contents - ijocs.org file18 contents dr humayun ayub editor-in-chief [email protected] dr alison...

18

Contents

Dr Humayun [email protected]

Dr Alison AndersonExecutive Editor [email protected]

Mrs Sally RichardsonSenior Associate [email protected]

Mr Keser AyubManaging [email protected]

Dr Waseem AhmedClinical Skills Lab [email protected]

Dr Raina NazarClinical Skills Editor [email protected]

Dr Hind Al DhaheriAssociate [email protected]

Contents March 2013

Executive Board

International Journal Of Clinical SkillsP O Box 56395LondonSE1 2UZUnited Kingdom

E-mail: [email protected]: www.ijocs.orgTel: +44 (0) 845 0920 114Fax: +44 (0) 845 0920 115

Published by Hampton Bond

The Executive Board Members 17 Foreword 17The Editorial Board 18

Original ResearchPreparation for your first surgical firm – an insight into perioperative practice - Jane Nicklin 19Patients’ attitudes towards participating in clinical skills training purely for teaching purposes- Nicole Koehler 23

Review Exchange plating in the management of infected dynamic hip screw fixation - Mohamed El Sayad 28Clinical examination of metacarpal rotation: proceed with caution- Yasette Vander 30

IJOCS - Volume 7 - Issue 2

Foreword

Welcome to the latest edition of the International Journal of Clinical Skills (IJOCS), Volume 7, Issue 2, March 2013.

The majority of medical students will enter their first surgical session not having had contact with immediate pre- or post-operative patients, never having set foot in an operating theatre before and with an overwhelming fear of fainting, or doing something inexcusable. A study conducted in Leeds, England, describes the planning, implementation and reflection of pilot sessions which utilise innovative resources and subject specific material. Use this pilot study to help implement perioperative education for your students, thus reducing risks and ultimately improving patient outcomes.

Exposure to real patients with real problems is highly valued by medical students. With medical student numbers increasing globally and opportunities to access real patients in healthcare facilities declining, alternative arrangements have to be made to provide students with a ‘real’ patient experience, including the use of ‘patient volunteers’. However, little is known in relation to patients’ experiences of being examined by medial students for purely teaching purposes. An Australian research group present an interesting study which discusses patients’ attitudes and experiences. Are volunteer patients a viable alternative to utilising patients in healthcare settings? Find out what the evidence shows.

The dynamic hip screw (DHS) is the most commonly used implant for hip fracture. One of its postoperative complications is infection, which can be associated with a high degree of morbidity and occasionally mortality. Our colleagues at the Trauma and Orthopaedic Department, Glan Clwyd Hospital, Wales, suggest a technical method for the management of deep-seated infection following DHS fixation. This novel technique has the potential to help manage early deep-seated would infection, without compromising stability of the fracture fixation or needing to perform excision arthroplasty. Utilise this technical tip to improve the quality of patient care and reduce morbidity.

Metacarpal fractures are very common with frequent presentation to Accident and Emergency Departments. However, caution is required when assessing such injuries. This interesting paper illustrates how healthy individuals can simulate a rotational deformity in the little or ring fingers of a ‘normal’ hand and therefore the importance of accurate clinical examination.

As always, your feedback is invaluable for the continued development of the International Journal of Clinical Skills – the only peer reviewed international journal devoted to clinical skills (e-mail: [email protected]).

The Executive & Editorial BoardInternational Journal of Clinical Skills

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International Journal of Clinical Skills

Editorial Board for the International Journal of Clinical Skills

Dr Ali H M Abdallah MB BSFamily MedicineDubai Health Authority (DHA)United Arab Emirates (UAE)

Mr Henry O Andrews FRCS(Eng) FRCS(Ire) FRCS(Urol) FEBU MBAConsultant Urological & Laparoscopic SurgeonDepartment of UrologyMilton Keynes General Hospital, UK

Dr Peter J M Barton MBChB FRCGP MBA DCH FHEADirector of Clinical and Communication SkillsChair of Assessment Working GroupMedical School University of Glasgow, UK

