Procedures

The ganglion impar is a  sacrococcygeal ganglion, also called ganglion of Wather. It is a retroperitoneal structure located at the level of the sacrococcygeal junction.

It is the final terminus of sympathetic chains formed by the fusion of both the chains.

Therefore, the ganglion impar block is used in patients with the pain in pelvic and perineal structures.

Relevant Anatomy

The ganglion impar is an irregularly shaped terminal ganglion of the sympathetic chain. It is located almost in the midline at the level of sacrococcygeal junction. It is of variable shape and can be located anywhere from the anterior surface of the sacrococcygeal junction to the lower coccygeal vertebral bodies.

The rectum is situated anterior to the ganglion. Fibers from the ganglion travel to the sacral spinal nerves along the gray rami communicantes.

This ganglion marks the end of the two sympathetic chains.

Visceral afferents from the perineum, distal part of the rectum, anus, distal end of the urethra, vulva, and distal third of vagina converge at the ganglion impar.

There is a wide range of variation in location of the ganglion.

Indications for Ganglion Impar Block

In orthopedics, ganglion impar block is used for coccydynia not amenable too other measures.

Other indications for this block are

• Intractable perineal pain
  • Rectal/Anal pain (proctitis)
  • Vulvar pain
  • Vaginal pain [distal one-third]
  • Postherpetic neuralgia
  • Pain  in complex regional pain syndrome
• Visceral pain
  • Endometriosis
  • Chronic prostatitis

Ganglion Impar Block

The classical technique was described by described by Plancarte and colleagues. Here, the patient is placed in lateral decubitus position with hips fully flexed.

A standard 22-gauge, 3.5-inch spinal needle is bent 1 inch from its hub to form a 30-degree angle. The needle is then introduced under local anesthesia through the anococcygeal ligament with its concavity oriented posteriorly, and under fluoroscopic guidance, it is directed along the midline at or near the sacrococcygeal junction.

A finger is placed in the rectum to avoid puncturing the structure.

A curved needle was later used instead of a bent needle. Spinal needle has also been advocated.

Technical difficulties and the procedure associated risks [needle break, rectal perforation] have made this approach unpopular.

Transcoccygeal approach is more commonly used now. This involves the placement a 20-gauge, 1.5-inch needle through the sacrococcygeal ligament under fluoroscopic guidance so that the tip of the needle is just anterior to the anterior portion of the sacrum, thus minimizing the risk of rectal perforation.

The transsacrococcygeal ligament needle-inside-needle is the most frequently used approach.

A needle-in-needle technique may avoid trauma to the disk and coccyx, in addition to decreasing needle breakage during the transcoccygeal approach

Imaging guidance markedly increased technical success rates. Fluoroscopy facilitated further development, including the transcoccygeal, transarticular, transdiscal, intracoccygeal, and paracoccygeal approaches.

Ultrasound-guided techniques provide the advantage of real-time visualization and avoidance of radiation.

There are four main anatomic approaches to consider when performing ganglion impar blocks:

Paracoccygeal approaches i.e., immediately to the right or left of the coccyx have also been described.

Ganglion Impar Block with Modified Needle-Inside-Needle Technique

• The patient is kept in a prone position
• Keep a pillow under the abdomen
  • Allow flexion of the lumbosacral spine
  • Allows internal rotation of lower limbs

• Prepare the skin of the area
• Use a local anesthetic to numb the skin over the insertion point using a 25-gauge needle over the sacrococcygeal disc
• Insert a 21-gauge, 1.5-inch needle through the sacrococcygeal disc under fluoroscopic guidance
  • Serves as guide for the other needle

• Introduce a 25-gauge, 2-inch through the 22-gauge needle.
• Confirm the needle placement in the retroperitoneal space by contrast agent insertion [0.2-0.5]. The comma sign confirms the placement.
• For diagnostic block/prognostic block
  • 1 to 3 mL of local anesthetic (lignocaine, ropivacaine or bupivacaine) is injected.

• For neurolysis
  • 1- 2 mL of a neurolytic agent [ 99% alcohol, phenol]
  • Given 20 to 30 minutes after the diagnostic block.

It is important that if pa atient complains pain with the neurolytic agent, the injection is stopped immediately.

Absolute bed-rest is indicated after neurolytic injection without position change. This is done to avoid the an unwanted spread of neurolytics to surrounding structures.

Risks and Complications

o             Rectal perforation and tract contamination

o             Infection

o             Fistula

o             Needle break

Digital nerve blocks are used for numbing digits [fingers, toes] for a procedure on the digits. Injury and infection are the two most common reasons for surgical procedures of digits. The digital block is generally effective for procedures distal to metatarsal or metacarpal heads.

Relevant anatomy

Each digit is innervated by 4 digital nerves – two dorsal and two palmar.

Median, ulnar, and radial nerves are responsible for the cutaneous supply of hand and digits. The two palmar digital nerves innervate the palmar aspect of the digit and the nail bed, whereas the dorsal nerves innervate the dorsum of the digit.

Digital nerves of the foot also follow a similar fashion. The tibial and peroneal nerves branch off into the digital nerves of the foot]

Indications of Digital Block

Any procedure of the digit not amenable to local infiltration is an indication of digital block.  Some surgeons prefer digital block to local infiltration.

