INSTRUCTIONAL COURSE 46: Patients and Procedures Those to Avoid and Those to Embrace

Transcription

1 INSTRUCTIONAL COURSE 46: Patients and Procedures Those to Avoid and Those to Embrace Handouts Saturday, September 20 * 6:45-7:45 AM 69TH ANNUAL MEETING OF THE ASSH SEPTEMBER 18-20, 2014 BOSTON, MA Moderator(s): Martin A. Posner, MD Faculty: Joseph E. Imbriglia, MD DISCLOSURES No relevant conflicts of interest to disclose (Posner) Speakers Bureau: Auxilium (Imbriglia) 822. West Washington Boulevard Chicago, Illinois Phone: (312) Fax: (847) Web: info@assh.org All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

2 Instruction Course #46: Sept. 20, 2014 Patients and Procedures: Those to Avoid and Those to Embrace Martin A. Posner, M.D. Joseph E. Imbriglia, M.D. Martin Posner, M.D. PATIENTS TO AVOID The education of hand surgeons has traditionally focused on understanding the effects of disease and injury on the upper extremity. However, many patients with organic problems have concomitant behavior problems that may be the predominant problem and, in some case, the entire problem. Many patients with dramatic symptoms have no organic pathology. Recognizing these patients is important because surgery is usually contra-indicated even when there is also an organic problem. While we, as hand surgeons, do not have the ability to treat these patients, we should have the ability to recognize them and refer them for appropriate treatment to psychiatrists or clinical psychologists. Two main categories of patients with non-organic problems: those with emotional or psychiatric disorders and those who are malingerers and are deliberatively deceptive. In some cases, malingering can be superimposed on an emotional problem. I. Conscious motivation: - malingering - patient is deliberately being deceptive for secondary gain, usually economic II. Unconscious motivation: There is no single classification that is generally accepted A. Somatization syndrome: - Patient experiences distressing symptoms and believes they are due to a medical problem - Physicians typically find nothing wrong - Patient continues to seek medical care B. Factitious (not fictitious) disorders common examples - Lymphedema - patient wrap a tourniquet around the wrist, forearm or upper arm - Ulcers that mysteriously appear and often fail to heal - Surgical incisions that fail to heal - Patients with factitious problems are not feigning illness, they are causing illness - They harm themselves in a variety of ways, including amputation - Regardless of the method, they are almost always secretive and will deny harming themselves - Individuals with factitious problems often are not diagnosed for years the problem that was originally non-organic can result in severe tissue damage, particularly factitious lymphadema that often leads to chronic fibrosis and permanent joint contractures 1

3 - Secretan s syndrome a factitious disorder? - hemosiderin in tissues around tendons suggests it may be due to self-induced trauma C. Munchausen syndrome - Named for Hieronymous Karl Friedrich von Munchhausen, an 18 th century nobleman, who became famous for the dramatic and whimsical tales he invented. - Patient seeks treatment for a factitious problem and invents a fanciful history of the problem in order to confound and intrigue the physicians D. SHAFT syndrome passive form of Munchausen s syndrome S = sad H = hostile A = anxious F = frustrating T = tenacious E. Conversion Disorders (conversion hysteria) - Unconscious loss of function patients unaware of psychological basis for their problems - Deficit in motor (paralysis) and/or sensory function (anesthesia) - Freud: substitution of a somatic symptom for a repressed idea F. Clenched Fist Syndrome ( psycho-flexed hand ) a conversion disorder - The fist typically comprising the middle, ring and little fingers that are flexed into the palm is symbolic of repressed rage - These fingers can cause ulcerations in the palm and when the clenched position of the fingers persists for weeks and months, secondary contractures of the PIP joints develop - Thumb and index fingers are usually not affected Many patients with emotional problems do not fit into any of these syndromes and identifying them requires listening carefully to their history and complaints, and correlating their comments to the physical examination are they consistent? - Words and phrases patient s use in relating their history and complaints usually provide an insight into the legitimacy of their reported problem - are their complaints hyperbolic? - When the history does not correspond to objective findings or tests, discard the history Physical examination very little of our examinations is objective 1. Tenderness not objective Can the patient localize the site with a finger tip? - Beware of patients who place their entire palm over a site and relate that the tender area - Beware when tenderness is reported to be severe and there are no local findings, no swelling, discoloration, etc. 2