Dr Jonathan Bath MB BS BSc (Hons)Department of SurgeryRonald Reagan UCLA Medical CenterLos AngelesUnited States of America (USA)

Dr Khaled Al Beraiki MB BSForensic MedicineKlinikum Der Universität zu KölnInstitut für RechtsmedizinUniversity of KölnGermany

Professor Chris Butler BA MBChB DCH FRCGP MDProfessor of Primary Care MedicineHead of Department of Primary Care and Public HealthCardiff University, UK

Dr Aidan Byrne MSc MD MRCP FRCA ILTM FAcadMInterim Director of Clinical Skills and SimulationSchool of MedicineCardiff University, UK

Dr Dason E Evans MBBS MHPE FHEAHonorary Senior Lecturer in Medical EducationBarts and the London, Queen Mary’s School ofMedicine and DentistryUniversity of London, UK

Mrs Carol Fordham-Clarke BSc (Hons) RGN Dip Nurse EdLecturer and OSCE Co-ordinatorFlorence Nightingale School of Nursing & MidwiferyKing’s College London, UK

Dr Elaine Gill PhD BA (Hons) RHV RGN Cert CounsHead of Clinical CommunicationThe Chantler Clinical Skills CentreGuy’s, King’s and St Thomas’ Medical SchoolKing’s College London, UK

Dr Glenn H Griffin MSc MEd MD FCFPC FAAFPFamily Physician Active StaffTrenton Memorial HospitalTrenton, OntarioCanada

Dr Faith Hill BA PGCE MA(Ed) PhDDirector of Medical Education DivisionSchool of MedicineUniversity of Southampton, UK

Dr Jean S Ker BSc (Med Sci) MB ChB DRCOG MRCGP MD Dundee FRCGP FRCPE (Hon)Director of Clinical Skills CentreUniversity of Dundee Clinical Skills CentreNinewells Hospital & Medical SchoolUniversity of Dundee, UK

Dr Lisetta Lovett BSc DHMSA MBBS FRCPsychSenior Lecturer and Consultant PsychiatristClinical Education CentreKeele Undergraduate Medical SchoolKeele University, UK

Miss Martina Mehring, PhysicianAssistenzärztin AnästhesieMarienkrankenhausFrankfurtGermany

Professor Maggie Nicol BSc (Hons) MSc PGDipEd RGNProfessor of Clinical Skills & CETL DirectorSchool of Community & Health SciencesCity University London, UK

Dr Vinod Patel BSc (Hons) MD FRCP MRCGP DRCOGAssociate Professor (Reader) in Clinical SkillsInstitute of Clinical EducationWarwick Medical SchoolUniversity of Warwick, UK

Miss Anne Pegram MPhil PGCE(A) BSc RN LecturerDepartment of Acute Adult NursingFlorence Nightingale School of NursingKing’s College London, UK

Dr Abdul Rashid Abdul Kader MD (UKM)Emergency MedicineUniversiti Kebangsaan Malaysia (UKM) Medical CenterKuala LumpurMalaysia

Professor Trudie E Roberts BSc (Hons) MB ChB PhD FRCPDirector – Leeds Institute of Medical Education University of Leeds, UK

Dr Robyn Saw FRACS MSSurgeonSydney Melanoma UnitRoyal Prince Alfred HospitalAustralia

Dr Mohamed Omar Sheriff MBBS Dip Derm MD (Derm)Specialist in DermatologyAl Ain HospitalHealth Authority - Abu DhabiUnited Arab Emirates (UAE)

Professor John Spencer MB ChB FRCGPSchool of Medical Sciences Education DevelopmentNewcastle University, UK

Professor Patsy A Stark PhD BA (Hons) RN RM FHEAProfessor of Clinical Medical Education and Director of Clinical SkillsUniversity of Leeds and Leeds Teaching Hospitals Trust, UK

Professor Val Wass BSc MRCP FRCGP MHPE PhDHead of Keele Medical SchoolKeele University, UK

Disclaimer & InformationVisit the International Journal of Clinical Skills (IJOCS) at www.ijocs.orgWhilst every effort has been made to ensure the accuracy of information within the IJOCS, no responsibility for damage, loss or injury whatsoever to any person acting or refraining from action as a result of information contained within the IJOCS (all formats), or associated publications (including letters, e-mails, supplements), can be accepted by those involved in its publication, including but not limited to contributors, authors, editors, managers, designers, publishers and illustrators.