The procedure list is exhaustive but generally includes

• Large lacerations
• Nail bed injuries
• Ingrown nails
• Paronychia
• Fractures and dislocation of phalangeal fractures

Contraindications

The digital block should not be given if there is a compromised digital circulation, infection at the site of injection or there is a known allergy to anesthetic

Equipment

The equipment necessary includes the following:

• Sterile gloves and drapes
• Gauze pads, bandages
• Betadine solution
• Syringe, 5-10 mL
  • 18-gauge needle for drawing up the anesthetic
  • 25 to 30-gauge needle for injection
• Local anesthetic of choice
  • Lidocaine
  • Procaine
  • Bupivacaine – long acting

Techniques of Digital Block

Various methods of giving digital block are

• Web-space block
• Transthecal block
• Three-sided digital block
• Four-sided ring block.

Following things should be kept in mind

• Follow standard sterile precautions in all the procedures
• Do not use epinephrine or adrenaline
• Use the smaller needle for injections. This leads to less pain.
• Use appropriate amount for the space available
• Anesthesia of the great toe more difficult and typically 3-sided/4-sided ring blocks [see belo].

Web-Space Block

It is the least painful of all and provides the right level of anesthesia.

• Prepare a sterile field [part preparation with betadine solution and sterile draping]
• Keep the hand of the patient with pal down.
• Keep the needle and syringe loaded with anesthetic just distal to metacarpal-phalangeal (MP) joint into the webspace.
• With a slow push inject the anesthetic in the dorsal aspect of the web space.
• Then, slowly advance the needle straight down toward the volar aspect of the web space and infiltrate the tissue of the web space.
• Keep a caution to avoid the piercing of the volar aspect of the web space.
• Now withdraw the needle and repeat the procedure on the web space on the other side of the of the involved digit.

This method is effective in toes also except the great toe.

Transthecal Block

This is a quite effective block but bit painful because the space available for an anesthetic is less.

• Keep the patient’s hand on the sterile field with the palm up.
• Palpate the distal palmar crease and locate the flexor tendon sheath just distal to the palmar crease and insert the needle at a 45-degrees.
• Inject the anesthetic slowly. If there is a resistance, reposition the needle by slowly withdrawing it.

A modified version of this technique inserts the needle at a 90-degree angle at the metacarpal crease until the bone is hit. The anesthetic is injected after slowly withdrawing the needle.

Use the other hand to keep the pressure just proximal to the injection site so that the flow is directed distally.

Three-Sided Digital Block

Though this anesthesia can be used for any digit, it is typically used in case of the great toe.

1. Place the patient’s foot on a surface in a sterile field with sole touching the surface.
2. For three-sided block
   1. Insert the needle at a 90-degree angle at the medial aspect of the digit, just distal to the metatarsal-phalangeal joint and inject the anesthetic as the needle is advanced toward the plantar side. Take care not to pierce the plantar skin
   2. Slowly withdraw the needle, redirect it medially and advance from medial to lateral side while injecting the anesthetic.
   3. Withdraw the needle and inject on the lateral side of toe in a similar fashion to the medial side

Four-Sided Ring Block

It is an extension of 3 sided block.

After completion of the above three steps, the needle is inserted at the lateral aspect of the digit on the plantar side and advance it medically as the anesthetic is slowly injected. This method is not preferred because of the risk of ischemic complications.

Wing Block Procedure

It is used when the distal part of the digit is affected, such as an injury to nail.

• Keep the hand/foot placed on the surface with the volar/plantar side down.
• With needle perpendicular to the long axis of the digit and at 45 degrees to the horizontal plane, insert the needle 3 mm proximal to an imaginary point where extensions of the lateral and proximal nail folds intersect
• Inject the anesthetic along the proximal nail fold and inject
• Slowly withdraw the needle and redirect it toward the lateral nail fold.
• If required, perform the procedure on the opposite side of the nail as necessary.

The method is not used very commonly. It is more painful than web space digital block

Trigger point injections are used as a treatment modality for inactivating trigger points to provide prompt relief. Trigger points are palpable painful nodules in the taut band of muscle fibers.

Trigger points are also called myofascial trigger points as they are seen in myofascial pain syndrome, a painful muscle disorder.

[Read more on myofascial pain syndrome]

Various other modalities for the treatment of trigger points including spray and stretch, ultrasound, manipulative therapy etc.

Indications for Trigger Point Injection

Trigger points are either active or latent. Latent trigger points are not symptomatic and do not require treatment.

For injection, the trigger points should be limited in number and at an appropriate site for injection. [Conditions having widespread pain complaints, such as fibromyalgia are not suitable. Fibromyalgia can exist along with myofascial syndrome. In such cases, it is important to treat fibromyalgia first.]

Contraindications

• systemic or local infection
• Bleeding disorders
• Pregnant patient
• Ill patients

Following patients would require precautions

• Patients on anticoagulants
• Patients who are at high risk for infection
• Debilitated patients
• Diabetes mellitus
• Patients on steroids.
• Acute muscle trauma

How Does Trigger Point Injection Act?

Several mechanisms have been suggested as possible explanations for the inactivation of trigger points by injection

Following mechanisms have been thought to cause the effect

• Disruption of abnormal muscle fibers or nerve endings breaking the sensorimotor loop
• The release of intracellular potassium causing depolarization and disruption of nerve conduction due to needling
• Dilution of nerve-sensitizing substances which reduces irritability and inactivate any neural feedback mechanisms.
• Interruption feedback mechanisms between the trigger point and the central nervous system by anesthetic
• Focal necrosis may destroy the trigger point.

Procedure of Trigger Point Injection

Preprocedural Work-Up

Choosing a needle of appropriate size is important.

• For superficial muscles – 22-gauge 3.8-cm (1.5 in.) needle
• When capillary fragility with bleeding is a concern – 25-gauge needle
• Thick subcutaneous muscles – 21-gauge 5-cm (2-in.) needle or thicker

The length of the needle should be such that it does not need full-length insertion.

If the muscle is quite deep, the spinal needle may be needed.

The following sizes of needles may be used in different situations

• Scalenus, sternocleidomastoid, and interossei: 22- to 25 gauge 1.5-in. needle
• Temporomandibular joint muscles – 25 gauge 1.5-in. needle
• Cervical and suboccipital areas, upper extremities, and ankle and foot – 22-gauge 1.5-in. needle
• Extremities – 21-gauge 2.0-in. needle
• Lumbar and gluteal areas – 20- to 21-gauge 3-in. needle
• Gastrocnemius – 25-gauge 2.0-in. needle

For Withdrawal of anesthetic solution – 16-gauge 1.5-in. needle would suffice.

The patient needs to understand that he would require a period of rest after the injection and avoidance of activity.

Other equipment required include

• Needles and syringes of various sizes
• Povidone-iodine solution or alcohol
• Sterile gauze pads
• Gloves
• Lidocaine
• Isotonic saline
• Vapocoolant spray [Optional]
• Bandages

Patient Preparation

The trigger point injection may be used in prone, supine, sitting or recumbent position. Part is cleaned with povidone iodine or alcohol-based solution.

Drugs Used

One of the following may be used

• 5% procaine [least myotoxic]
• 1% lidocaine
• Bupivacaine [Long acting Anesthetics]
• Isotonic saline [when there is an allergy to anesthetic agents]

Steroids are used only for ligamentous trigger points

Needling and Injection of Trigger Point

The trigger point is located. It is felt as the most tender point in a taut muscle band. A twitch response may occur leading to muscle contraction or patient jerking or jumping [also called jump sign]

Pinch the trigger point between the thumb and index finger to prevent the trigger point from rolling away when the needle is advanced.

Insert the needle about 1-2 cm away from the trigger point and advance at an acute angle of 30º to the skin.

Before the needle gets to the point, warn the patient about sharp pain which may occur when the contacts the trigger point.

Aspirate before injecting.

Once inside, inject about 0.2 mL of anesthetic.

Withdraw the needle to the level of the subcutaneous tissue, and then redirect superiorly, inferiorly, laterally, and medially repeating the process of needling and injecting.

The process is repeated in each direction until the local twitch response does not occur or the muscle relaxes.

Apply pressure over the injection sites by a pressure bandage.

Stretching after trigger point injection

It is an integral part of treatment to stretch involved muscles so as to try and obtain full length.

Vapocoolant spray in a parallel direction over the muscle helps to relax remaining tense fibers.

After this apply hot pack overall injected trigger points for several minutes.

After that ask the patient to do the full active range of motion of the muscle several times. This will relieve residual stiffness and would also tell how effective the procedure has been.

This also reestablishes awareness of normal muscle function.

Postprocedural Care

Activity Modification

Ask the patient to rest the affected areas for one to two days after the injections.

As long as injection soreness is there, strenuous activities should be avoided but otherwise, the patient is encouraged to use muscle for the full range of motion.

In the long run, the patient needs to recognize and avoid the pain-provoking activities and muscle stressing movements. Learning to use muscles well and with proper alignment is key to long-lasting relief.

Exercise

After inactivation of trigger points and resolution of rest pain, a carefully graded exercise program is introduced.

Stretching exercise of the involved muscles, improved conditioning, and increased strength reduces the likelihood of developing trigger points.

Thus a  graded exercise program begins with stretch exercises and the patient may progress to strengthening exercises once a tolerance to stretch occurs.

Isotonic exercises are usually better tolerated than isometric.

Conditioning exercises should be added when tolerated and done at least twice weekly. Swimming, bicycling, tennis, jogging, and jumping rope are various exercises to choose from.

Complications

Complications may include the following 

• Vasovagal syncope
• Skin infection
• Pneumothorax
• Needle breakage
• Hematoma formation

References

• Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002 Feb 15. 65(4):653-60.
• Ge HY, Nie H, Madeleine P, Danneskiold-Samsøe B, Graven-Nielsen T, Arendt-Nielsen L. Contribution of the local and referred pain from active myofascial trigger points in fibromyalgia syndrome. Pain. 2009 Dec 15. 147(1-3):233-40.
• Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain. 2009 Jan. 25(1):80-9.

Methylene blue injection is an easy and safe way to rule out or confirm breakage of the joint capsule when there is an injury near or around the joint,  thus establishing or ruling out the presence of open joint injury.

Open joint injuries consist of are skin and soft-tissue injuries which communicate with the joint.

It is important to identify open joint injury early so that further aggressive workup and management could be undertaken timely.

Many of the injuries are clearly open but others appear doubtful because the injury to the capsule may not be evident.

Intra-articular injection of methylene blue would lead to extravasation of dye in case of an open from the wound site is highly suggestive of open joint injury.

However, the absence of extravasation does not entirely rule out the possibility of open joint injury.

The reported sensitivity of the procedure is as high as 90%. Some studies though report only 30% sensitivities.

The relevance of the procedure is also controversial, with some authors saying that the test is not clinically relevant whereas others asserting its relevance.