4 2. Joint motions active and passive motions are not objective measurements - When evaluating passive motions, patients who resist by forcefully contracting their muscles are usually being deceptive - Re-evaluate passive motions when patient is distracted such as when evaluating sensibility - Patients who claim they are unable to actively flex and/or extend their fingers but are able to actively hold them in positions that they are passively placed by the examiner are malingering - These are Gumby fingers and they are not due to any organic pathology 3. Muscle force - not an objective measurement (since it requires patient s cooperation) - Important to determine if there is muscle atrophy - Measuring the girths of both forearms and both hands are objective measurements - Measurements in the affected extremity are then compared to those in the other extremity - Significant if there is no decrease in girth yet patient reports unable to use that hand f - Patient s with Gumby fingers usually have no muscle atrophy 4. Sensibility evaluation - not objective - Does numbness correspond to an anatomical distribution? - Beware of numbness that is inconsistent in distribution and severity - Two-point discrimination when patient consistently reports one when two points applied and two when one point applied, the only explanation is malingering - When patient claims anesthesia, is there an absence of perspiration and trophic skin changes? Patients to avoid general caveats: 1. Those with unrealistic goals includes children whose parents have unrealistic goals 2. Those who have had multiple operations by different surgeons and don t improve 3. Angry patients who don t focus that anger on a particular episode or individual - OK to operate on neurotic patients provided they are benign avoid malignant neurotics whose anger is free floating 4. Adolescent patients, usually female, who have chronic wrist pain without any abnormal objective findings and normal x-rays. References 1. The Upper Extremity and Psychiatric Illness. Louis, Lamp, Green, JHS 10A: , The S-H-A-F-T Syndrome in the Upper Extremity. Wallace, Fitzmorris, JHS 3: , Factitious Lymphedema of the Hand. Smith RJ, J Bone Joint Surg 57A:89-94, Factitious Disorders of the Upper Limb. Burke, JHS 33E: , , Expanded Profile if the SHAFT Syndrome. Kasdan, Soergel,et al, JHS 23A:26-31, Factitious Injuries of the Upper Extremity. Kasdan, Stutts, JHS 20A: S57-S60, Factitious Disorders of the Upper Extremity. Birman MV, Lee DH, JAAOS 20:78-85, Peritendinous Fibrosis of the Dorsum of the Hand. Van Demark, Koucky, Fischer, J Bone Joint Surg 30A , Classification System for Factitious Syndromes in the Hand with Implications for Treatment. Gunnert BK, Sanger JR, Matloub HS, Yousif NJ, JHS 16A; , Recognition of Factitial Hand Injuries. Carlson MJ, Linscheid RL, Lucas AR, Clin Orthop and Related Research 122: ,1977 3

5 Joseph E. Imbriglia, M.D. - PROCEDURES I NO LONGER PERFORM 1. Medial Epicondylectomy and Submuscular Transposition of the Ulnar Nerve - Both procedures yield 85 to 90% good results according to the literature. In situ release achieves the same results long term with much less morbidity in the short term (six weeks). - There are also significant complications associated with epicondylectomy and submuscular transposition. Epicondylectomy - flexion contracture of the elbow Submuscular transposition - ulnar nerve neuropraxia or worse 2. External fixation for distal radius fractures - With better internal fixation devices available, including internal spanning distraction plates, we rarely use external fixation. - We continue to see complications from ext fixation including radial sensory nerve problems and contractures of small joints. The x-ray may look fine but the hand doesn't work and is painful. 3. Extensive fasciectomy for Dupuytren s contracture - I now use XIAFLEX when appropriate as the initial treatment. - In more severe cases with marked PIP involvement I make transverse incisions in both the palm and fingers. I leave the palm open (McCash technique) and skin graft the skin defects in the fingers. This approach decreases morbidity and results in faster overall recovery. - Smaller incisions result in less pain and swelling --- better early ROM References Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. 2005, 56: Bartels RH, Termeer EH, van der Wilt GJ, van Rossum LG, Meulstee J, Verhagen WI, Grotenhuis JA. Simple decompression or anterior subcutaneous transposition for ulnar neuropathy at the elbow: a cost-minimization analysis Part 2. Neurosurgery. 2005;56: Dellon AL, Chang E, Coert JH, Campbell KR: Intraneural ulnar nerve pressure changes related to operative techniques for cubital tunnel decompression. J Hand Surg [Am] 19A: ,

6 Gelberman RH, Yamaguchi K, Hollstien SB et al. Changes in interstitial pressure and crosssectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavers. J Bone Joint Surg Am. 1998, 80: Gervasio O, Gambardella G, Zaccone C, Branca D. Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study. Neurosurgery. 2005, 56: Karthik K, Nanda R, Storey S, Stothard J. Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression. J Hand Surg Eur Vol : 115 Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where s the evidence? J Bone Joint Surg Am. 2008;90: Margaliot Z, Haase SC, Chung KC et al. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg (Am). 2005;30A(6): Orbay JL. The treatment of unstable distal radius fractures with volar fixation. J.Hand Surg Dec;5(2): Richard MJ, Wartinbee DA, Ruch DS et al. Analysis of the Complications of Palmar plating verus external fixation for fractures of the distal radius. J Hand Surg (Am). 2011;36A: Wilcke MK, Abbaszadegan H, Adolphson PY. Wrist function recovers more rapidly after volar locked plating than after external fixation but the outcomes are similar after 1 year. Acta Orthop. 2011:82(1):76-81 Van Rijssen AL, Gerbrandy FS, Werker PM et al. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren's disease: a 6-week follow-up study. J Hand Surg (Am) 2006 May-Jun;31(5): Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007, 89: