation.
Figure2:X-raysofbothkneesinaweight-bearinganteroposteriorview,demonstratingsevereosteoarthritiswithmarkedvarusdeformity.
WHERE DOES THE OSTEOARTHRITIS USUALLy OCCUR IN THE KNEE jOINT?
Mostcasesofprimarykneeosteoarthritisoccurinthemedialcompartmentofthekneeintheearlystages.
Narrowing or loss of joint space (bestseeninweight-bearinganteroposteriorviewforthetibiofemoraljoint,andskylineviewforthepatellofemoraljoint)
Presence of osteophytes
Subchondral sclerosis
Formation of subchondral cysts(whichareoftenalatefeatureinkneeosteoarthritisandmaynotbepresent)
Figure1:Specificfeaturesthatindicateosteoarthritis.
Knee Osteoarthritis: 5W’s + H
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 13
Thisoccursasthemedialcompartmenttakes60%ofthestressesduringweight-bearingactivities,whilethelateralcompartmenttakes40%,henceisrelativelyspared.Inkneesthataredevelopmentallyvarusinalignment,whicharecommoninEastAsianraces,theloadingonthemedialcompartmentisfurtherexaggerated,leadingtoearlieronsetofwearandtear.Thenextcommoncompartmentaffectedisthepatellofemoraljoint,withafemalepreponderanceandcontributedbypatellarmalalignmentortilt.Patientswithisolatedormainlypatellofemoraldiseasetypicallyhaveproblemswithstairsandsquatting,whilewalkingonflatgroundislesstroublesome.
Figure3:Skylinex-raydemonstratingpatellofemoralosteoarthritiswithmarkedosteophyteformationintherightknee(leftofpicture)andpatellarmaltrackingwithlossofjointspaceintheleftknee(rightofpicture).
Lateralcompartmentkneeosteoarthritisislesscommon,andassociatedwithpreviouslateralmeniscusinjuryorsurgery,lateralfemoralcondylehypoplasia,orincasesofburnt-outrheumatoidarthritiswithsecondaryosteoarthritis.Otherformsofinflammatoryarthritis(e.g.crystalarthropathiesandsero-negativearthritides)mayalsoresultinsecondaryosteoarthritisintheirlaterstages,oftenpan-articularinnature.
WHO GETS KNEE OSTEOARTHRITIS AND WHEN?
Population-basedstudieshaveestablishedcertainriskfactorsforprevalenceofradiographicandsymptomatickneeosteoarthritis.Femalepreponderancehasbeenascertainedinanumberofstudies,andobesityprecedesandincreasestheriskofkneeosteoarthritis,especiallyinwomen.Otherriskfactorsdocumentedtobeimportantasriskfactorsfordiseaseincludekneeinjury,chondrocalcinosis,andoccupationalkneebendingandphysicallabour(Felson1990).SpecificstudiesinAsianpopulationshavefoundthatactivitiessuchasprolongedsquattingarestrongriskfactorsforkneeosteoarthritis,withsignificantdifferenceinprevalenceoftibiofemoralosteoarthritisbetweenChinesesubjectsandCaucasians(Zhangetal.2004).Increasingageisamajorfactor,andithasbeenestimatedthatapproximately13%ofwomenand10%ofmenaged60yearsandolderhavesymptomatickneeosteoarthritis(Heidari2011).
WHy DOES KNEE OSTEOARTHRITIS OCCUR?
Kneejointdegenerationistheresultofbothbiologicalandmechanicalevents.Atthetissueandcellularlevel,withageingthereisadisturbedbalancebetweendegradationandsynthesisofarticularcartilage,extracellularmatrixandsubchondralbone.Thisleadstoaweakeninganddisruptionofthecartilagesurface,whichprogressivelydeepenstoinvolvethesubchondralbone.Cellulardegenerationresultsintheabnormalexpressionofvariousgrowthfactors,whichmaycontributetodisruptionofthebarrierbetweencartilageandbone,andleadtodevelopmentofosteophytes.
Figure4:Secondaryosteoarthritisduetogout,showingchalkywhitedepositsofuratecrystalsseenduringtotalkneereplacementsurgery.
Knee Osteoarthritis: 5W’s + H
14 médico APR -JUN 2016
Figure5:Histologicalslideontherightshowsnormalarticularcartilage.Pictureonleftshowsdegenerateosteoarthriticcartilage.(Fromauthor’sowncollection)
Mechanically,damagetothejointandarticularcartilagemayoccurwhenthereisimbalancebetweentissuestrengthandforcesactingonthejoint.Inonescenario,normalcartilageloadedbyabnormalforceswillresultinchondralinjury,andifsuchforcesarepersistentthedamagethenbecomesprogressive,suchasinobesity.Inparticular,squattingisverystressfulonthekneejointasitcanproduceaforcethatissixtimesbodyweightthroughtheknee.Conversely,inabnormal,weakenedorageingcartilage,reducedresiliencecanmeanthatevennear-normalforcescanresultinjointdamage.Onecommonscenarioisinageingmeniscithatresisttwistingforcespoorly,andtheresultantdegeneratemeniscaltearscanendinonsetofosteoarthritis.
