Merry Christmas and a Happy New Year - 2012

Well we have come to that time of the year where we bid adieu to 2011 and look forward to another awesome year ahead.
The Bomoh Tulang would like to wish all loyal readers a very happy new year and one that's filled with peace, prosperity and happiness always.
For those celebrating, a very Merry Christmas and happy holidays for the rest of us!

- the BomohTulang -

Congratulations to Dr Mel

The Bomoh Tulang would like to congratulate Dr Mel for passing her part 1 masters exam for Orthopedics in UM recently. It was tough but u made it! Wishing you continued success in your journey to become a certified Orthopod!

L-R: FerrariBoy, BomohTulang, Aishah, Mel

Dr Mel is a photography enthusiast too, mainly dabbling in retro analog film cameras and has quite a collection of vintage cameras. So if film cameras are your thing, head on to CGSF where Mel blogs about her film collection!

- The BomohTulang -

SAFETY AT THE PLAYGROUND

Due to its location in a residential area, the hospital sees a fair amount of injuries involving children. The numbers seen in the emergency room usually correspond to the school holidays, where we see an increase in the number of children being brought in due to some kind of injury, usually due to a fall while playing.  I suppose the holidays are the time children are given more freedom to play outdoor, free from the pressures of homework and tuition.

The neighbourhood playground is a natural spot for children to congregate, interact and play; at the same time it helps to build their physical skills, co-ordination and strength. It is also a wonderful place for families to get some fresh air and exercise.  It may look like a safe place, but hidden dangers do lurk. The hospital had a “Smart Parent Safe Kids” campaign earlier this year where I gave a talk on prevention of playground injuries.  Why playground injuries? Well, apart from the home, accidents occur more frequently on the playground than any other places. 
In the US, more than 200,000 playground-related injuries occur annually. Similarly in Malaysia, a recent study has shown that 17% of childhood fractures occur in the parks, second only to the home (35%). Now scrapes and bruises are a normal part of growing up, but injuries that are brought to the hospital are usually of a more severe kind. We see sprains, fractures, dislocations, and rarely, amputated fingertips.

Children can injure themselves at the playground in a variety of ways.  As I have explained above, the majority of the injuries result from a fall from playground equipment. They might slip, lose their grip while climbing, or lose balance while playing on the “monkey bars”. Another way is by improper usage of equipment.

The onus is on parents and caregivers to create a safe environment for children to play. One should firstly choose a safe playground based on the location and surrounding hazards. Watch out for open drains, exposed electrical wires and busy roads among other things.

Close supervision by a responsible adult may be the most important factor in preventing playground injuries.  For young children, adults should be with them the whole time they are playing on play equipment. The word is “Active supervision” – one should not be distracted by other activities such as reading a book, talking on the phone or texting.  Although I do agree that  sometimes  adult supervision might be a problem in urban areas as both parents may be working, delegating this responsibility to the grandparents, housemaids or elder children might not be as effective.  Educating the child on the correct usage of play equipment not only decreases the chance of injuries but also goes a long way in preserving the lifespan of the play equipment.

All these might sound frightening, so should you stop sending your children to the playground? My thoughts are that the benefits of fresh air and exercise far outweigh the danger, and so long as mummy and daddy keep an eye and play an actively supervise, time spent at the playground need not end up a tearful experience.

-The BomohTulang 

Eid-Ul Fitri and Happy Independence Day 2011

The end of August this year coincides with the two largest celebration for Malaysians.

Muslims throughout the country, according to calculation, will observe Eid-ul Fitri on Tuesday the 30th of August, marking the end of Ramadhan, where muslims fasted daily for a month from dawn till dusk. Traditionally the eid holidays (also known as Hari Raya Aidil Fitri) run for two consecutive days but this year, the second day coincides with Malaysia's 54th Independence Day.

So this year is indeed a double celebration for Malaysians in general and especially for the muslims throughout; the Bomoh Tulang would like to take this oppurtunity to wish a Selamat Hari Raya and Happy Independence day to all Malaysians!