Indications for Methylene Blue Injection

The injection is indicated in soft-tissue injury associated with at least one of the following-

• Periarticular fracture
• Visible joint capsule
• Any of the following injuries in proximity to a joint
  • Skin laceration
  • A visible joint capsule through a wound
  • Open fractures
  • Extravasation of serous or serosanguineous fluid from a wound

Contraindications

Following cases are considered clear-cut open joint injuries and therefore the injection is not necessary

• Open fracture with obvious joint involvement on X-ray
• Air or foreign bodies in joint on x-ray

Methylene blue may increase serotonin levels in the central nervous system and caution should be taken in patients on sertonergic drugs.

Intra-articular injection of methylene blue dye works by creating enough dye pressure to distend the joint capsule and maximize the chances of visualizing dye extravasation from the wound.

The dye is injected through one of available site, far from the wound using an  18-gauge needle. As the procedure involves injection and capsular distension, the procedure is painful.

Therefore, parenteral analgesia and local anesthesia are indicated.

Intra-articular injection of methylene blue that demonstrates extravasation of dye from the wound site is highly suggestive of open joint injury. However, the open joint injury may still be present in the absence of dye extravasation

In patients who are allergic to methylene blue, injection of sterile fluorescein in normal saline (NS) solution into the joint space.

Procedure of Injection of Methylene Blue Into Joint

Patient Preparation

Obtain consent for the procedure

The positioning of the patient varies according to the joint that is to undergo injection.

Preparation of Solution of Methylene Blue

Using sterile envrionment mix  1-2 ml of methylene blue to the bowl of normal saline to create a dark colored solution. Fill 20- or 30-mL syringe with this solution.

Part Preparation

Identify the injection site. Select an approach for injection that is as far as possible from the skin wound. Make sure to avoid any neurovascular structures. Prepare the part after providing appropriate parenteral analgesia by scrubbing a wide field with a sterile preparation or a surgical scrub. As a rule after scrubbing the desired field once, it is repeated 2-3 times more for active aseptic preparation.

Local Anesthesia

At the desired site, elevate a skin wheal of local anesthetic [1-2% lidocaine] and then inject the anesthetic deeper into the subcutaneous tissue and further until the joint space is entered. [Confirmed by increased ease of injection and by aspiration of joint fluid].

Secure Needle into Joint Space

After joint is entered,  secure the needle in the joint space by the other hand that holds the hub of the needle. Remove the syringe while the needle is held secure and switch the syringe with the syringe that contains the methylene dye solution.

Injecting the Methylene Blue Dye into Joint

Inject the solution into the joint until it is fully distended. THe volume required for distention would vary from joint to joint.

Watch the wound for extravasation of the methylene blue dye.

Once a satisfactory observation has been made, aspirate back as much fluid as possible followed by needle withdrawal.

Clean the skin and wound and apply a sterile dressing over the wound and injection site.

Conclusion

If extravasation is present, the injury to the joint is open in nature. Administration of IV antibiotics, further evaluation by specialist and decision for exploration and irrigation is considered.

If no extravasation is present and clinical evaluation is in sync with the finding, the injury is treated as closed and appropriate treatment measures are taken.

In case of no extravasation but strong clinical suspicion, an evaluation by a specialist is desirable.

Complications of Methylene Blue Injection

Potential complications of intra-articular injection of methylene blue include the following:

• Infection
• Bleeding or nerve injury
• False-negative results from the injection

• •  Small open defects in a joint capsule [The dye will leak through and the joint would not distend enough for extravasation]
  • The dye is not injected into the joint [some false track is created]

A radial Gutter splint is a splint that is applied on the radial aspect of forearm and sandwiches  2nd  [index]and 3rd [middle] fingers to provide both volar and dorsal support.

Splints, as we know from our previous discussions are used to immobilize the injuries either temporarily or as definite treatment. Most common use of splints is in emergency settings but the splints can be used to provide rest in non-traumatic conditions.

Indications for Radial Gutter Splint

• Soft-tissue injuries to the second and third fingers
• Fractures of the second and third metacarpals
• Fractures of the phalanges of second and third ray
• Positioning for rheumatoid arthritis
• Laceration over the joints of the second and third phalanges or metacarpals

Contraindications

There are no absolute contraindication but open fractures and those with associated neurovascular insults need to be considered for surgical treatments and monitoring and the radial gutter splint may not be considered.

For angulated neck fractures of the second and third metacarpals, a volar intrinsic plus slab may be preferred.

Procedure of Radial Gutter Splint Application

Patient Preparation

Radial gutter splinting is usually tolerated without anesthesia. However, anesthesia or analgesia may be required in cases where a reduction is required. In such cases, the following may be used alone or in combination

• Hematoma block or nerve block
• Procedural sedation
• Administration of oral or intravenous pain medications
  • NSAIDs
  • Opioid

The correction of the deformity may be needed in

• Malrotated fracture
• Angulations beyond acceptable limits which are
  • 10 degrees in second and third metacarpals

[Just to mention the acceptable limit is 20 degrees in the fourth metacarpal, 30° in the fifth]

A complete neurovascular examination should be performed after the splint has been applied.

Place the patient in a comfortable position (eg, seated or reclined). A sedated patient needs to recline or lie supine.

Cover the patient with a sheet to avoid splatter from the wet plaster.

The wrist has to be in 15-25 degrees of extension and fingers flexing gently as if holding a glass. An actual or imagined glass may be held.  A can or a bandage wrap will also do. Alternatively, the patient can imagine holding a wine glass.

Application of Radial Gutter Splint

Apply the stockinette Stockinette should be applied longer than the extent of the splint and 2-3 cm beyond the overlying padding. Distal end should be cut to allow coverage for the second and third digits only.

[Later together, the stockinette and padding are pulled over the edges of the wet plaster to create smooth edges.]

A hole for thumb should be cut wide enough to avoid constriction of the thumb.

Place a piece of padding/cotton between the second and third digits to prevent skin maceration. The padding is wrapped over the stockinette, overlapping each layer by half the width.

Extend the padding should extend 2-3 cm beyond the overlying plaster on both ends. Leave nails exposed to assess for perfusion. The padding should appear smooth, creaseless and wrinkle-free.

Apply extra padding to the bony prominences.

In prefabricated plaster applications, the stockinette and padding are not required. [For the application of  this plaster, just follow manufacturer’s advice]

The plaster length is measured from the proximal third of forearm to distal IP joint. Make a splint of plaster of Paris using a 4-inch bandage and 10-14 layers thick allowing 5mm of extra length on either end to allow for plaster shrinkage when wet.

The excess wet plaster on the ends will is folded over to create smooth edges. Measure and mark an opening on the plaster for placement of the thumb through the splint, and cut out the opening. Another and safer method is to cut the plaster in two halves from the thumb base and slit till the farther end.

Submerge the plaster and let the plaster escape. All all the bubbles to escape to allow allows the layers to bond together. Squeeze out the excess water by milking action.

Straighten out any wrinkles if present.

Apply the wet plaster, over the padding, to the lateral or radial surface of the forearm extending from the second DIP joint to the proximal third of the forearm.

If the plaster is split, the two halves of the distal part of plaster are arranged anterior and posterior aspect of second and third metacarpals so as to sandwich second and third metacarpals.

If the plaster is not slit, the thumb is passed through the plaster hole and the plaster is rested on the radial aspect of fingers and wrapping them anteriorly and posteriorly.

Fold any excess plaster on the ends followed by folding of stockinette and padding on both ends, creating smooth edges.

Apply the bandage wrap over the wet plaster. Start distally, at the DIP joints of the second and third digits, and wrap proximally.

The thumb and fourth and fifth digit are left free.

Cut an adequate hole for the thumb. The thumb and the fourth and fifth digits should be left free. Avoid wrapping too tightly.

Mold the splint into the desired shape while the plaster is still wet.  The wrist is in 15-25° extension, the thumb is abducted and flex the metacarpophalangeal joints to 70°. [ 90 degrees in metacarpal neck fractures]

Let the splint dry while the position is held.

The patient would feel some warmth due to the exothermic reaction of plaster setting but if the heat is too intense [ can occur with quick setting plasters and if hot water is used], remove the plaster to avoid a risk of thermal burns.

Once the splint is dry, check for neurovascular function and capillary refill.

Ask the patient to flex and extend fingers and enquire about any pressure points.

Clean any extra plaster on the patient.

After Splint Care

[Read more on plaster care]

The patient is instructed to rest and elevate the limb.

The patient should report back immediately in the emergency department if there is increased weakness or numbness or color change (pale or blue). Same should be done in cases of pain that does not relent, feeling of plaster constriction.

A spreading redness or streaking should be reported immediately too.

Plaster should be kept dry and clean.

Patient should not stick any items into the splint to scratch an itch. Sticking objects into the splint can wrinkle the padding and lead to pressure sores. It may also cause a break of skin and infection that would be overlooked because of the presence of covers.

Call the patient back for a recheck after 48 hours and further as necessary.

Complications of Radial Gutter Splint

[Read more on complications of plaster]

• Skin burns form plaster heat during setting
  • may occur when very hot water is used]
  • Wrapping towels or blankets around the splint after application to shorten drying time may cause excess heat.
• Pressure sores
  • provide extra padding  at  prominences
  • Avoid creases.
• Contact dermatitis
  • Antihistmines provide relief
• Swelling and pain
  • Remove splint and elevate the limb
  • Reapply after swelling is gone.
• Joint stiffness
  • Noticed after splint removal
  • requires physical therapy.

References

• Howes DS, Kaufman JJ. Plaster splints: techniques and indications. Am Fam Physician. 1984 Sep. 30(3):215-21
• Hutchinson MJ, Hutchinson MR. Factors contributing to the temperature beneath plaster or fiberglass cast material. J Orthop Surg Res. 2008 Feb 25. 3:10
• Playe SJ, Filener WS. Principles of Splinting. Hart RG, Rittenberry TJ, Uehara DT. Handbook of Orthopaedic Emergencies. Philadelphia, Pa: Lippincott-Raven; 1999. 92-115.

Aspiration of olecranon bursa is performed to obtain fluid for analysis.

A bursa can become inflamed due to infection or for noninfective reasons like trauma, overuse, crystal deposition diseases etc.

Non-infective or aseptic causes account for approximately two-thirds of all bursitis diagnoses.

Infective or septic bursitis most commonly occurs due to seeding of bacteriae or other infective agents.

An infective cause is distinguishable clinically by the presence of aggressive signs of inflammation [warmth, redness, pain, tenderness]

But clinical differentiation is not always possible

Aspiration of a bursa fluid and studying that could provide cues regarding the nature of the affliction.

