Friday, 9 June 2017

Weakness or non working hand of new born, what parents need to know

Obstratic brachial Plexus Palsy {OBPP}


A brachial plexus injury, also known as neonatal brachial plexus palsy (BPP), is when a newborn experienced arm weakness , or complete loss of function of the arm.  Science have learned a great deal about the causes and dangers associated with harm to the brachial plexus, yet it still remains one of the most common types of birth injuries today, affecting thousands of infants each year. 

Causes of OBPP/ Birth Palsy

The brachial plexus is a group of

 nerve fibers that run from the spine and through the neck into the arms. When an infant experiences a brachial plexus injury, it can happen to any part of the nerve fibers, and can range in severity depending upon the location of the injury and how it happened. One of the most common causes of infant brachial plexus include excessive stretching and force during labor and delivery. In most instances, the delivery is stressful and difficult, often marked by the use of birth-assistance tools such as forceps or a vacuum extraction tool. Other causes include:
  • A breech delivery
  • Large infant weight and size (fetal macrosomia)
  • The infant’s shoulders lodged in the mother’s pelvic area
  • Maternal diabetes
  • Underdeveloped muscles in the neck
  • Maternal obesity

Even if birth-assisting tools are not used, brachial plexus injuries can occur if a doctor applies improper pressure and force on the baby while delivery by hand. For instance, infant shoulder dystocia occurs when the baby’s head is delivered but the shoulders remain lodged in the mother’s pelvic area. In an attempt to delivery the infant before asphyxia or any other dangerous medical complication occurs, a physician may pull the baby’s shoulders with excessive force.  This can lead to tearing and stretching the brachial plexus nerves.
In some instances, contractions may cause brachial plexus injuries. If the labor is prolonged and the baby is stuck in the birth canal, the mother’s contractions can place stress on the infant’s shoulders, head, and upper arms, leading to bruising, tearing, and in some rare cases, fractures.

Types of Brachial Plexus Injuries

There are several types of brachial plexus injuries, some more common than others, and as previously stated, some more severe and serious than others.

Neurapraxia

Neuropraxia, the most common and least severe type of brachial plexus injury, is marked by minor strains or tears in the brachial plexus nerves. Since it’s the the mildest brachial plexus injury, it usually clears up on its own within a few months. Neurapraxia injuries affect the protective lining and covering of the nerve, yet the actual nerve is usually unharmed. Regardless, this type of injury can bring on pain and difficulties until it clears up.  Symptoms of neurapraxia can include:
  • Muscle weakness in the affected area
  • Burning, tingling, and/or numbness in the affected area
  • Extreme sensitivity in the affected area
  • Sensation disturbances

Erb’s Palsy (Rupture)

Erb’s palsy is often referred to as another name for BPP. It occurs when the brachial plexus nerves in the upper arm are damaged. It’s also known as Erb’s palsy rupture or rupture of the brachial plexus. Erb’s palsy will range in severity depending upon how the injury happened. Some of the dangers of Erb’s palsy include:
  • Full or partial paralysis in the affected arm
  • Loss of sensory and/or motor function in the affected arm
  • Decreased grip and arm numbness in the affected arm
  • The affected arm may be bent towards the body or hang limp
Depending on how serious the injury is, Erb’s palsy treatment options include:
  • Medications
  • Surgery
  • Physical therapy
  • Massaging the affected arm regularly

Neuroma

Neuroma occurs when the scar tissue grows around and over the injury, causing excessive pressure on the injured nerve. This is turn makes it difficult for the affected nerve to send signals the muscles. Neuroma may clear up on its own if the scar tissue is small and minor. However, if it’s too large, surgery may be required to remove the scar tissue.
Neurolysis, a treatment in which agents (hot and cold packs or chemicals such as alcohol)  are applied to affected area, is the most popular treatment for infants with neuroma. According to the National Institutes of Health (NIH), more than 50% of patients with brachial plexus injuries experienced success after neurolysis treatment.

Symptoms of Brachial Plexus Injuries

The symptoms of a brachial plexus injury usually surfaces shortly after birth. As mentioned earlier, the symptoms may include:
  • No Moro Reflex on the affected side
  • Limited or no movement on the affected side
  • Claw-like hand appearance
  • Abnormal muscle contractions, which may become permanent, even after treatment options

How is a Brachial Plexus Injury Determined?

In order to diagnose a brachial plexus injury, physicians may go through a series of tests and evaluations. For example, a motor evaluation determines how the muscles function via a five-point grading system that assesses an infant’s ability or inability to use certain muscles.
A Moro Reflex test is also usually administered to test for absent reflexes in the affected area. In addition, physicians will perform a physical examination, sometimes including X-rays, to look for any fractures to the clavicle bone.

Brachial Plexus Treatment Options

As aformentioned, treatment will depend upon how severe the injury is and what type of injury occurred. While some infants will go on the heal naturally or with the help of physical therapy, others my require surgery and medication.
Surgery for brachial plexus injuries may include a medical procedure known as a “nerve transfer.” A nerve transfer allows doctors to take a healthy, functioning nerve from a muscle that is used less often, known as nerve grafting, and transfer it to the damaged nerve. Although it may not completely treat a brachial plexus injury, studies suggests that many infants who underwent nerve transfer surgery were able to recover and use the damaged area.
It’s important to note that surgery is usually reserved until three months after the injury occurred. Since the majority of babies who experience brachial plexus injuries recover within the first three months or so, doctors usually wait to see if the injury heals on its own. During this time period, however, physical therapy and daily massaging of the damaged area may be recommended.
The goal of physical therapy is help infants develop the muscles in the affected area and eventually go on to have full use of the damaged arm, hand, and/or wrist. Massaging, range-of-motion activities, stretching, and exercises are all typical physical therapy activities. Although physical therapy may start without surgery, it is almost always recommended after an infant undergoes any surgical procedures.
Medication is primarily used for pain and to help relax muscles for those who have tight, painful contractions. If surgery is required, the baby will be given a light anesthesia medication for pain.

Brachial Plexus Injury Prognosis and Outlook

Most infants fully heal from their brachial plexus injuries. However, the outlook for those who don’t heal within three to six months still remains unclear. Although studies have shown that many people go on to have better use of their damaged areas after surgery and treatment, there are still not enough studies and research performed to indicate a clear prognosis.
In addition, the more serious the injury is, the less chance of a full recovery. According to the NYU Langone Medical Center, the success rate for severe injuries are at 50%, meaning that the patients have a 50% chance of recovering and having full use of the affected area. For less severe brachial plexus injuries that still require surgery, there may be a success rate as high as 90%.
It’s important to note, however, that each injury and each situation is unique. Physicians will work with the parents and explain the chances of recovery according to the baby’s specific injuries. Wound infections, although uncommon, may develop after surgery.
Additionally, difficulties with breathing, artery and vein damage, and paralysis are all risks of surgery. Fortunately, all of these risks are extremely rare and most infants heal without additional trauma. The area may be swollen and infants may be experience numbness in the affected area for a while after surgery, but this typically diminishes within a few weeks after the procedure.

Friday, 11 April 2014

Traumatic Brachial Plexus Injury

Definition

CT myelogram
CT myelogram revealing a
small fluid collection indicating
rootlet avulsion from the spinal
cord (above). Fluid collections are
also seen near other spinal
nerves (small arrows, lower image).
The brachial plexus (brachial means arm and plexus mean communication or meeting point) refers to the nerves that exit the cervical spine and pass down to the shoulder and arm. Five major nerves comprise the brachial plexus: C5, C6, C7, C8, and T1 (C refers to cervical [or neck] and T refers to thorax [or chest]). These nerve pass under the skin in the neck and axilla, where they are vulnerable to injury. When the neck and arm are forced away from each other during trauma (e.g., car accidents, motorcycle accidents, falls) the brachial plexus nerves can be stretched or torn apart. If the force is severe, these nerves can even be pulled away from the spinal cord where they originate. Damage to these nerves causes pain, numbness, and weakness in the shoulder, arm, and hand. The pain can be quite severe, and is often described at burning, pins and needles, or crushing. In general, the C5 nerve controls the rotator cuff muscles and shoulder function, C6 controls flexing the arm at the elbow, C7 partially controls the triceps and wrist flexion, and C8/T1 controls hand movements. Several patterns of injury occur, the most common is referred to as an Erb's palsy. This is when C5 and C6 are predominantly affected. These patients are unable to lift their arm or flex at the elbow. Severe atrophy can occur in the shoulder muscles. Another pattern of injury is when C8/T1 is mostly damaged. These patients have hand weakness and pain. Some finger movement may remain, however. The most severe type of injury is when the arm is completely paralyzed due to extensive brachial plexus injury.

Diagnosis

A brachial plexus injury is diagnosed with a thorough history and physical examination. Imaging of the spine with either MRI or CT myelography is important for determining any detachment of the nerves from the spinal cord, which determines prognosis and treatment. Electrical testing also helps guide treatment and predict outcome, however, in general, it should not be performed until 3 weeks after injury. Direct imaging of the brachial plexus is usually not helpful with currently available techniques. It is important to see a physician who specializes in examining, diagnosing, and treating brachial plexus injury within the first few weeks after the accident.

Treatment Options

brachial plexus injury
An example of a severe brachial
plexus injury where C5 and C6
were non-functional, C7 was
avulsed from the spinal cord
(lifted in air), and C8/T1 were
damaged but partially functional
based on intraoperative nerve
action potentials.
In general, patients are observed for spontaneous recovery during the first 3 months after injury. Many patients regain some function during this time. Surgery is not immediately performed because many people may spontaneously recovery without treatment. Furthermore, delicate nerves that may have spontaneously recovered may be injured with early surgery. During this waiting period, pain is aggressively controlled and physical therapy is performed. Imaging of the cervical spine and electrical testing is also performed. No medication is currently available to hasten recovery.
When paralysis remains at 3 months, and electrical testing does not indicate an early recovery, then exploratory surgery is often indicated. Recovering nerves are protected. Injured, non-functional nerves are exposed and examined with both a microscope and intraoperative electrical testing. When possible, injured nerves are repaired or replaced, which allows recovery. Repairing nerves with surgery gives them the opportunity to regenerate themselves. Nerve regeneration progresses about one inch per month. Therefore, even after successful surgery, it can take up to 6 to 12 months before the regenerating nerves reach their target muscle and for movement to occur. Surgery is usually scheduled between 3 and 6 months after injury. If you wait much longer than this then the chances of surgery working decreases with time. The exact timing and type of surgery is often different for each patient. Therefore, it is important for the patient to be evaluated early so that they may consider all of their treatment options.
Despite how well the surgery goes, the chance of recovery is somewhat uncertain. In addition to factors we do not understand, surgical success depends on the type of injury, the nerve injured, the age of the patient, motivation of the patient, and timing of repair. On average, there is a 50% chance surgery for each nerve will allow movement to return. This number may be as high as 90% for certain nerves and injuries. Your surgeon will provide you with an estimate about your chances of recovery. A "success" is defined as strength against both gravity and some resistance. In general, greater the distance a nerve has to regenerate, the less likely there will be a good recovery.

Surgery

Brachial plexus exposed
Brachial plexus exposed (above)
in an adult with Erb's palsy
(shoulder and arm flexion
weakness). The upper trunk
(C5/C6) was heavily scarred and
nonfunctional (asterisk). Therefore,
it was removed and replaced with
multiple sural nerve grafts (below).
Three general types of brachial plexus surgery are performed:
  • Erb's palsy repair (shoulder/elbow weakness)
  • Complete brachial plexus reconstruction
  • Isolated nerve transfers
Each patient may undergo a combination of procedures.
Erb's palsy surgery requires an incision along the side of the neck and/or the clavicle. The injured C5 and C6 nerves are identified and examined. Depending on the injury, one or more of the following is performed (see technologies and techniques available section): scar tissue is removed, the nerves are re-attached directly or with nerve grafts from the leg, or nerve transfers are performed. This surgery takes about four to six hours.
Severe injuries require a complete exposure of the brachial plexus. Although muscle and bone are preserved, the incision can be long, passing from the neck and over the shoulder. The nerves are examined and reconstructed with multiple nerve grafts and transfers. This surgery can take up to 8-12 hours.
When nerves are found detached from the spinal cord on preoperative imaging, then select nerve transfers away from the site of injury may be recommended. The incisions for these transfers are often placed above the clavicle, behind the shoulder, under the arm, or near the wrist. Your average nerve transfer takes about 90 minutes per nerve transferred. Although certain brachial plexus techniques are associated with postoperative pain (e.g., intercostals nerve transfers), in the majority of patients incisional pain is minimal. Nerve pain before surgery may or may not improve immediately after surgery. More commonly, nerve pain slowly improves as the nerves regenerate.

Complications

axillary nerve
A branch to the functioning long
head of the triceps was cut and
attached to the nonfunctioning
axillary nerve to allow this patient
to once again lift their arm. This
is an example of a nerve transfer.
Although complications are uncommon, they can occur. A frank discussion with your surgeon prior to surgery is mandatory. Because of long surgery and large incisions, wound infections may occur in some patients. Damage to important arteries and veins going to the arm may occur, which can lead to loss of limb. Fortunately this is so rare it hardly ever occurs. Additional numbness near the neck or chest may occur, but this usually goes away in a number of months. Additional paralysis is possible, but this is rare considering any functioning nerves are either not exposed, or operated on very gently. Trouble breathing, especially when exercising, may occur after surgery and can be related to new diaphragm weakness, fluid on the lung, or air compressing the lung. The latter two of which may require chest tube drainage. The wound is often mildly swollen for a few weeks after surgery. This is normal and goes away with time. If sural nerve grafts are taken from the legs, then a patch of numbness on the outside of the foot almost always occurs, even though some patients do not notice it. This numbness may diminish over time. Because the sural nerve carries no motor fibers, foot paralysis does not occur after removing the nerve graft.

Day of Surgery

All brachial plexus surgery is performed under general anesthesia with intraoperative electrical testing and microscopic magnification. You should not eat or drink after midnight the day before surgery. Medications may be taken with a sip of water the morning of surgery. You wake in the operating room and may see your family an hour later in the recovery room. Depending on the extent of surgery, you may discharged the same day, or a few days later. Pain is well controlled and you are encouraged to sit in a chair and even walk within the first day after surgery. This movement prevents muscle spasms, which reduces pain.

Recovery

During the first two weeks after surgery you wear a sling to protect the arm and let the wound heal. Pain medication is prescribed as needed. One week after surgery you visit your surgeon who checks your wound and removes any sutures. After about two weeks, physical therapy is prescribed. For the first three months, therapy concentrates on shoulder and elbow range of motion. Immediately after surgery your paralysis should be the same. However, when movement eventually returns, strengthening exercises are performed. Recovery often takes one year or longer.

Wednesday, 2 April 2014

Kienbocks Disease- A cause of slow wrist pain

What is Kienbock’s Disease?


Lunate bone looses its blood supply
Kienbock’s disease, or avascular necrosis of the lunate, is a condition in which the lunate bone, one of eight small carpal bones in the wrist, loses its blood supply, leading to death of the bone.  The lunate is a central bone in the wrist, important for proper movement and support of the joint. The lunate, along with the adjacent bones on either side of it, the scaphoid and triquetrum, make up the proximal carpal row. This row of bones articulates with the 2 forearm bones (the radius and ulna), to form the portion of the wrist that provides the most motion.  Damage to the lunate can lead to pain, stiffness, and in late stages, arthritis of the wrist. Kienbock’s disease is most common in men between the ages of 20 and 40 and rarely affects both wrists.




What causes it?

There is probably no single cause of Kienbock’s disease. Its origin may involve multiple factors, such as the blood supply (arteries), the blood drainage (veins), and skeletal variations. Skeletal variations associated with Kienbock’s disease include a shorter length of the ulna, one of the forearm bones, and also the shape of the lunate bone itself. Trauma, either single or repeated episodes, may possibly be a factor in some cases.  Kienbock’s disease can be found more commonly in people who have medical conditions that affect blood supply, and it is also associated with diseases like lupus, sickle cell anemia, and cerebral palsy.