Happy Holidays and have a safe journey home!

Selamat Hari Merdeka!

- the BomohTulang -

ACHILLES TENDON CUT due to TOILET BOWL INJURY

The patient slipped in the bathroom and his foot crashed into the toilet bowl. (no he was not squatting on the edge of the toilet seat - see bottom pic)

He sustained a deep laceration over his calf and a clinical examination showed that the achilles tendon was torn.
This was confirmed intra-operatively, where an emergency debridement, exploration and tendon repair was done the same day.

Intra-op findings

Wound blurred out as deemed too gory for public viewing :

Post operatively, a backslab with the ankle in equinus was applied so as to relieve the tension on the operated tendon. This will be replaced later with a special walking boot allowing range of motion exercises to the ankle, with partial weight bearing of the affected limb. Total rehabilitation would take about 4-6 weeks

Apparently a group of doctors reported on this seemingly "rare" case and got it published in the foot and ankle journal.

On another related note, have you been to the toilets in the malls? you would probably come across this sign:

The bottom right symbol is an apt reminder of what not to do if one wishes to avoid getting the injury that our friend above had... perhaps the mall management might want to use the picture above to illustrate the consequences of slipping into a toilet bowl.. hmm...

- the Bomoh Tulang -

reference:

the AAOS Clinical Practice Guideline on the Diagnosis and Treatment of Acute Achilles Tendon Rupture 2009

FALL PREVENTION IN THE ELDERLY - KEMUNING NEWS magazine article

Broken bones are a very real risk in the elderly, partly due to the fact that bones are brittle at that age, and  minor falls could lead to a catastrophic fracture.
The Bomoh Tulang was featured in the July-September 2011 edition of Kemuning News the other day, featuring a write up on do's and dont's on fall prevention in the elderly.

 

Kemuning News is published on a quarterly basis, exclusively for the residents of Kota Kemuning, which is the housing area adjacent to the hospital.
If you are a resident of Kota Kemuning (or just happened to be in the vicinity), do pick up a copy as the publication is freely available at the convenience stores and the Petronas stations.

In case you have missed it, I have appended the article on my website here.

- the Bomoh Tulang -

SCUBA DIVING - Dr Asri's OW dive certification

As you know I'm an avid diver, having had my PADI dive certification in 2005. Since then I have had the opportunity to log numerous dives around the islands off Malaysia's coast.

I managed to "racun" Dr Asri, our Anesthetist in the hospital to take the Open Water Diver Certification, which is basically a "licence" to scuba dive and the first step to experience what the wonderful world beneath the waves has to offer.
Part of the certification is to do a few dives in the open water (as opposed to the confined waters of the pool)

So one fine July weekend, we took a flight to Kuala Terengganu and met up with Divemaster Halimi of Ocean Elements.The speedboat brought us to Pulau Perhentian where we spent the weekend and for Dr Asri to practice his ability to breathe underwater :P

More pics after the jump..

Before the first dive

SYNDACTYLY - joined together

Syndactyly, or "webbed fingers," is caused by the failure of the fingers to separate during embryological development. It is the most common congenital anomaly of the hand, with an occurrence of 1 per 2000 births. Hereditary causes has been suggested, with up to 40% of patients having a positive family history of syndactily.

Syndactyly can also be associated with a variety of other syndromes, some of them rare - for example in the patient below with Apert Syndrome.

Syndactyly in an infant - part of a larger problem - the Apert Syndrome

Syndactyly is most commonly seen in the middle and ring fingers; it can be classified as simple when it involves soft tissues only and complex when it involves the bone or nail of adjacent fingers. It can also be classified as complete or incomplete depending on the degree of soft tissue union between the fingers.

Timing of separation of the digits depends on the fingers affected. If the affected digits grow at unequal lengths (for example the little and ring fingers) then separation should ideally be done within the first few months of life as the tethering of the skin will cause the fingers to deviate and cause contractures.

Ring and mddle finger syndactyly usually does not pose functional problems, as in the case of the older child below. In this case, it is a simple, complete syndactyly of the ring and middle fingers. Since both fingers grow at equal lengths, surgery to separate the fingers can be delayed later in life.

- the BomohTulang -

Smart Parents Safe Kids campaign

Columbia Asia Hospitals, in collaboration with the parenting website parenting2u, organized a series of talks on children safety at CAHBR recently. This event kicks off a nationwide campaign themed "Smart Parents, Safe Kids". 

The aim is to educate parents and caregivers on the importance of children's safety and also highlight the hidden dangers found at home, the parks and in the water.

Given the fact that the ortho surgeons deal a lot with children's fracture, guess who was honoured with the chance to talk on playground safety?..

Earnestly talking

what's this about

Part of the audience

activities for kids

The talks will be held at the Columbia Asia Hospitals nationwide, so check out your nearest hospital for the date of the roadshow.

More on the campaign can be found here

- the BomohTulang - 

In appreciation of our Nightingales - HAPPY NURSES' DAY

International Nurses' Day is celebrated between 6-12 May every year. 

CAHBR had a celebration on the 11th of May this year- where the agenda was "speech, makan and more makan":P

Ehem.. on a more serious note - this year's theme was "Closing the Gap: Increasing Access and Equity". The International Council of Nurses notes that there are still some areas of the population that has minimal or non existent access to health care - they believe that nurses, as a frontliner in the provision of healthcare, have an important role in bridging the gap to reduce health inequities and providing better access to healthcare for the general population- hence the theme for this year's International Nurses' Day.

okay, enough of the ceramah dudes! on to the pics..

The nurses day cake

Matron with the staff

More makan

 - the BomohTulang -

sources:

the international Nurses Day Wiki

International Council of Nurses, ICN

Elbow fractures in Children - Supracondylar fracture of the humerus

We see a fair number of children's injuries in the hospital, the reason being that the hospital is situated in a residential neighbourhood.

Children frequently fall, and in the process, has the tendency to extend their arms out to protect themselves.
This fact makes injuries involving the upper limbs more frequently seen in the ER (Emergency Room) as compared to the lower limb. The force from the fall, if large enough, can fracture the bone in two common places - the wrist or the elbow.

For the elbow, the forces from the fall travel through the forearm, levers the elbow joint in extension and the bone breaks at the weakest part of the arm - the supracondylar part of the humerus.
This is the so-called supracondylar fracture of the humerus and is the commonest elbow injury seen in children, seen most frequently in the 3 to 8 year old age group. It is also the 2nd most common children's fracture, second only to wrist fractures.

Patients with a suspected supracondylar fracture of the humerus frequently present to the ER with a history of fall, with associated swelling of the elbow and inability to bend the elbow.

*For the parent, if there is a suspicion of an elbow injury or fracture, one should ideally immobilize the limb in a sling prior to bringing to the ER. Besides providing comfort to your child, it limits further movement and displacement (moving out of alignment) of the suspected fracture. Dont know how to do it? look it up here. *

And that was how I met my 7 year old patient in the ER a couple of months ago. He had a nasty fall and was brought to the ER by his parents. His left elbow was deformed and swollen, and painful to the touch.

Swollen left elbow

X rays confirmed my suspicions: a supracondylar fracture of the left humerus.

Now fractures which are minimally displaced, or better yet, undisplaced, can be treated with nothing more than a plaster slab and an armsling. However our patient had what is known as a type III Gartlands fracture, where the fracture ends are totally not in contact with each other. This necessitates an operative reduction (where the surgeon manipulates the fracture ends into place) and fixation with wires.

Fortunately the parents understood the gravity of the situation and agreed for surgery that night. Here are the before and after pics of the X rays:

fracture site (arrowed)

frontal view of the elbow showing the fracture

Fracture reduced (put back) and temporary wires in place. Compare with the first picture

You can see that humpty-dumpty the bone ends has been put back together again.
The wires were removed after a month -   on the x rays below you will note that the fracture is healing well with new bone around the fracture site.

after 2 months

There was still some slight stiffness of the elbow on the last day of treatment which should go away after some physiotherapy. Now our patient is well on his way to playing football again and probably has a nice story to tell his kids later!

- the BomohTulang -

references:


Clinical Practice Guidelines
The Treatment Of Pediatric Supracondylar Humerus Fractures
American Academy of Orthopaedic Surgeons 2011

Current Concepts Review Supracondylar Humeral Fractures in Children
J Bone Joint Surg Am. 2008;90:1121-32

Crossed-pin versus lateral-pin fixation in pediatric supracondylar humeral fractures.
Shamsuddin SA, Penafort R, Sharaf I. Med J Malaysia. 2001; 56(Suppl D):38–44.

Wheeless' Textbook of Orthopaedics (online)

DE QUERVAIN's TENOSYNOVITIS - Pain at the side of the wrist

Wrist pain has multiple causes and can be localized to various areas around the wrist; one of the common ones being pain at the side of the wrist near the base of the thumb. This can be attributed to De Quervains tenosynovitis

De Quervain's tenosynovitis refers to inflammation of tendons together with their enclosing sheath on the side of the wrist at the base of the thumb. These tendons, the extensor pollicis brevis and the abductor pollicis longus tendons, help move the thumb a certain way - to extend and to abduct the thumb (hence their names). On their way to the thumb, the tendons passes through a tunnel (the extensor retinaculum) which helps hold the tendons in place. Much like trigger finger, irritation of the tendon causes the lining (synovium) around the tendon to swell, which makes it difficult for the tendons to move and glide into the tunnel. However, unlike trigger finger, there is no 'catching' sensation - just pain at the side of the wrist during certain positions of the hand.

Patients with De Quervain's frequently complain of pain with certain movements of the wrist, for example when pouring tea from a teapot, using a watering can and lifting the grocery bags during shopping. These particular wrist movements will cause a strain on the said tendons - leading to the wrist pain.

The pain can be replicated by bending your thumb inwards into your palm and making a fist - this is the basis of the eponymous Finkelsteins test. (if you can read Thai, here's a DIY video of the test :P)
Here's a picture of the test - it can be quite painful for the patients to perform so I would proceed slowly if I were to conduct the examination.

Patients are commonly women aged 30 to 50, and frequently mothers of infants. Indeed sometimes when the patients of a child bearing age sees me in the clinic for the problem, my usual interview question would include "have you recently had a baby?" Apparently picking up and carrying of the baby puts the wrist in an awkward position, putting strain to the tendon, and hormonal changes in the tissues further aggravates this situation.

Other conditions that may mimic this would include basal thumb arthritis or the intersection syndrome (most commonly confused with)

Treatment is basically conservative. A period of splinting would help to rest the inflamed tissue; there are smaller splints now which are more comfortable to wear, do ask your therapist about it. Non-steroidal anti-inflammatory medications (NSAIDs), ultrasound therapy and ice all help to relieve the inflammation. These conservative means are all that is needed for the majority of patients

Steroid injection directly into the sheath can be given for more severe cases, although there is a risk of discolouration of the skin at the injection site.

Failed conservative management would necessitate a surgical release of the constricting sheath of the tendon ( the 1st dorsal compartment ). This could be done on an outpatient basis, ideally under general anaesthesia.



- the Bomoh Tulang -

references:

Treatment of de Quervain's disease:role of conservative management.

 Journal of Hand Surgery - British Volume. 26(3):258-60, 2001 Jun.

	Ilyas AM "de Quervain Tenosynovitis of the Wrist" J. Am. Acad. Ortho. Surg., December 2007; 15: 757 - 764.

BOMOH TULANG talks about Back Pain - RAPI magazine

RAPI magazine contacted the Bomoh Tulang the other day, and enquired whether would he be kind enough to write about back pain and prolapsed disc? Well of course I obliged.

The April issue of RAPI mag is already at the newsstands and features a four-page spread on all you need to know about back pain and prolapsed disc. So ladies and gents, if you have any questions about back pain, head over to your nearest newsagent and get your copy now. I'll be signing copies at MPH. ;)

..and no, this is not an April Fool's joke..

  

- the BomohTulang -

TRIGGER FINGER - your finger is catching

Trigger finger (stenosing tenosynovitis),  is one of the common causes of pain and dysfunction in the hand.
The initial symptom is of a painless "click" in the hand on moving the fingers which might eventually progress into a locked finger. The finger might be locked in flexion, whereby a forceful extension of the finger is required to unlock the finger , causing a feeling of "triggering" at the base of the finger (the metacarpo-phalangeal joint). Patients may or may not notice a lump or knot in the palm of the hand, again typically at the base of finger.

The problem occurs when there is a constriction where the finger flexor tendon enters the tendon sheath at the base of the finger. It is caused either by a thickening (hypertrophy) of the tendon sheath, or a nodular swelling of the tendon itself just proximal to the sheath. Either way, the basic problem lies in the discrepancy between the size of the tendon nodule and the thickened tendon sheath. This means that the tendon can no longer slide easily through it and it becomes harder to bend or straighten the affected finger or thumb as a result. 

Trigger finger occurs two or three times more frequently in women than in men and has a peak incidence of around 40- 60 years of age (the demographics sounds similar to carpal tunnel syndrome... ) The ring finger is the most frequently involved, followed by thumb and ring finger.Frequently one finds that multiple fingers are affected and bilateral hand involvements are not uncommon.

As many as 85% of trigger finger can be successfully treated non-operatively. These include activity modification, splinting, anti-inflammatory drugs (NSAIDs) and steroid injections.

Steroid injection around the flexor sheath can be an effective treatment, and in my experience, for the patients with mild triggering and short duration of symptoms, one can expect a complete resolution of symptoms.

Surgical release of trigger finger is reserved for patients not responding to conservative management, the chronically locked finger, long duration of symptoms, and multiple digit involvement. As with most of my minor hand surgery cases, this can be done as a daycare procedure under local anaesthesia and takes about 15 minutes. However, in instances where multiple fingers need to be operated upon, general anaesthesia may be a more comfortable option.

Similar to carpal tunnel release, a small incision about 1cm is made at the base of the affected finger and the constricting sheath is then cut open longitudinally under direct vision. Care is taken to ensure that the nerves running alongside the tendon is not disturbed, and this can only be done if the surrounding structures are well visualized; this is the reason that I am not in favour of percutaneous release of trigger finger, although the proponents say that it is a reasonably safe option.

A surgical loupe is frequently needed to identify the structures

Incision at the base of the finger

the constricting sheath (A1 pulley) is visualized and divided

sutured up

Trigger finger in infants or children almost always involves the thumb and could be a different entity from the adult type. Most authors recommend observation as children below 6 months can have spontaneous resolution of symptoms ( I know, because my nephew had the same problem - it resolved spontaneously!). Surgery, as with adults, could be considered if symptoms persist.

- the BomohTulang - 

References: 

Trigger digits: diagnosis and treatment.   J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):246-52.

Trigger digits: principles, management, and complications. J Hand Surg Am. 2006 Jan;31(1):135-46.

The Natural History of Pediatric Trigger Thumb. The Journal of Bone and Joint Surgery-American Volume

Issue: Volume 90-A(5), May 2008, pp 980-985

Core Knowledge in Orthopaedics: Hand, Elbow, and Shoulder. Trumble, Budoff, Cornwall. Mosby 2005

BOMOH TULANG - a bit about me

*ehem* I have taken the liberty to "cekup" my profile from the ColumbiaAsia's blog and put it here, just for you loyal readers.