Definitive diagnosis of septic bursitis can be made only by culture isolation of the causative organism but features like raised WBC [>100,000/µL] with a predominance of neutrophils do favor a diagnosis of the sepic bursa.

In contrast fluid from an inflamed aseptic bursa may show a moderately increased WBC count with mononuclear cells being the predominant type. A bursal fluid glucose–to–serum glucose ratio lower than 50% is almost diagnostic of the septic bursa. 

Aspiration of the olecranon bursa should not be done in cellulitis at the needle insertion site, bacteremia and in presence of a joint prosthesis

The Procedure

Position the patient sitting upright on a stretcher. Rest the affected arm on a side table with the elbow flexed ninety degrees.

Standard technique

• A posterolateral site of insertion is chosen to posterolateral to avoid the ulnar nerve that is located medially
• Avoid insertion an area of overlying cellulitis lest the infection may be spread.
• Prepare the part and drape in a sterile towel
• Inject lidocaine 1% to raise a skin wheal over the needle insertion site
• Insert an 18-gauge needle attached to 10 ml syringe through the raised skin wheal, and advance it into the most dependent aspect of the bursa.
• Keep a pull on the syringe to aspirate the contents. Milk the bursa for complete evacuation.
• After the needle is withdrawn, clean the skin, and place an adhesive bandage over the injection site.

Z-tract technique

This provides better sealing of the needle track. In this, the skin overlying the insertion of the needle is pulled to one side [either medially or laterally] to create a longer subcutaneous needle tract and zig zag. The sealing of tract is better.

Complications

• Local infection.
• Fistula formation [Z-tract technique minimizes the risk]

References

• Stell IM. Septic and non-septic olecranon bursitis in the accident and emergency department–an approach to management. J Accid Emerg Med. 1996 Sep. 13 (5):351-3.
• Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. 2002 Dec 1. 66 (11):2097-100.

Laminectomy is a surgical procedure for decompressing the cord or nerve roots by removal of lamina part of the vertebra which forms the vertebral or neural arch.

The vertebral arch is the ring of bone that joins the vertebral body to surround the spinal cord. [see anatomy]

Each vertebra contains two laminae and the procedure may remove one or both laminae. Removal of the single lamina is called hemilaminectomy.

Although the literal meaning of laminectomy is ‘excision of the lamina’, a conventional laminectomy involves excision of the posterior spinal ligament and some or all of the spinous process

The main aim of the laminectomy is to relieve the pressure on the nerve tissues.

It can be done as the stand-alone procedure or may be done as part of some other procedure. For example, laminectomy may be done to access the disc better for its removal.

Laminectomy is most commonly done in the lumbar spine. It is done less often in the cervical spine and even more rarely in thoracic.

Spinal stenosis is the most common indication of laminectomy. Discectomy also involves cutting of lamina but most of the surgeries now preserve lamina or do partial laminectomy only.

Depending on the disease levels, the laminectomy may be done for a single vertebra or multiple levels.

In some cases, spinal fixation and fusion may be done. Fusion aims at prevention of the recurrence.

Laminectomy versus Laminotomy

Laminectomy and laminotomy, both are procedures for decompression of the cord or roots

Laminectomy is the removal of the entire bony lamina, a portion of the enlarged facet joints, and the thickened ligaments overlying the spinal cord and nerves.

Laminotomy is the removal of a small portion of the lamina and ligaments. It is usually done on one side., usually on one side. This procedure is often done for accessing the disc. It has the advantage of leaving the lamina in place, decreasing the chance of postoperative spinal instability.

Relevant Anatomy

Each vertebra consists of an anterior body which is attached to a posterior ring called the posterior neural arch. Two struts of bones called pedicles arise from the body and join two converging struts called laminae.

Pedicles, laminae and posterior surface of the body forms boundaries of the spinal canal. This spinal canal is the space where spinal cord passes. There is a transverse process on either side of the arch which serves as an attachment to various muscles and ligaments.

Dead posteriorly is the posterior spinous process that can be felt on our back as bumps. Posterior spinous processes also serve as an attachment to ligaments and muscles of the spine.

Adjacent to the base of transverse processes are bony projections that go superior and inferior. These are called superior and inferior articular facets and take part in the formation of facet joints. There are two facet joints between each between each pair of vertebrae one on each side. They are primarily designed to allow the vertebral bodies to rotate with respect to each other.

The lamina is a posterior arch of the vertebral bone lying between the spinous process and the pedicles [which then connect to the vertebral body completing the arch] and the transverse processes of each vertebra.

Indications of Laminectomy

• Spinal stenosis
• Sciatica
• Osteoarthritis
• Degenerative disc disease
• Herniated disc
• Ankylosing spondylitis
• Posterior Tumors

Contraindications of Laminectomy

Anterior vertebral disease

Procedure of Laminectomy

General anesthesia is used for this surgery.

Laminectomy is performed by midline posterior approach and the patient is placed prone on a spinal frame. The operative site is radiographically localized. The proposed midline incision site is marked and the surgical field prepared and draped.

The incision site is infiltrated with 1% lidocaine mixed with 1:100,000 epinephrine. The incision extent varies on the vertebrae involved. Place a midline incision after confirming the vertebral levels and marking the extent. Cut the subcutaneous in line.

The paravertebral fascia is cut on either side of the spinous process and leaving a rim of tissue between two processes intact. [Classical laminectomy removes the spinous process as well].