HOW CAN THIS CONDITION bE MANAGED?
Itisimportanttotreatthepatientasawhole,ratherthanjustconcentratingonthekneepathology.Generalmeasuressuchasmodificationofactivitiestoreduceoravoidstressfulactivitiessuchassquattingandkneelingcanbebeneficialinslowingtheprogressionofdisease,especiallyintheearlierstages.Holisticapproacheslookingatweightloss,musclestrengtheningwithphysiotherapy,andinmoreseverecasesoff-loadingthekneejoints
withwalkingaidscanhelpwithpainrelief,functionandgeneralwell-being,ascan
simpleanalgesicsandtopicaltherapies.Adjuncttreatmentssuchasjointsupplementsandhyaluronicintra-articularinjectionsarestilldebatedastotheirefficacyandmodesofaction.Inallcases,riskversusbenefitratiosneedtobe
evaluated.
Attheprimaryhealthcarelevel,muchcanbedonetoalleviatethepatient’ssuffering.However,
areferraltoaspecialistorthopaedicorkneeserviceshouldbeconsideredwhenthesymptomsarenotmanagedadequatelybyconservativemeans,whenthepatient’sdisabilityand/ordeformityissignificantorprogressive,orwhentherearered-flagfeaturesofamoreseriouspathology,suchasnon-mechanicalpain.
Head & Senior ConsultantDepartment of Orthopaedic SurgeryDivision of Hip and Knee SurgeryUniversity Orthopaedic, Hand and Reconstructive Microsurgery Cluster
AssociateProfessorWilsonWangisHeadoftheDepartmentofOrthopaedicSurgeryattheNUHandattheYongLooLinSchoolofMedicine,NationalUniversityofSingapore(NUS),andalsoHeadofDivisionofHipandKneeSurgeryatNUH.HecurrentlyservesasSecretaryoftheASEANArthroplastyAssociation,andasEditor-in-ChiefofthescientificjournalScienceInsightsMedicine.AssocProfWangcompletedhismedicaldegreewithdistinctionsandawardsatUniversityCollegeLondon(UCL),andwasawardedtheGirdlestoneScholarshipbytheUniversityofOxfordforhisDoctorofPhilosophydegree.HisspecialtytraininginkneeandhipsurgerywasattherenownedNuffieldOrthopaedicCentreinOxford,UK.Hespecialisesinawiderangeofkneeandhipprocedures,includingpartial,totalandrevisionjointreplacements;arthroscopicsurgerysuchasligament,cartilageandmeniscalrepairsandreconstructions,andcomplexjointsurgerysuchasmeniscaltransplantsand3Dguidedsurgery.Heleadsaprize-winningprogrammeinorthopaedicresearch,withspecialinterestinhipandkneereconstruction,implants,tissueregeneration,and3Dprintinginmedicaltechnology.
AssociateProfessorWilsonWang
References
1.FelsonDT.Theepidemiologyofkneeosteoarthritis:ResultsfromtheFraminghamosteoarthritisstudy.SeminarsinArthritisandRheumatism,Dec1990,Volume20,Issue3,Supplement1,Pages42–50.
2.ZhangYetal.Associationofsquattingwithincreasedprevalenceofradiographictibiofemoralkneeosteoarthritis:TheBeijingOsteoarthritisStudy.Arthritis&Rheumatism,Volume50,Issue4,pages1187–1192,April2004.
3.HeidariB.Kneeosteoarthritisprevalence,riskfactors,pathogenesisandfeatures.CaspianJInternMed.2011Spring;2(2):205–212.
Knee Osteoarthritis: 5W’s + H
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 15
– A Primer
Adolescent Idiopathic
Scoliosis
16 médico APR -JUN 2016
CLINICAL PRESENTATIONS
Patientsmaypresentwithcomplaintssuchas‘crookedback’,‘prominentshoulder’or‘prominenthip’.Attimes,theymaybepromptedtovisitadoctor,becausetheirseamstressortheballetteachernoticedposturalasymmetry.Painisrarelyapresentingcomplaint.
Leglengthdiscrepancymayresultinapparentscoliosisandshouldbelookedforduringphysicalexamination.
Althoughscoliosisisdefinedaslateraldeviationofthespine,thetorsionalorrotationaldeformityofthevertebraeformsthebasisofthescreeningtestcalledAdamsforwardbendingtest.Theforwardbendingtest(FBT)isperformedwiththechildbendingforwardwhileallowingtheupperextremitiestohangfreely,withthepalmsopposedinarelaxedmanner,andtheexposedbackisviewedfromthefrontaswellasfromtheside(Figure2).Childrenwithscoliometerreadingsof≥5ºwouldrequirex-raysassessment.Truncalshapeisalsoassessed,notingtheshoulderandhipprominence(Figure3).
Figure2:Scoliometerisusedtomeasurethetruncalrotationattheforwardbendingtest.
Figure1:Cobbangle,b°ismeasuredbytheanglesubtendedbythelinesperpendiculartotheendplatesofthevertebra.