Always follow the guidelines issued by the appropriate authorities in the country in which you are practicing and the manufacturers of specific products. Medical knowledge is constantly changing and whilst the authors have ensured that all advice, recipes, formulas, instructions, applications, dosages and practices are based on current indications, there maybe specific differences between communities. The IJOCS advises readers to confirm the information, especially with regard to drug usage, with current standards of practice.

International Journal of Clinical Skills (IJOCS) and associated artwork are registered trademarks of the Journal. IJOCS is registered with the British Library, print ISSN 1753-0431 & online ISSN 1753-044X. No part of IJOCS, or its additional publications, may be reproduced or transmitted, in any form or by any means, without permission. The International Journal of Clinical Skills thanks you for your co-operation.

The International Journal of Clinical Skills (IJOCS) is a trading name of SkillsClinic Limited a Company registered in England & Wales. Company Registration No. 6310040. VAT number 912180948. IJOCS abides by the Data Protection Act 1998 Registration Number Z1027439. This Journal is printed on paper as defined by ISO 9706 standard, acid free paper.

© International Journal of Clinical Skills


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Miss Yasette Vander MB BS BSc MRCSSpecialty Registrar in Orthopaedics 1

1 St Richards Hospital, Chichester, United Kingdom

Correspondence:Miss Yasette VanderSt Richards HospitalRoyal West Sussex TrustSpitalfield LaneChichesterWest SussexPO19 6BFUK

E-mail: [email protected]: +44 (0) 1243788122Fax: +44 (0) 8450920115

Keywords: MetacarpalPseudoRotationFractureExaminationDeformity

IntroductionFollowing changes to medical training within the UK in recent years, it has been noted within the orthopaedic department at our district general hospital that junior doctors knowledge in basic orthopaedics is limited, whether it be in the direct setting of orthopaedics or within the Accident and Emergency Department (A+E). Orthopaedic exposure as a medical student can be restricted and many junior doctors will only have read about how to perform hand examinations. The altered training patterns and working time directives of junior doctors have further highlighted this lack of knowledge.

Metacarpal fractures are one of the common injuries to present to Fracture Clinic following attendance to A+E. It has been cited that the incidence is 2.5% in 10 – 29 year olds [1]. The fractures are most usually sustained in patients that have punched objects with a closed fist, fallen, and after transport accidents [1, 2]. It is crucial that a full assessment of the patient is undertaken and a decision made for conservative or operative management.

Indications for surgery generally include unstable fractures and those with rotational deformity [2]. Our Orthopaedic Department believes that although obvious rotational malalignment should be corrected, the health professional needs to keep in mind a few fundamental principles when examining such patients so as not to be caught out, especially in the early years of training. What may appear as rotational deformity to the untrained eye may not be due to the fracture pattern and actually be due to swelling after injury, or the simple active (and passive) movement that can occur at the metacarpal and phalanx, as this study aims to highlight.

ObjectiveThe hypothesis was tested that one does not need to have a fractured metacarpal to simulate a rotational deformity.

Clinical examination of metacarpal rotation: proceed with caution

Abstract

Metacarpal fractures are very common and present frequently to both Emergency Departments and Fracture Clinics. Often junior doctors and specialist nurse practitioners assess these injuries and have been taught to examine for rotational deformity, due to the fact that this is an indication for surgery.

This study shows how 15 healthy individuals from the orthopaedic department at a UK district general hospital can simulate a rotational deformity in the little or ring fingers of a ‘normal’ hand. The mean angulation of the little finger was 20.5 degrees and of the ring finger 15.9 degrees.