Retract with right-angled retractors and using sharp wide osteotomes, the paraspinal muscles are erased from the posterior part of vertebrae. The paraspinal muscles are stripped from the spinous processes using a subperiosteal technique down along the laminar to the edge of the facets either bluntly or with monopolar cautery.

Self-retaining retractors are used to widen the exposure. These also help to create tamponade effect to control the bleeding

Following adequate exposure and hemostasis, the levels to be decompressed are accurately are confirmed with the image intensifier.

In a classical laminectomy, the spinous process is removed and from thereon, the lamina is cut with a high-speed drill or rongeurs. In severe stenosis, the dura should be well protected with either instrument.

The thickened ligamentum flavum that connects the laminae of the vertebra below with the vertebra above is also removed.

For decompression of the spinal nerve, the facet joints [directly over the nerve roots] may be trimmed to provide more space to the nerve roots. This procedure is termed as foraminotomy and could be done along with the laminectomy or laminotomy.

Not more than 50% of the facet should be removed to prevent joint instability. A more extensive foraminotomy to laterally decompress the exiting nerve root will require additional removal of the superior and inferior facet complex.

Bleeding points from bone are most effectively controlled with bone wax.

Surgicel (oxidized cellulose) and Gelfoam (Gelatin) act through chemical and direct contact activation of the clotting cascade.

After adequate decompression and hemostasis is achieved, the operative site is generously irrigated with saline or lactated ringers solution, with or without antibiotics. When the dura is opened, antibiotics are avoided. The incision is then closed in layers and the skin secured with sutures, staples, or skin adhesive.

This is done on each side for each affected vertebrae.

Often the laminectomy is done as part of discectomy. In such cases, the spinous process is not removed.
In some cases, the surgeon may not want to remove the entire lamina. A small opening of the lamina above and below the spinal nerve may be able to relieve compression. [Laminotomy]

The surgery may be aided by the use of the surgical loupes or a microscope may be used at any time during the procedure.

Once the lamina and ligamentum flavum are removed the protective covering of the spinal cord (dura mater) is visible. The surgeon can gently retract the protective sac of the spinal cord and nerve root to remove bone spurs and thickened ligament. The decompression effect is generally visible on the neural tissue which is examined for any residual compression. If present, the residual compression is removed.

In selected cases, the decompression may be followed by surgical stabilization and bone grafting for spinal fusion.

After the desired surgery, the e muscle and skin incisions are closed in layers.

The following video shows a lumbar laminectomy demo.

Follow up after Laminectomy

Stitches are removed after 10-14 days. Depending upon the type and levels of surgery, the patient may be allowed to walk in immediate postoperative period or has to wait for few days.

The patient needs to avoid activities that strain the back. These could be lifting a heavy weight or household activities that require repeated or constant bending of the spine.

Complications of Laminectomy

Following complications have been associated with this procedure

• Thrombophlebitis
• Infection
• Hardware Fracture
• Implant Migration
• Spinal Cord Injury
• Persistent Pain
• Sexual Dysfunction
• Transitional Syndrome
• Pseudoarthrosis

Prognosis

Most people report measurable improvement in their symptoms after laminectomy recurrence of arthritis.

Decompressive laminectomy is successful in relieving leg pain in 70% of patients allowing significant improvement in function.

However, back pain may not be relieved and 17% of older adults need another operation. Symptoms may return after a few years.

Endoscopic laminotomy results in lesser blood loss, shorter hospital stay, and less postoperative pain drug requirement.

Smoking has been associated with poorer results.

Internal fixation of scaphoid can be done either percutaneously or using open reduction.

In modern orthopedic practice, percutaneous fixation of the scaphoid is preferred where feasible because it is minimally invasive and there is no need for wide dissection and tissue injury caused by surgical dissection.

Preoperative Planning

The fracture pattern should be clear. Conventional radiographs may not adequately demonstrate the complete fracture configuration.

A CT scan is strongly desirable if a percutaneous procedure is planned.

Read more about the anatomy of the scaphoid.

As 80% of the surface of the scaphoid is covered with articular cartilage and the scaphoid bone itself is curved, it makes it difficult to choose entry points for fixation and not many options are available.

This also means fixation device, along with the true central axis of the scaphoid, is not possible from a palmar approach

Implant

Herbert screw or headless screw is the screw used for scaphoid fixation in both percutaneous fixation and open reduction and internal fixation.

Closed reduction and Percutaneous Fixation of Scaphoid Fracture

Percutaneous fixation is largely indicated for undisplaced or minimally displaced fractures of the waist of the scaphoid.

Before starting the surgical procedure, examine the fracture pattern under the image intensifier. Be sure that the fracture is suitable for percutaneous technique, and that no secondary displacement has occurred.

The patient is placed supine and wrist is hyperextended on a bolster or rolled towel.

Hyperextension and ulnar deviation facilitates the fracture reduction and also assists in bringing the trapezium dorsal to the insertion point of the guide wire, it being at the scaphoid tubercle.

Place a rolled towel or bolster under the wrist and hyperextend it.

It may be helpful to mark on the skin the position of the scaphoid, the palmar rim of the distal radius, and the level of the scaphotrapezial joint.

A stab incision of 5 -10 mm is made distal to the scaphotrapezial joint.

Deepen through the subcutaneous tissues by blunt dissection. Then incise the capsule of the scaphotrapezial joint.

The distal pole of the scaphoid is now accessible for insertion of a K-wire.

Use a hypodermic needle to determine the insertion point radiologically before inserting the threaded guide wire.