Dr Saiful Akhtar Shamsuddin - Consultant Orthopedic Surgeon

Dr Saiful Akhtar Shamsuddin

Consultant Orthopedic Surgeon

Columbia Asia Hospital, Bukit Rimau, Malaysia

MBBS (UM), MS Ortho (UKM), CMIA (NIOSH)

Fellowship in Lower Limb Arthroplasty & Reconstruction (Aus)

AO Fellowship in Hand Surgery (USA)

saiful.akhtar@columbiaasia.com

Dr Saiful Akhtar Shamsuddin is an orthopedic surgeon, with a keen interest in Hand surgery and also Arthroplasty surgery as a sub-specialty.

He brings to Columbia Hospitals a wealth of experience and knowledge in orthopedics, having had 18 years of orthopedic experience and more than a decade of specialist orthopedic experience, serving in one of the busiest hospitals in Malaysia.

Dr Saiful was born, raised and schooled in Klang, Selangor,  making him a native Klang-ite. After Form Five, he furthered his studies in Pusat Asasi Sains and henceforth continued to study medicine in University Malaya.

Having completed his undergraduate studies, he went on to work mainly in the Orthopedic and Surgical departments throughout his career. His first ever posting as a houseman was in the Orthopedic Department in Hospital Kuala Lumpur, where he made the decision to pursue Orthopedics as a career. He had the priviledge to work in various hospitals throughout his career; namely Hospital Seremban, Hospital Kuala Pilah, Hospital Kuala Lumpur and Hospital UKM, prior to completing his Masters Progamme in Orthopedic surgery. He last served Hospital Tengku Ampuan Rahimah Klang before joining Columbia Asia Hospital, Bukit Rimau as a Consultant Orthopedic Surgeon

During the earlier part of his career as a specialist, he was attached to the Hand and Micro-Surgery Department of Hospital Selayang, under the guidance of Dato’ Dr Pathmanathan, where he developed a keen interest in Hand Surgery as a sub-specialty. He continued his involvement in hand surgery while in Hospital Klang and was instrumental in setting up the hand services there.

Dr Saiful later obtained a fellowship in Lower Limb Arthroplasty and Reconstruction from the Gold Coast Hospital, Australia  to strengthen his knowledge in Joint replacement surgery.

Besides hand surgery and arthroplasty surgery, he also manages various orthopedic problems, ranging from simple backache to congenital deformities to severe limb and spine trauma.

Dr Saiful is married, and is blessed with three wonderful children. In his spare time he can be found scuba diving beneath the tropical waters off Malaysia’s east coast islands. He is also passionate about photography, a hobby he picked up during his student days.

Contacts or appointments?
click here


- the BOMOH TULANG -

At the AO principles course 2011

The AO principles and advanced course Malaysia 2011 was held at the Dorsett Regency, Subang, and attended by more than 70 local and international participants. Held over a period of two days, it encompasses lectures, case discussions and hands-on workshops on fixation techniques.

The Bomoh Tulang has been fortunate to be a part of the teaching faculty for past few years, and this year was not an exception. 

The AO Foundation - Arbeitsgemeinschaft für Osteosynthesefragen (German for: Association for the Study of Internal Fixation) - is a non-profit organization based in Davos Switzerland, dedicated to the advancement of the treatment of musculoskeletal injuries. Founded in 1958, the AO foundation promotes the understanding of fracture management through research, meetings and education. 

As an integral part of education, the AO foundation through AO Education conducts courses on the principles and techniques of fracture fixation,  for Orthopedic surgeons and also operating room personnel. These courses are held on a regular basis throughout the world and is a great place for trainee orthopedic surgeons or even senior surgeons to learn, exchange notes and at the same time update their skills on the latest fixation techniques.

Dr Ivan explaining the finer points of external fixation to the participants

Plating the fibula

Dr Rashdeen and Dr Hazrin trying out some fixation techniques. This was at the 2010 course.

Also at the 2010 course. Dr Azfar was a participant.

Interested in next year's AO course?
Click here for registration. Spaces are limited so better hurry!

- the BOMOH TULANG -