This study emphasises that caution is required when assessing such injuries, so as not to lead to patient anxiety.

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Methods15 healthy doctors within the Orthopaedic Department at St Richards Hospital, Chichester, UK, were examined and photographed for the purpose of this study, none of whom had a history of injury to the hand in question.

The hand was first clinically assessed and then the fingers actively flexed to observe the normal cascade. In flexion the distance between the midpoints of the ring and little fingernails was measured. Photographs were then taken in this position. Each subject was then asked to actively simulate rotational malalignment in either their ring or little fingers by simply flexing the finger in question slower that the others causing overlap. Further photographs were taken and the distance between the midpoints of the fingernails measured.

The photographs were printed out and lines drawn down the mid-shaft of the distal phalanx of the middle, ring and little fingers. For each subject, ‘normal’ angles of finger cascade towards the scaphoid were determined by where the lines intersected.

The same lines were drawn down the fingers in the simulated rotation scenario and the difference in the angles between the middle and ring finger, and those of the ring finger and little finger, calculated.

Correspondence with the Royal West Sussex Trust’s Research and Ethics Committee deemed that the project was for developing a teaching aid and therefore did not need formal ethical approval.

ResultsAll 15 individuals were able to simulate a rotational deformity commonly looked for in fracture of the metacarpal of the ring and little fingers, whilst flexing their fingers down towards their palm (Table 1). The mean overlap of the little and ring fingertips was 0.4 cm. The amount of simulated angulation between the middle and ring fingers was 15.9 degrees (range: 9 – 28, median 16). The mean amount of simulated angulation between the little and ring fingers was 20.5 degrees (range: 14 – 30, median 19).

Table 1: Table of measured rotation (ring and little fingers)

Angle True difference in rotation

SubjectNumber

Little to ring finger

(degrees)

Ring to middle finger

(degrees)

Little to ring finger with

rotation(degrees)

Ring to middle finger with

rotation(degrees)

Little finger(degrees)

Ring finger(degrees)

1 3 2 17 11 14 9

2 4 3 34 12 30 9

3 4 3 19 29 15 26

4 4 2 22 18 18 16

5 5 4 19 21 14 17

6 6 4 34 20 28 16

7 4 3 31 14 27 11

8 5 3 27 21 22 28

9 3 2 18 15 15 13

10 2 1 17 13 15 12

11 4 3 23 19 19 16

12 4 2 20 21 16 19

13 5 4 32 24 27 20

14 3 2 24 18 21 16

15 4 3 30 13 26 10

Mean 4 2.73 24.46 17.93 20.46 15.86

Median 4 3 23 18 19 16

DiscussionThis observational study aims to highlight to medical students and junior doctors both the importance and pitfalls of examining the hand for rotational malalignment after injury. Many junior doctors find themselves treating these fractures in Accident and Emergency Departments and Fracture Clinics having had little or no previous exposure to such cases.

To examine such an injury one is taught to examine the hand with the fingers extended and to look at the alignment of the nail plate. The fingers are then examined in flexion as each finger tip should individually and in combination strike the palm in the

direction of the scaphoid [3, 4]. If the finger in question shows rotational malalignment one needs to decide whether operative correction is necessary. Even 10 degrees of malrotation at the metacarpal can cause up to 2 cm of overlap at the finger tip and consequently there can be significant disability [5].

Rotational deformity is highly unlikely after a single metacarpal fracture due to the strong interosseous ligaments at the bases of the metacarpals and the deep transverse (palmar and dorsal) intermetacarpal ligaments distally that serve to maintain the transverse arches of the hand [6]. Should there be multiple

Review March 2013


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metacarpal fractures and associated soft tissue injury the likelihood of rotational deformity is thereby understandably higher.

All 15 subjects examined in this study were able to simulate a deformity that many inexperienced doctors may construe as an indication for operative intervention, should this have been in addition to a fractured metacarpal on radiograph (Figures 1 and 2). This, under certain circumstances and in times when senior advice is not immediately available, could lead to patient anxiety over treatment if called back for review at a later date for discussion as to whether surgery is necessary. Upon referral to fracture clinic such patients may require appropriate counselling to manage both their injury and expectations.