The insertion point is on the distal surface of the scaphoid tubercle, at the edge of the scaphotrapezial joint.

Using a drill guide or protective sleeve, a threaded guide wire is inserted at the confirmed entry point directed angled 45 degrees dorsally, and 45 degrees medially, along with the mid-axis of the scaphoid.

The position of the wire should be as perpendicular as possible to the fracture line but it may not be possible in oblique fractures.

Entry is from the distal point and should not pierce the proximal cortex of the scaphoid.

In the next step, screw length is measured by either of the following methods

• Using a dedicated measuring device over the guide wire, through the drill guide. This is the preferred method.
• Take another guide wire of the same length and place its tip onto the bone at the insertion point. The difference in length between the protruding ends of the two wires indicates the length.

Subtract 2 mm to determine the screw length.

Using a power drill preferably with slow rotation. [Exerts a more controlled force on the fragments, thus reducing the risk of displacement than manual drilling] while checking the position of the tip of the drill bit using image intensification.

Use of self-tapping screws would eliminate the need for tapping, which may be carried if non-tapping screws are used.

The screw is inserted over the guide wire. The threaded section of the tip of the screw passes completely beyond the fracture plane to achieve interfragmentary compression.

Guidewire should be removed before tightening the screw.

The screw threads should be fully buried in the bone at the insertion site.

The position of the screw should be confirmed on all views using image intensification and stability of the wrist should be checked.

Open Reduction and Internal Fixation of Scaphoid Fracture

Open Reduction and Internal Fixation of scaphoid fractures is considered in fractures which are not geometrically suitable for surgery and for perilunate equivalent injuries.

In latter case, acute ligament repair is also recommended because late carpal instability invariably occurs with closed treatment.

As an urgent treatment, the carpus should be reduced as soon as possible by extending the wrist to reduce the capitate into the lunate fossa.

Open reduction is also used in fracture no-union.

Approach?

If the scaphoid has minimal comminution, this injury can be treated with a palmar Russe approach for screw fixation of the scaphoid and percutaneous pin fixation of the lunotriquetral joint.

A dorsal approach with retrograde screw fixation of the scaphoid is recommended when

• The scaphoid remains significantly displaced despite an initial closed reduction
• The lunotriquetral articulations is unstable to stress under fluoroscopy
• Comminution of the scaphoid involves a significant portion of the scaphoid waist

Dorsal approach is chosen in these cases as it provides the necessary exposure to realign the scaphoid and repair the lunotriquetral interosseous ligament.

Surgery via Palmar Approach

Palmar approach is favored for waist fractures because it protects the major vascular supply to the scaphoid.

• A  standard Russe incision along the course of the flexor carpi radialis and extended distally along the border of the glabrous skin of the thenar eminence.
• Splitting the sheath of the FCR allows it to be retracted ulnarly to protect the palmar cutaneous branch of the median nerve.
• The floor of the FCR sheath is incised longitudinally to the scaphoid, try and preserve as much radioscaphocapitate (RSC) ligament as possible because this helps to contain the proximal pole and prevent it from subluxating palmarly.
• Reduce the fracture by using dental picks/ k-wires as joysticks
• Bone grafts are used to wedge open collapsed scaphoid fractures to correct their alignment. These grafts may be taken from the iliac crest or the distal radius. The inner wall of the dorsal scaphoid cortex can be notched with a small osteotome to accommodate the wedge graft. However, the dorsal cortex of the scaphoid should be preserved as that can detach the blood supply and make the fracture highly unstable.
• Screw fixation of the scaphoid is done using the same principles as outlined above.
• Confirm the screw in the image intensifier.
• Repair palmar capsule and other layers of the wound.

Dorsal Approach

Dorsal approach is indicated in comminuted scaphoid fractures and to repair the lunotriquetral interosseous ligament.

It is important to preserve the blood supply entering with the cuff of tissue on the dorsal surface of the scaphoid just distal to the articular surface.

The dorsal approach provides better exposure for bone grafting and allows for more accurate placement of implants in small proximal-pole fractures.

• Make a straight dorsal skin incision starting over Lister’s tubercle .and extending for about 4 cm distally.  Lister’s tubercle or the dorsal tubercle of the radius is a bony protuberance on the dorsal surface of the distal radius. It separates the 2nd (ECRB and ECRL)  and 3rd (extensor pollicis longus) extensor compartments. It acts as a pulley for the EPL tendon, changing its mechanical direction of action.
• In the radial skin flap and supplies the lateral part of hand and digits, Identify and preserve the dorsal superficial branch of the radial nerve.
• Incise the extensor retinaculum over the extensor pollicis longus (EPL) tendon and open the distal part of the third extensor compartment.
• The EPL tendon is then retracted radially together with the tendons of the second extensor compartment (extensor carpi radialis brevis and longus).
• Open the capsule by a  longitudinal, or inverted T-shaped, incision, starting at the dorsal rim of the distal radius, extending to the dorsal intercarpal ligament.
• Flexion of the wrist aids in the exposure of scaphoid, especially proximal pole.
• Carry out the fixation as outlined before.

Ligament repair is carried after the scaphoid is stabilized. This may include scapholunate and/or lunotriquetral ligament.

Postoperative Care

The limb is splinted. Two weeks after surgery, the splint and sutures are removed and a short cast is applied for 1 month, at which time the cast is discontinued and a removable splint is used until the x-rays confirm union.

After that patient is put on rehabilitation protocol.