How is it diagnosed?

Most patients with Kienbock’s disease initially present with wrist pain. There is usually tenderness directly over the lunate bone, decreased motion or stiffness of the wrist, and there can be swelling. The diagnosis of Kienbock’s disease can often be made by history, physical examination, and plain x-rays. In early stages the x-rays may be normal and special studies are needed to confirm the diagnosis. Probably the most reliable special study to assess the blood supply of the lunate is Magnetic Resonance Imaging, or MRI . CT scanning, specialized CT scanning, and bone scan may also be used. Patients often have the condition for months or even years before they seek treatment, and especially in its earlier stage it can be difficult to diagnose.
Avascular Lunate on X ray




             
How lunates looks on MRI


          










What is its course?

The progression of Kienbock’s disease varies but is usually slow over many years. There are 4 stages used to classify Kienbock’s disease. In stage 1, x-rays appear normal, but the lunate has lost its blood supply and is painful and may fracture. In stage 2 the bone hardens due to lack of blood supply and appears abnormally dense on X-ray. In stage 3 the bone collapses and fragments. In the final stage, stage 4, the lunate is collapsed and the bones around the lunate have developed degenerative changes and become arthritic. In the early stages there may be only pain and swelling, but as the disease progresses the mechanics of the wrist become altered, which puts abnormal stresses and wear on the joints within the wrist itself. One should be aware that not every case of Kienbock’s disease progresses through all stages to the severely deteriorated arthritic end-stage.

What are the treatment options?

Treatment options depend upon the severity and stage of the disease. In very early stages, the treatment can be as simple as observation or immobilization. For more advanced stages, surgery is usually considered to try to reduce the forces on the lunate bone by lengthening, shortening, or fusing various bones in the forearm or wrist. Surgery can also be aimed at trying to restore blood supply to the lunate (revascularization), using a bone graft with a blood vessel attached to it. This is not an option in more advanced stages if the relationship of the bones has markedly deteriorated; complete wrist fusion may then be the preferred treatment. Hand therapy does not change the course of the disease; however, hand therapy can help to minimize the disability from the problem. Treatment is designed to relieve pain and restore function. Your hand surgeon will advise you of the best treatment options and explain the risks, benefits, and side-effects of various treatments for Kienbock’s disease


 What can I expect?

The results of Kienbock’s disease and its treatment vary considerably, depending on the severity of the involvement, and whether or not the disease progresses. The disease process and response to treatment can take several months. On occasion, several forms of treatment, and even multiple operations, might be necessary.

Saturday, 29 March 2014

Scaphoid bone fracture in the Wrist- A common misdiagnosed cause of wrist pain


The scaphoid bone is one of the carpal bones in your hand around the area of your wrist towards the thumb side. It is the most common carpal bone to break (fracture). This bone broken usually  by a fall on to an outstretched hand. Symptoms can include pain and swelling around the wrist. 

Diagnosis of a scaphoid fracture can sometimes be difficult, as not all show up on X-rays. for a  period of one to two weeks, and an MRI/CT Scan may be needed to ascertain the treatment. 

Treatment is usually with a cast worn on your arm up to your elbow for 8 to 12 weeks. Sometimes surgery is advised. Correct diagnosis and prompt treatment of a scaphoid fracture can help to reduce complications.

Anatomy around your wrist


In the hand, there are eight small bones known as the carpal bones. They are arranged in two rows, one on top of the other.

The proximal row is the row that is closest to the elbow. In the proximal row are the scaphoid, lunate, triquetrum and pisiform bones. The distal row is the row below this. In the distal row are the hamate, capitate, trapezoid and trapezium bones.

The scaphoid bone(marked with arrow) is one of the largest of the carpal bones and is on the thumb side of the wrist. It looks a bit like a cashew nut and is roughly the same size. It links the two rows of carpal bones together and actually helps to stabilise them. The scaphoid bone and the lunate bone connect with the radius at the wrist joint.


What is a scaphoid fracture and what is the usual cause?
A scaphoid fracture occurs when you break your scaphoid bone. It most commonly happens after a fall on to your outstretched hand. That is, when your palm is flat and stretched out and your wrist is bent backwards as you fall to the ground. Instinctively, you will usually put your hands out in this position for protection if you fall forwards.

Sometimes a direct blow to the palm of your hand can cause a scaphoid fracture. Occasionally, repeated 'stress' on the scaphoid bone can lead to a fracture. This can occur, for example, in gymnasts and shot putters.

Commonly you will just fracture your scaphoid bone but sometimes other bones around the wrist area may be broken at the same time.

Scaphoid fractures may be non-displaced (the fragments of the broken bone haven't moved out of position) or displaced (there is some movement of the bone fragments).

How common is a scaphoid fracture?
The scaphoid bone is the most commonly fractured carpal bone. This is because of its size and position in the two rows of carpal bones in the hand.

What are the symptoms of a scaphoid fracture?
Usually, most people who break (fracture) a scaphoid bone will remember a specific injury or fall. There will be pain around the wrist area after the injury. There may also be some bruising or swelling around the wrist on the affected side.

In some people, symptoms may be milder. Quite commonly, people with a scaphoid fracture just assume that they have sprained their wrist and they don't seek medical attention for some time afterwards. The fracture may only be diagnosed when they see a doctor some weeks later because of pain that is not settling or reduced movement around their wrist.

How is a scaphoid fracture diagnosed?
A doctor will usually suspect a scaphoid break (fracture) by the mechanism of the injury that has happened - for example, a fall on to an outstretched hand. Also, when they examine your wrist and hand, there is a specific point where you are likely to be tender if you have a scaphoid fracture. This is known as the anatomical snuffbox. It is a depression in your skin on the back of your hand near to the base of your thumb. Movement of your wrist in certain directions may also be painful if you have fractured your scaphoid.

It can sometimes be quite difficult to diagnose a scaphoid fracture. However, it is important to recognise and treat a scaphoid fracture as soon as possible because the complication of non-union and wrist arthritis  is more likely if treatment is delayed.

Standard X-rays may not pick up all scaphoid fractures. This is because the scaphoid bone can 'hide' behind the other carpal bones on an X-ray. Special scaphoid view X-rays taken with your hand and wrist in a certain position may help to show up a scaphoid fracture. However, between 1 and 2 in every 10 scaphoid fractures may not be seen on X-ray.

In some cases, a scaphoid fracture will not show up on an X-ray until around 10 to 14 days after the initial injury. At this time, the healing process will have started in the bone, which will help the fracture site to show up. So, if a scaphoid fracture is suspected but not confirmed on an initial X-ray, you will usually be treated as if you have a scaphoid fracture and a repeat X-ray may be suggested after 10 to 14 days.

Sometimes, at this time, it is still not clear whether you have had a scaphoid fracture. If this is the case, a CT scan or MRI scan may be suggested to look for the fracture. A radionuclide bone scan is occasionally used as an alternative but this is used less often these days, as MRI and CT scans are more widely available.



What is the treatment of a scaphoid fracture?

If a non-displaced scaphoid break (fracture) is confirmed on X-ray or is suspected, it is usually treated by putting your arm in a cast (commonly referred to as a plaster cast but actually made of fibreglass or another similar synthetic material) up to your elbow. The cast is usually worn for 8 to 12 weeks until the scaphoid bone heals. In some cases, it may be needed for longer.

If a scaphoid fracture is displaced, surgery may be advised. A small screw or a special pin is inserted into the scaphoid bone to hold the bone fragments together in the correct position. This can often be done via a small cut in your skin.

Sometimes surgery may be an option for some groups of people even if a scaphoid fracture is non-displaced. The idea is that it avoids you having to wear a cast for a long period of time. In some cases it may remove the need for wearing a cast altogether. Some also argue that it allows normal movement of your wrist to return more quickly than if you had just been treated with a cast. This means that you can return to your usual activities more quickly. For example, if you are an athlete, a musician, or if there is another reason why you have significant pressure to return to high-level activity quickly, this treatment option may be a consideration. However, this does mean going through a surgical procedure that does carry some small risks.

Are there any complications?
A scaphoid break (fracture) will usually heal well if it is recognised and treated early. However, occasionally, complications can occur after a scaphoid fracture. These can include the following.

Delayed union or non-union
Delayed union occurs when the scaphoid bone has not healed completely after four months of being treated in a  cast. Non-union occurs when the scaphoid fracture has not healed at all. In non-union, the bony fragments are still completely separated. Delayed and non-union may be more likely if treatment of a scaphoid fracture is delayed for some reason. So, this is the main reason why a scaphoid fracture needs to be recognised and treated promptly. However, the exact position of the fracture in the scaphoid bone, whether the fracture is displaced of not, and whether or not there is avascular necrosis  can also affect the healing of a scaphoid fracture.

If delayed or non-union occurs, various treatments may be suggested, including wearing a cast for a longer period or surgery to help join the bone fragments together. Surgery may involve a bone graft to help with fracture healing. This is a procedure where bone tissue is taken from another area of bone in the wrist and inserted into the fracture site.

Malunion
This is where the fragments of the scaphoid bone heal in an incorrect position - for example, at a slight angle. If this occurs, it may affect the movement of the wrist and lead to pain and problems gripping and holding objects. Malunion may be seen on an X-ray or scans of the scaphoid bone. Surgery is usually needed to correct this complication. The scaphoid bone is re-broken, aligned correctly and a bone graft is used to correct the deformity and encourage healing.

Avascular necrosis
Most commonly, a fracture occurs at the narrowest part of the scaphoid (known as the waist). This is where the blood supply to the scaphoid bone enters. So, there is a risk that if you have a fracture in this area, it can sometimes interrupt the blood supply to part of the scaphoid bone, leaving part of the bone without a blood supply. This means that the scaphoid will not be able to heal properly and part of the scaphoid bone 'dies', collapses and breaks up. ('Avascular' refers to having no blood supply and 'necrosis' means death.) If it occurs, avascular necrosis can be seen on an X-ray of the scaphoid bone some months after the initial injury. However, avascular necrosis does not occur with all fractures around the waist of the scaphoid.

Arthritis
Osteoarthritis can develop some time after a scaphoid fracture in some people. It is more likely if there have been complications of non-union, malunion or avascular necrosis.

Wednesday, 19 March 2014

Post Traumatic Elbow Stiffness- A problem with meager options

Elbow - the middle joint of our upper limb, is that joint of our body which lies between shoulder and wrist joints. Its main role is in the spacial orientation of the hand, both towards and away from the objects .

The commonest fracture of paediatric age group occurs around elbow, and mismanagement of this injury is a major cause of deformity and stiffness due to massage leading to formation of bone in the muscles, a condition known as heterotrophic ossification. It has been observed that in adults the chances of developing heterotrophic ossification in simple elbow dislocation is around 3%, but increase to 20% if dislocation also involves a fracture of the joint, moreover its important to note that if any person has head injury along with injured elbow his chances of developing heterotrophic ossification are increased to 75 to 90%

Although it is not the commonest joint to get injured in the adults, but its a joint where post traumatic stiffness is very common. Not only this, the management of this stiffness is even more time consuming and difficult and in some cases the stiffness may persist for life.

The first and foremost requirement to prevent this stiffness is the appropriate management of any type bony or soft tissue injury around the joint. Any insult to the joint can cause stiffness if adequate measures are not taken to prevent it. But what if the stiffness is already set in?

As soon as you recognize that your elbow movements are restricted, you should consult an expert, the treatment of elbow stiffness  is dependent on the type, severity, duration and age of the patient.

On the basis of how much movement you have the stiffness is categorised as mild moderate and severe, In mild to moderate types with duration of insult of less than 6 weeks physiotherapy is tried with splinting, but with more duration and in severe cases surgery is only alternative left to gain if not full movement, at least functional range which in studies have been found to be between 30 degree to extension to 130 degree of flexion ( the normal range being 0 degree to 150 degree).

The surgery of stiff elbow is not without complications, and poor results can come if adequate follow up and physiotherapy post surgery is neglected. So the decision to operate on stiff elbow is taken with a judicious consultation between the patient, the therapist and the doctor.