Figure 1: Photograph showing simulated rotational deformity in the little finger

Figure 2: Photograph showing simulated rotational deformity in the ring finger

The deformities in this observational study are caused by flexing the affected finger down slower than the others in the cascade, which is an often seen clinical finding if there is pain inhibition secondary to injury. Passive internal rotation of the little finger can occur at the carpometacarpal joint and the metacarpophalangeal joints [7, 8]. Smith et al [7] have also shown how this affect is produced by the injection of normal saline in the intermetacarpal space to simulate swelling that is sustained after injury. They found that this increased the intermetacarpal distance and intermetacarpal angles giving the appearance of rotational deformity with no underlying fracture. One can extrapolate how exaggerated the finding would be with both swelling and pain inhibition present after an otherwise undisplaced or minimally displaced fracture. It is noted, however, that neither simulated swelling nor active movement causes fingernail orientation to change.

The observations in this study could be better assessed by a larger sample size of different aged patients and with radiological markers as used in other studies. Furthermore, with ethical approval, fracture clinic patients with metacarpal fractures could also be examined and results compared.

ConclusionMetacarpal fractures are common and it is important that health professionals remain aware to look for rotational deformity, so as not to overlook an injury that could lead to significant patient morbidity and disability. If the finger is rotated in such a way that it is divergent from the other fingers or scaphoid, the need for operative stabilisation is clear. In more subtle cases where a rotational or angular deformity exaggerates the ‘normal’ plane of movement, the decision can be much harder and a senior clinical opinion should be sought.

As evidenced by photographs taken in this study, an element of rotation can be actively achieved by how the subject positions their fingers into flexion (Figures 1 and 2). Should this complicate an examination, explanation to the patient in regards to clinical assessment is paramount. If necessary, the examination should be repeated after adequate analgesia to aid in diagnosis.

DeclarationsThe author has no financial or other interests to declare in relation to this paper.

AcknowledgmentsThanks to Miss S Burgert (Consultant Hand Surgeon St Richards Hospital, Chichester, UK) who helped develop the theme of this paper.

Author InformationMiss Yasette Vander is currently undertaking ST5 specialist trauma and orthopaedics training in the South West Thames Rotation, London Deanery, UK.

References1. de Jonge J J, Kingma J, van der Lei B, Klasen H J. (1994).

Fractures of the metacarpals. A retrospective analysis of incidence and aetiology and a review of the English-language literature. Injury. 25(6):365-369.

2. Soong M, Got C, Katarincic J. (2010). Ring and little finger metacarpal fractures: mechanisms, locations, and radiographic parameters. Journal of Hand Surgery. 35(8):1256-1259.

3. McRae R. (2002). Practical fracture treatment. 4th Edition. Edinburgh, Churchhill Livingstone.

4. Royle S G. (1990). Rotational deformity following metacarpal fracture. Journal of Hand Surgery (Edinburgh, Scotland). 15(1):124-125.

5. Bucholz R W, Court-Brown C, Heckman J, Tornetta P (Editors). (2010). Rockwood and Green’s Fractures in Adults. 7th Edition. London, Lippincott Williams and Wilkins.

6. Dzwierzynski W W, Matloub H S, Yan J G, Deng S, Sanger J R, Yousif N J. (1997). Anatomy of the intermetacarpal ligaments of the carpometacarpal joints of the fingers. Journal of Hand Surgery (American). 22(5):931-934.

7. Smith N C, Moncrieff N J, Hartnell N, Ashwell J. (2003). Pseudorotation of the little finger metacarpal. Journal of Hand Surgery (Edinburgh, Scotland). 28(5):395-398.

8. Stern P. (1999). Fractures of the metacarpals and phalanges. In Green D P, Hotchkiss R N, Pederson W C (Editors), Green's operative hand surgery, pages 763-764. Volume 2. 4th Edition. Edinburgh, Churchill Livingstone.



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