Adolescent Idiopathic Scoliosis – A Primer
INTRODUCTION
Scoliosis–athreedimensionaldeformityofthespine,hasbeenrecognisedsinceancienttimes.Ithasbeenmentionedinmythologyinrelationtoevilandassomethingtobefeared.Insomecultures,itisevenperceivedasaformofdivineretribution.Itisnosurprisethatvariousmethodsofmanipulationshavebeendescribedtostraightenthespine.NicholasAndy,aFrenchpaediatricianborninLyonpublishedhisseminarworkin1741titledOrthopédieliterallytranslatedas‘TheartofcorrectingdeformitiesinChildren‘toguidemedicalpractitionersinmanagingscoliosisingrowingspines.Thelegacyofhisworkremainstothisday,notofthecontentbutthetitleofhiswork,wheretheoriginof“Orthopaedics”camefrom.
DEFINITION OF SCOLIOSIS
Scoliosisisdefinedaslateraldeviationofthespineof>10°.Thelateraldeviationismeasuredinaplainpostero-anteriorradiographshowingthespinefromT1toS1withpatientinastandingpositionusingCobbangle(Figure1).Thisistheanglesubtendedbythemosttiltedvertebraeattheirendplates.Cobbangleisusedtodocumenttheprogressionandtheseverityofthescoliosis.
TyPES OF SCOLIOSIS
Scoliosisisdescribedsimplybyitsaetiologyandtimeofonset.Theaetiologycanrangefromcongenital,neuromuscular,syndromic(orsyndromal),idiopathictodegenerativeconditions.GeneralPractitionersaremorelikelytoencounteridiopathicanddegenerativescoliosisintheirday-to-daypractice.Scoliosismaydevelopinvariousstagesoflife.Whenitoccursintoddlersandschool-goingchildrenoflessthan10yearsold,itiscalledearlyonsetscoliosis.Considerationsofspinalheightandpulmonarymaturationareimperativeinthisgroupofpatients.Significantcurvemagnitudesoftenevolvefromthisgroup.
Late onset scoliosisoccursfromadolescenttoadulthood.Adolescentidiopathicscoliosisanddegenerativescoliosisarethecommontypesencountered.Theformerisinvariablypainless;thelatterisoftenpainful.
Thisarticlewillfocusonadolescentidiopathicscoliosiswhichhasapointprevalenceof2-3%inSingapore,andmainlyaffectsgirlsatthepubertyperiod.30%ofthepatientsmayhavefamilyhistoryofscoliosis.
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 17
Figure3:Patientwithscoliosishasalteredtruncalshape.
INvESTIGATIONS:
X-raysaredonetoconfirmthediagnosis.Anoptimalx-rayrequiresalongcassettethatspanstheentirespinalcolumn.Adolescentpatients,especiallygirlswithdevelopingbreastbudsorpatientswithfamilyhistoryofcancers,shouldbeexposedtominimalradiation.Aspecialx-raymachine(EOSImaging)thathasninetimeslessradiationcomparedtoconventionalradiographymachineisusedinNUHtoscreenforscoliosiswhenindicated(Figure4).
Figure4:AnEOSradiographhas1/9ofthedoseoftheconventionalradiography,isideallysuitedforscoliosisfollow-upwhereanx-rayistakeneverysixmonths.
InadditiontotheCobbanglemeasurement,thepatient’sgrowthpotentialisassessed.Clinically,thepatient’sheightistakenateachvisit,theageofmenarcheorchangeofvoiceisdocumented.Radiologically,theapophysisoftheiliaccrestisassessedforbonematurity.Insomeinstanceswheremoreaccuracyisneeded,alefthandx-rayistakentoassesstheboneage.
MRIscanisindicatedwhenthereisasuspicionofunderlyingsyringomyelia,Chiarimal-formation,tetheredspinalcord,tumourorinfection.Intheprimarycaresetting,apainfulscoliosisinanadolescent,orpositiveneurologicalfindings,wouldwarrantfurtherreferralforassessment(Figure5).
Figure5:A16-year-oldpatientpresentedwithbackpainandscoliosis.MRIofthespineshowsL3/4spondylodiscitis(seearrow).
Adolescent Idiopathic Scoliosis – A Primer
18 médico APR -JUN 2016
MANAGEMENT:
Adolescentidiopathicscoliosisisthoughttoberelatedtothegrowingmismatchoftheanteriorandposteriorcolumnofthespine.Thespinalgrowthdrivestheprogressionofthecurve.Patients’whosecurvesare≥25°withsignificantgrowthpotentialareputonrigidbraces.WeinsteinetalinamulticentreprospectivestudythatpublishedinNEJMshowedthatrigidbracingcouldhalttheprogressionofthecurve,providedthattheweartimeis≥12hoursperday.Thereisadose-responserelationshipifthepatientwearsthebracelonger.Temperatureloggerscanbeincorporatedintothebracetodetecttheweartime(Figure6).Thebraceiscustommadetoindividualpatients,ideallywiththecurveinamaximallycorrectedposition,yetwithoutcausingunduediscomforttothepatient.Thebraceisconcealedunderthenormalclothingbearinginmindthatteenagersmaybesensitivetotheopinionoftheirpeers(Figure7).Whilebracingisimportant,patientsareencouragedtocontinuetheirphysicalexercise.BracingisstoppedwhenthegrowthceasestooccurorwhentheCobbangleisbeyond40°.Theaveragebracingdurationisaroundtwoyears.Thenumberneedtotreat(NNT)withbracetoavoidasurgeryisfour.
Thedoctorcantellwhetherthepatientiswearingthebraceatallwithoutaskingthepatient
Figure6:Bracewithtemperaturelogger.
Figure7:Ateenagegirlwearingarigidbraceunderneathhernormalclothing.
Adolescent Idiopathic Scoliosis – A Primer
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 19
ConsultantDivision of SpineDepartment of Orthopaedic SurgeryUniversity Orthopaedics, Hand and Reconstructive Microsurgery Cluster
DrLaucompletedtwoyearsofspinetraininginNUHafterexitingfromorthopaedicadvancedtraining.HethenembarkedonaoneyearclinicalfellowshipprogrammeinpaediatricspineinA.I.duPontHospitalforChildren,Delaware,USA.HewasawardedtheAmericanOrthopaedicAssociation-ASEAN(AOA-ASEAN)travellingfellowshipin2012andtheJapanesePaediatricOrthopaedicAssociationtravellingfellowshipin2014.Hespecialisesinallaspectsofthespinecareparticularlyspinaldisordersinchildren.
DrLauLeokLim
Figure8:Thispatienthadacurvewithamagnitudeof55°Cobbangle,pre-operatively(leftradiograph).Withsurgery,thecurveimprovedsignificantly(rightradiograph).
Surgeryisindicatedwhenthecurveexceeds45-50°(Figure8).ThebasisofthisisbornefromastudyofthenaturalhistoryofadolescentidiopathicscoliosisfromIowa,USA.Modernsurgicaltechniquesthatentailtheusageofreal-timespinalcordmonitoring,bloodsalvage,antibioticsandsafeinsertionofpediclescrewsminimisecomplications.Theemphasisofpainmanagementhasshortenedthehospitalstaytoaroundthreetofivedays.Patientsoftenreturntoschoolinfourtosixweeksaftersurgery.Long-termstudiesonpatientsafterscoliosissurgeryusingoldergenerationimplantsshowednosignificantdifferencesinsociallife,qualityoflifeandchildbearingissuescomparedtonormalpopulation.
Adolescent Idiopathic Scoliosis – A Primer
20 médico APR -JUN 2016
INTRODUCTION
Wristpainhasbeendescribedasthelowerbackpainoftheupperlimbandwhilesomeamongstuswoulddisputethis,therearesomesimilarities.First,wristpainisverycommon.Arecentsystematicreviewplacedtheprevalenceofwristpainat32%to73%inayoungactivepopulation.Second,wristpaincanbedebilitatingespeciallywhenitaffectsgripstrengthandrestrictswristrangeofmotion.Asaresultofthis,activitiesofdailylivingareadverselyaffectedwhilesomevocationalandleisureactivitiesarecurtailed.Wristpainisalsodifficulttodiagnoseandasaresultsometimesdifficulttotreat.Likethelumbarspine,manystructuresthatcangeneratepainarefoundwithininaverysmallarea,makingpinpointingtheexactanatomicallocationratherchallenging.Fortunately,notallsimilaritieswithlowerbackpainarenegative.Akintolowerbackpain,wristpaincanbetreatedintheearlystageswithrestandactivitymodification.Thisinvolvesrefraining,ifpossible,fromactionsthatelicitpaine.g.switchingfromtraditionalpush-ups(Figure1)withthewristextendedto‘knuckle’push-upswhichkeepthewristinneutral(Figure2).Lastbutnotleast,surgicaltreatmentforwristpathology,likespineproblems,canoftenbesuccessfulifthecorrectdiagnosisismadeandallotherconservativeavenueshavebeenexhausted.
Figure1 Figure2
Wrist pain -
LOCATING SOURCE OF THE PAIN
Onewaytostarttheprocessofidentifyingtheanatomicalstructureandthepathologyaffectingitistoclassifythewristpainintoeither“radialsidedwristpain(RSWP)”or“ulnarsidedwristpain(USWP)”.ThisisusefulastheconditionsthatcauseRSWPandUSWParelargelydistinct.
Top causes and their patient profilesThetopthreecausesofRSWPareDeQuervain’stenosynovitis,1stcarpometacarpalosteoarthritisandscapholunateligamentpathology(Figure3).DeQuervain’stenosynovitisiscausedbyinflammationwithinthefirstextensorcompartmentofthewristthereforeresultinginRSWPespeciallywithmovementofthethumb.Womenintheperipartumperiodareespeciallypronetothis.1stcarpometacarpalosteoarthritisisadegenerativeconditionthataffectsusuallyinthe5thdecadeoflifeandalthoughitoccursinbothgenders,thereisapreponderanceforfemales.Patientscomplainofpainatthebaseofthethumbassociatedwithpinchandgripaswellaslossofhandspan.Scapholunateligamentinjuryoccursmoreoftenintheyoung
the lower back pain of the upper limb
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 21
Figure4Figure3
activepopulationafterafallontheoutstretchedhandandtypicallytroublesthepatientwhenthewristisaxiallyloadedinextremeextension.Anothercauseofpainwhenassociatedwithamassisadorsalwristganglion(Figure4).
ThethreecommoncausesofUSWParetriangularfibrocartiligenouscomplex(TFCC)tears,extensorcarpiulnaris(ECU)pathologyandulnocarpalimpaction(Figure5).Whilenotabsolute,theseconditionstendtoaffectpatientsintheiryouthtomiddleage.PatientswithTFCCtearsusuallyreportUSWPafterafalloracutetwistinginjurye.g.fromliftingweightsinthegym.ECUpathologyintheformofECUtendinitisorECUsubluxationistypicallymoreinsidiousononsetwiththeUSWPassociatedwith‘clicking’atthewristforthelattercondition.Lastly,ulnocarpalimpactioncanoccurinpatientswhonaturallyhaveanulnathatislongerthantheradius,oritcouldbeacquiredinpatientsafterconservativelytreateddistalradiusfractureswhentheradiushealsinashortenedposition(Figure6).Themalunionofadistalradiusfracturemayalsoleadtodistalradioulnarjointincongruitywitheventualpost-traumaticosteoarthritisandsubsequentcausethepatientUSWP.
Examination of the patient
Afternotingthepatientprofileandtheirsymptomsasbrieflyoutlinedinthepreviousparagraph,examinationofthepatientisparamounttoreachapreliminarydiagnosis.Firmpalpationandtheelicitingofpainasaresult,isthekeytoidentifyingthepaingeneratingstructureinthewrist.Ontheradialsidefromdistaltoproximal,tendernessatthebaseofthethumbmetacarpalwouldindicate1stcarpometacarpalosteoarthritis,tendernessattheradialstyloidmayindicateDeQuervain’stenosynovitisandtenderness1cmdistaltoLister’stuberclemaysignifyscapholunateligamentpathology(Figure3).Ontheulnarside,againfromdistaltoproximal,tendernessintheulnarfovea(thesoftspotdistaltotheulnarhead,inbetweentheECUandflexorcarpiulnaris)mayindicate
Figure5 Figure6
Wrist Pain - The Lower Back Pain of the Upper Limb
22 médico APR -JUN 2016
aTFCCtearorulnocarpalimpactionwhiletendernessovertheECUasitcoursesovertheulnarheadmaypointtoECUpathology(Figure5).
Althoughthereisahostofspecialteststofurthernarrowthediagnosis,acomprehensivereviewofthemwouldbebeyondthescopeofthisarticle.Havingsaidthat,forRSWP,itisworthmentioningthegrindtest,theFinkelstein’stestandtheWatsonshiftmaneuverfor1stcarpometacarpaljointosteoarthritis,DeQuervain’stenosynovitisandscapholunateligamentpathologyrespectively.ForUSWP,thefoveasignisausefulwayofdetectingpathologyoftheTFCC.
Confirming the diagnosis
WhileDeQuervain’stenosynovitisandECUpathologyistypicallyconfirmedclinically,plainradiographsareespeciallyusefulinshowing1stcarpometacarpaljointosteoarthritis(Figure7)andscapholunateintervalwidening(Figure8),whichisanindicatorofsignificantscapholunateligamentpathology.MRIscansareusefulfordiagnosingTFCCtears,ulnocarpalimpactionandscapholunateligamentpathology,althoughdiagnosticarthroscopyisarguablythegoldstandardtoolforthispurpose(Figure9).Inaddition,arthroscopycanalsodiagnosesecondaryproblemssuchascartilagewearandultimately,osteoarthritis.
TREATING THE PAINConservative measures
Fortunately,thefirstlineoftreatmentofalltheseconditionsthatinvolvesrest,splintageanduseofanti-inflammatorymedicationiseffectiveforthegreatmajorityofpatientswhopresenttotheclinicforthefirsttime.Fortheunfortunateminorityinwhomthesymptomsrecurorfailtoabateadequately,intra-lesionalsteroidinjectionsarealsohighlyeffective,atleastintheshortterm.Infact,forcertaincasesofDeQuervain’stenosynovitisandECUtendinitis,thesesteroidinjectionsmayserveasdefinitivetreatmentwithopensurgeryreservedforthemostintractableofcases.
Wrist arthroscopy as a useful tool
Afterrulingouttenosynovitisastheprimarycauseofpain,wristarthroscopyshouldbeconsideredinpatientswhohavefailedatrialofconservativetreatment.Thisminimallyinvasiveproceduremaybeperformedunderregionalanaesthesiaandconscioussedation,avoidingmostoftherisksofgeneralanaesthesia.Duringthisprocedure,athoroughassessmentoftheintra-articularstructuresmaybeperformed,withdirectvisualisationoftheligamentsaswellasarticularsurfaces.Inthecaseofearlystagescapholunateligamentpathology,theligamentcanbetreatedwiththermalshrinkage.TFCCtearscanalsoberepaired,paingeneratingsynovitisremovedandmicro-fracturetreatmentperformedforcartilagedefects,allthroughfour5mmincisionsoverthebackofthewrist(Figure10).Inaddition,dorsalwristganglionscanbedecompressedwithwristarthroscopywithouttheneedforalargescar.
Figure7 Figure8
Figure9
Wrist Pain - The Lower Back Pain of the Upper Limb
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 23
ConsultantDepartment of Hand & Reconstructive MicrosurgeryUniversity of Orthopaedics, Hand and Reconstructive Microsurgery Cluster
DrAndreCheahcompletedhisundergraduatemedicaldegreeattheNationalUniversityofSingaporein2003andobtainedhisMastersinMedicine(Surgery)in2007.HeattainedhisSpecialistAccreditationBoardcertificationinHandSurgeryin2010andwontheCollegeofSurgeonsGoldMedalinHandSurgeryforthebestperformingcandidatethatsameyear.In2012,heobtainedhisMastersinBusinessAdministrationfromINSEADandunderwentfurthertrainingin2015attheRobertChaseHandandUpperLimbCenter,StanfordUniversityMedicalCenter.Hehasclinicalandresearchinterestsinwristandotherjointproblemsoftheupperlimb,includingdeformitycorrection,managementofcomplexinjuriesandminimallyinvasivesurgeryincludingarthroscopyandendoscopy.
AssistantProfessorAndreCheah
CONCLUSION
Whilethesimilaritiesbetweenwristpainandlowerbackpainweredescribedearlierinthearticle,itisfittingtopointoutadifference.Wristpain,onanaverage,affectstheactiveandyoungatheartmorethanlowerbackpain.Wristpaintroublespatientsattheprimeoftheirlife,affectingtheirwork,leisureactivitiesandevendisturbsthequalitytimeayoungmotherneedstospendwithhernewborn.Fortunatelyformostofourpatients,wristpainisverytreatableonceaccuratediagnoseshavebeenmadeandappropriatetreatmentrecommendedtothem.
Figure10
Wrist Pain - The Lower Back Pain of the Upper Limb
24 médico APR -JUN 2016
Specialist in Focus
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Dr Mark Puhaindran
One of your clinical interests is in tumours of the musculoskeletal system. How did you get started in it?WhenIwasamedicalstudent,IdidanorthopaedicsurgerypostingatNUH,andgottospendsometimewithProfessorRobertPho.Itwasaprivilegetolearnfromthisworldpioneerinmusculoskeletaloncology.Whatinspiredmethemostwastoseesomeofhispatientswalkingintohisclinic,some10-15yearsaftercancersurgery.Notonlyhadhehelpedthemtobeatthecancer,healsomanagedtopreservetheirlimbsandqualityoflife,usingtechniquesthathedevelopedlocally.Iappliedtocomebackasatrainee,andwasfortunatetobeaccepted.Ithasbeen20yearssinceIfirstmetProfPho,andIstillgotohimforadviceonpatientcare,andmanyotherthings.WeareuniqueinNUHinhavingsuchexperiencedmentorsaround,withawealthofknowledgeandexperiencethatwecantapon.
you do both hand and reconstructive microsurgery, and musculoskeletal oncology. Why is this so?ProfPhowastheheadoftheDepartmentofHandandReconstructiveMicrosurgerywhenIbecameaMedicalOfficerin1999.IwasadvisedbyaseniortodoarotationatthedepartmentasIwouldbe“welltrained”.Hewasright–lifewastoughandweworkedreallyhard,butwelearnedalottoo.Eventhoughthebosseswerestrictanddemandedthebestfromus,theyalsocaredandwatchedoutfortheirjuniorstaff.ThatiswhyIaskedtocomeback.Aftercompletingmyadvancedspecialtytraininginhandsurgery,IdidfurthertraininginmusculoskeletaloncologywithProfPhoaswellasaclinicalfellowshipatMemorialSloan-KetteringCancerCenterintheUS.
The Hand & Reconstructive Microsurgery Centre (HRM Centre) at NUH is a one-stop centre for all hand, wrist and upper limb conditions. How do the services and facilities at the HRM Centre benefit patients?Wetrytomakeitasconvenientaspossibleforourpatients,bylocatingallourservicesandstaff(nurses,handtherapistsanddoctors)togetherinonecentre.Wewanttodecreasetheamountof“runningaround”thatourpatients
needtodo,aswellasthetimespentwaitingandcostforthem,whileprovidingthebestpatientcarethatwecanforthem.
