Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Multiple factual errors in the ABC of emergency radiology
- Norbert Kang (7 May 2005)
-
Re: Multiple factual errors in the ABC of emergency radiology
- milind m deshpande (12 May 2005)
-
Re: Multiple factual errors in the ABC of emergency radiology
- milind m deshpande (12 May 2005)
-
ABC of Emergency Radiology; Hand
- Shehan Hettiaratchy (14 May 2005)
|
|
|||
|
Norbert Kang, Consultant Hand and Plastic Surgeon Mount Vernon Hospital, Northwood, Middlesex HA6 2RN
Send response to journal:
|
I frequently read the ABC series in the BMJ as they seem to offer a quick and accurate summary of other areas of medicine or surgery with which I have little familiarity. This week's article on emergency radiology may have to change this impression as it was full of factual errors. To begin with, the diagram showing the arrangement of the extendor tendons of the finger, bears little resemblance to the anatomical structures that I see on a virtually daily basis when operating on fingers. I fully understand that the diagram was intended as a schematic - but little effort would have been required to modify the diagram to appear more like what it was intended to represent. The labelling on the diagram is also inaccurate. The "middle slip" is more normally called the "central slip". The "common extensor tendon" is more properly referred to as the "lateral bands" (either ulnar or radial). There is also no indication on the diagram of the tendinous contribution of the intrinsic muscles which are critical to the normal functioning of the finger. This is particularly important in the context of the advice given on the management of boutonierre and mallet deformities given on subsequent pages of the article. In the text, the authors suggest that the majority of mallet injuries heal with splinting of the joint in a mallet splint. This is correct advice. Why then do they muddy their advice by suggesting that complete tears of the tendon may need surgery? Closed mallet deformities, whether the result of a tear in the extensor tendon (which is really the same thing as avulsion of the extensor tendon from its insertion) or avulsion with a bony fragment can all be treated equally well by splintage in a mallet splint - end of story. The radiograph used to show a volar plate avulsion is also erroneous and misleading. The x-ray clearly shows a Type III (Leddy and Packer) avulsion of the flexor digitorum profundus insertion from the base of the distal phalanx. The treatment and management of this condition is completely different to that of a volar plate injury. The authors would have been better off showing a true volar plate avulsion injury involving the proximal interphalangeal joint. In fairness, this is what they try to describe in the text. The errors continue. There is inadequate labelling of the schematic diagram explaining the boutonniere deformity. The diagram is also misleading since it gives the impression that there is a tendinous connection between the proximal phalanx and the distal phalanx. There isn't. A boutonniere deformity is the result of rupture or stretching of the central slip of the extensor mechanism followed by gradual migration (in a lateral and then volar direction)of the radial and ulnar lateral bands. If you did not understand the last sentence I am not surprised. The first diagram in this article showing the structure/anatomy of the extensor mechanism was so confusing and badly labelled that no one else would be able to understand the mechanism of a boutonniere deformity either. The radiographs showing a typical boxer's fracture were spectacularly unhelpful. A lateral or oblique view showing a typical, angulated fifth metacarpal neck fracture would have been more understandable to the jobbing A&E doctor. I would have thought that there were more than a few of these available to the radiologist who wrote this article. The authors recommend that the treatment of Bennett's fracture of the thumb should be carried out by specialist orthopaedic surgeons. This may well be the case in the United States. In the UK, approximately 50% of hand surgeons are also plastic surgeons. It would have been more correct to say that treatment should be carried out by hand surgeons (either plastic or orthopaedic). Finally, ultrasonography may certainly be helpful in the diagnosis of rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. But, I take issue with the suggestion that it should be carried out in every case of suspected rupture. In this article, no facts might well have been better than the erroneous facts presented. Might I suggest that future ABC articles be reviewed by other specialists in the field to avoid a repeat of this debacle? Best wishes Norbert Kang Competing interests: None declared |
|||
|
|
|||
|
milind m deshpande, consultant orthosurgeon hubli,india,580031
Send response to journal:
|
Sir, The misleading volar plate avulsion fracture xray is not a FDP avulsion injury either! It is a comminuted fracture of the TPX & since the FDP is incidentally attached to the volar fragment, the fragment has displaced proximally & volarly. The management is definitely different from that of a purely clear cut case of a FDP avulsion fracture. Best Wishes
Competing interests: None declared |
|||
|
|
|||
|
milind m deshpande, consultant orthosurgeon hubli.india,580031
Send response to journal:
|
Sir Adding to my previous comment, the Leddy & Packer classification cannot be applied to such a fracture of the TPX.The classification classically applies only to isolated FDP avulsion injuries. The treatment of such injuries is extremely difficult and could result in a stiff DIP joint. In the x-ray shown it appears that the volar fragment being pulled by the FDP is just a small chunk of the articular surface, which has not managed to go across the A4 pulley and hence can be managed conservatively. It would have warranted surgery if it were a type 3 Leddy Packer!!! I am of the opinion that hand surgery is a teamwork of which the bony component has to be dealt by an orthohand surgeon and the soft tissue by the plastic, hand, microvascular surgeon. Best wishes
Competing interests: None declared |
|||
|
|
|||
|
Shehan Hettiaratchy, Specialist Registrar, Plastic and Reconstructive Surgery Chelsea and Westminster Hospital, London, UK
Send response to journal:
|
I completely agree with Norbert Kang that this ABC chapter had numerous inaccuracies which undermined its quality. I suspect the chapter was not reviewed by a hand surgeon who might have spotted these obvious errors. It would be useful if these errors could be addressed before the series is published as a book, otherwise the target audience will be misinformed. Advice about management of hand injuries probably best comes from a hand surgeon so perhaps the authors should remove their pieces of advice and simply suggest that the cases should be discussed with a hand team. It is somewhat irrelevant whether the volar plate x-ray is an FDP avulsion or a fracture being displaced proximally by the FDP as Dr Deshpande suggests- it is clearly not a volar plate avulsion, as the authors claim. This should be changed. Dr Deshpande's opinion that in the hand, bones are best dealt with by orthopaedic surgeons and the other tissues dealt with by plastic surgeons may be fine for him but it is: i)impractical ii)at variance with common practice in the UK, US,Canada, Western Europe and, I suspect, India. Hands should be dealt with by a hand surgeon; it does not matter whether they come from an orthopaedic or plastic surgical background. Competing interests: None declared |
|||