university orthopaedics, professionals/gp...university orthopaedics, hand and reconstructive...

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

Allrightsreserved.NopartofthispublicationmaybereproducedwithoutpermissioninwritingfromNationalUniversityHospital.

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


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


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


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.


NUH ORTHOGERIATRIC HIP FRACTURE SERvICE– a Holistic approach


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’.


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


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



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!


KNEE OSTEOARTHRITIS:5W’S + H



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.



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.



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.



– A Primer

Adolescent Idiopathic

Scoliosis


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.


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).



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.



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.



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


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


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



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



Specialist in Focus

1

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:

23

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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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Specialist in Focus


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


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.


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

university orthopaedics, professionals/gp...university orthopaedics, hand and reconstructive...

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