What conditions does the HRM Centre see most commonly? Do you think there will be more referrals from primary healthcare/GPs in the future, and for what conditions?Weseepatientswithinjurieslikefracturesoftheirhandandwrist,handandwristarthritis,aswellaspatientswithcarpaltunnelsyndromeandtriggerfingers.WearealsoseeinganincreaseinpatientswithhandinfectionsduetothehighincidenceofdiabetesinSingapore.Weexpecttoseeevenmorepatientswithhandinfectionsinthefuture,aswellasmorepatientswithdegenerativeconditionsofthehands,becauseofouragingpopulation.
Could you share with us an interesting fact about our hands?Ithinkwedonotappreciatehowimportanttheyareuntilwe“lose”them,whetherthroughinjuryor
SpecialistinFocus:
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University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 25
Picture 1:Oneofthegreatestrewardsforusiswhenourpatientsgettoreturntotheactivitiesthatthelove.Thispicturewassenttomebyoneofmycancerpatientswhoreturnedtoplayinggolfwithinsixmonthsofsurgery(abitearlierthanIhadadvised!).
Picture 2:Thehandsurgerydepartmentisacloselyknitteam.Overtime,ourchildrenhavealsobecomefriends.WerecentlywentforacampingtripatMtOphirwithoursons.
Picture 3:Manyoverseasfellowshavebeentrainedatourdepartment,andtheyhavegonebackhometoestablishexcellenthandandreconstructivemicrosurgeryunitsintheirrespectivecountries.Thishasallowedustowidentheoutreachofourdepartment,tohelpraisethestandardofhandsurgeryintheregion,andtheworld.Theyalsobecomelifelongfriends,whomwegettovisitandmeetatinternationalconferences.
DrMarkPuhaindranisaSeniorConsultantintheDepartmentofHandandReconstructiveMicrosurgery,andHeadoftheDivisionofMusculoskeletalOncology,UniversityOrthopaedics,HandandReconstructiveMicrosurgeryCluster.HegraduatedfromtheNationalUniversityofSingapore,andtrainedinHandSurgeryattheNationalUniversityHospital,beforedoingafellowshipinMusculoskeletalOncologyatMemorialSloan-KetteringCancerCenter,USA.Sincereturningfromhisfellowship,hehasworkedtopromoteandcoordinatemulti-disciplinarycareforsarcomapatientsinNUH,aswellascollaborationwithcolleaguesacrossinstitutionsinSingapore.Hissub-specialtyinterestsincludetumoursoftheupperextremity,atopicthathehaspublishedseveralresearchpapersandbookchapterson.Theprideandjoyofhislifearehiswifeandthreechildren,whohelphimtorememberwhatthemostimportantthingsinlifeare.Duringhissparetime,hecanbefoundrunningorcyclingalongEastCoastBeach.
persistentpainornumbness.Wehavetotakecareofthem,andavoidmisusingthem,sothattheycancontinuetoworkwellforusthroughourlives.
What is a typical day like for you?Itstartsat715inthemorningwitheitherateachingsessionormeeting.WethendoourwardroundsbeforeheadingtotheOTorclinics,whichstartat830or900.Wetrytofinishthemorningsessionby1230,butfrequentlyoverrun.Theafternoonclinicsessionstartsat1400andweareusuallydoneby1800.Wethenreviewourpatientsinthewardsbeforereturningtotheofficetoreviewpatients’scansandresults,replytoemailsandpreparemedicalreports.Hopefully,Icanbedoneby1930andheadhomeafterthat.
If not medicine, are there other areas that you might have pursued a career in? IwouldhavetriedtobeapilotifIdidnotgetintomedicine.
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26 médico APR -JUN 2016
Happenings @ NUH
UPCOMING EvENTS
Eventinformationlistediscorrectattimeofprint.Whileeveryattemptwillbemadetoensurethatalleventswilltakeplaceasscheduled,theorganisersreservetherightstomakeappropriatechangesshouldtheneedarises.Pleaserefertooureventscalendaratwww.nuh.com.sg/nuh_gplcformoreupdatesandinformation.
+2 APR 2016Fundamentals of Upper GI Diseases and Advances in TreatmentUniversitySurgicalClusterNUHSTowerBlockAuditorium,2pm–4pm
ThissymposiumwillshedlightonthefundamentalsofUpperGIdiseases,andtherationalebehindthetreatmentsofferedtoday.
Topics:Current Treatment for Acid Reflux, Peptic Ulcer and Achalasia | Updates on Esophagogastric CancerAssocProfessorJimmySoHead&SeniorConsultantDivisionofGeneralSurgery(UpperGastrointestinalSurgery)&CentreforObesityManagementandSurgery(COMS)Surgery for Obesity & Metabolic Surgery – An Evidence-based ApproachAsstProfessorAsimShabbirDirector,ClinicalServices&SeniorConsultantDivisionofGeneralSurgery(UpperGastrointestinalSurgery)&CentreforObesityManagementandSurgery(COMS)
9 APR 2016“I CAN!” Doctors’ Symposium 2016 – Essentials in the Practice of Childhood Asthma and AllergiesNUHkidsNUHSTowerBlockAuditorium,2pm–4pm
Topics:Common Skin Manifestations In Childhood AllergyProfessorHugoVanBever“ICAN!”Chairman&SeniorConsultantDivisionofPaediatricAllergy,Immunology&RheumatologyDiagnostics (Proven & Unproven Tests in Diagnosing Allergies and Allergies Diagnostics)AssocProfessorLynetteShekPei-ChiHead&SeniorConsultantDivisionofPaediatricAllergy,Immunology&Rheumatology
7 MAy 2016A Closer Look into Cardiovascular Diagnosis and CareNationalUniversityHeartCentre,Singapore(NUHCS)NUHSTowerBlockAuditorium,2pm–4pm
Thisuniqueeventcomprisesofaseminar,clinictourandahands-onsession,allspeciallydesignedforaninteractiveandin-depthunderstandingoftheservicesandfacilities.Theeventwillcoverheartandvasculardiseases,patients’needsandmonitoringservices,aswellascommonsymptomsandpossiblekeyindicators;causesandriskfactorsandpost-dischargecare.Thehands-onsessionaimstoshareondiagnosticproceduresandresults,andvascularprocedures,allwhichcanhelpwithpatientadviceandmanagement.
28 MAy 2016Common Issues in Developmental Paediatrics NUHkidsNUHSTowerBlockAuditorium,2pm–4pm
Thissessionwillusecase-basedapproachtocoverthreecommonlyencounteredproblemsindevelopmentalpediatrics.
Topics:Managing Common Sleep Disorders in ChildrenDrJenniferKiingSeniorConsultantDivisionofDevelopmentalandBehaviouralPaediatricsMedia Use & Its Developmental EffectsDrSerenaTungSiWunConsultantDivisionofDevelopmentalandBehaviouralPaediatricsDevelopmental Screening in the Primary Care SettingDrKangYingQiAssociateConsultantDivisionofDevelopmentalandBehaviouralPaediatrics
Myths and Facts in Asthma TreatmentDrMaheshBabuRamamurthyHead&SeniorConsultantDivisionofPaediatricPulmonary&Sleep
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 27
Happenings @ NUH
16 jAN 2016NUH ENT Updates for GPs
NUHGPLCstarted2016withanextensivefeastofENTupdatesfortheGPs.TheattendingGPsweretreatedtoanexcitingsessioncoveringfourspecificareas:nasopharyngealcarcinoma,the8thcommonestcanceramongstmeninSingaporebyA/ProfThomasLoh;thyroidnodulesbyDrLimChweeMeng;tinnitusbyProfBillyMartinandobstructivesleepapneabyDrOngYewKuang.
POSTEVENTS HIGHLIGHTS+
30 jAN 2016NUH Orthopaedics Updates for GPs – The Joints
A‘joint’effortbythespecialistsfromtheUniversityOrthopaedics,Hand,andReconstructiveMicrosurgeryCluster(UOHC)resultedinanenjoyablesessionforallattendingGPs.
19 MAR 2016Contemporary Cancer Issues for Primary Care Physicians
Coveringcancerprevention,gastriccancer,andadvancecareplanning,thepracticalaspectsofthesethreeareasprovedtobeahitamongtheattendingGPs,especiallyinhelpingpersonsindifferentstagesofcancertreatmentandprevention.
19 MAR 2016NUH Spine Updates for GPs
SpinesurgeryisarapidlyevolvingfieldandattendingGPswentonanexpressseriesofupdatesonspecificspinetopics.Thefocusedsessionsawaninteractivesessionwheremanagementofcommonspinalconditionswerefreelydiscussed.
Coveringjointsattheknees,foot,ankleandeventhewrist,thepresenters,A/ProfWilsonWang,DrMarkChongandDrDavidTan,gaveaverybeneficialsession,especiallywithmorepatientsseekinghelpforpainatthejoints.
28 médico APR -JUN 2016
GPLCNUH GP Liaison CentreAt the NUH, we recognise the pivotal role general practitioners (GPs) and family physicians play in providing and ensuring that the general public healthcare is of the highest quality and standard. As such, we believe that through closer partnerships, we can deliver more personalised, comprehensive, and efficient medical care for our mutual patients. The GPLC aims to build rapport and facilitate collaboration among GPs, family physicians and our specialists. As a central coordinating point, we provide assistance in areas such as patient referrals, continuing medical education (CME) training, and general enquiries about our hospital’s services.
Through building these important platforms of shared care and communication, we hope that our patients will be the greatest beneficiaries.
NUH CME EventsAt the NUH, we strive to advance health by integrating excellent clinical care, research and education. As part of our mission, we are committed to provide regular CME events for GPs and family physicians. These events aim to provide the latest and relevant clinical updates practical for your patient care.
Organised jointly by the GPLC and the various clinical departments within NUH, our specialists will present different topics in their own areas of specialties in these monthly symposiums.
For more information on our CME events, you can go to www.nuhcme.com.sg or scan the following QR code.
If we could be of any assistance to you, please feel free to contact our office fromMon - Fri : 0900-1200hrs, 1400-1800hrs
GP Appointment Hotline Tel: +65 6772 2000 Fax: +65 6777 8065
GP Liaison CentreTel: +65 6772 2535 / 5079