Vaughan-Jackson Syndrome Workup

  • Author: John A McAuliffe, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Sep 17, 2010
 

Imaging Studies

  • Radiographs
    • Plain radiographs are imperative to assess the status of the distal radioulnar and wrist joints. The degree of joint destruction, subluxation, or dislocation, as well as the presence of bony prominences that may be directly responsible for tendon attrition, can be determined by good-quality plain radiographs in 3 projections (anteroposterior, lateral, and oblique). See images below. Anteroposterior radiograph of the wrist following Anteroposterior radiograph of the wrist following wrist arthrodesis and resection of the distal ulna displays the scallop sign, which is the term used to describe the scooped-out appearance of the sigmoid notch of the radius that results from synovial proliferation and bone erosion. Radiograph of a rheumatoid hand with metacarpophalRadiograph of a rheumatoid hand with metacarpophalangeal joint dislocations. These joints are incapable of extension.
    • Radiographic and clinical evaluation of the radiocarpal joint is necessary, because the condition and function of this articulation may influence the choice of reconstructive options for the distal radioulnar joint (DRUJ). If a mobile wrist is to be maintained, simple excision of the distal ulna may not be advisable, and alternatives (eg, Sauve-Kapandji procedure) may help prevent or delay subsequent ulnar translation of the carpus.[23, 24]
    • Because the purpose of reestablishing extensor tendon function is to restore active metacarpophalangeal (MCP) joint extension, the MCP joints should be evaluated radiographically. Most authors would suggest that the reconstruction or replacement of badly damaged MCP joints should precede tendon restoration, although this point can be debated. Regardless of which reconstructive approach is believed to be appropriate, adequate planning is impossible unless the condition of the MCP joints is known.
  • Advanced imaging
    • Although magnetic resonance imaging (MRI) depicts effusion, synovitis, and even tendon involvement quite accurately, it has not proven to be predictive in the risk assessment of tendon rupture.[25]
    • Both ultrasonography and 3-dimensional computed tomography (CT) scanning have been utilized to demonstrate tendon ruptures on the dorsum of the hand and wrist.[26, 27, 28, 29, 30]
    • Proper diagnosis can almost always be made on the basis of careful physical examination. Advanced imaging seldom influences the decision for surgery or the procedure itself; therefore, routine use of these studies is not currently advocated.
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Other Tests

  • Thorough preoperative evaluation must precede any surgical procedure. This is particularly important in the case of the patient with rheumatoid disease who may be significantly debilitated. Rheumatoid arthritis is a misnomer; this is a systemic disease that may produce cardiac, pulmonary, and other organ system dysfunction.
  • Preoperative laboratory, cardiac, and respiratory evaluation is most appropriately directed by the primary care provider; the rheumatologist may function in this capacity. Other subspecialty evaluation may also be necessary because of specific organ system involvement.[31]
  • Medications used to treat rheumatoid disease may produce significant hematologic, hepatic, or renal effects that must be evaluated preoperatively. Certain medications, including corticosteroids, penicillamine, and methotrexate, may alter wound-healing potential and possibly increase the risk of infection.
    • The newer tumor necrosis factor antagonists have improved the lives of many patients who have rheumatoid arthritis, but they are associated with an increased risk of opportunistic infection. Data regarding possible increased risk of postoperative infection in patients treated with these agents are scant and, sometimes, conflicting.[32] It may be advantageous to adjust the dosing regimen of these agents in the perioperative period, although evidence-based recommendations cannot be made at this time. We must balance our desire to avoid surgical complications with the fact that a flare of the rheumatoid process in the perioperative period from alterations in medication can also contribute significantly to morbidity. Rheumatologic consultation is recommended.
  • Rheumatoid involvement of the cervical spine leading to instability is a common occurrence that must be anticipated preoperatively. Even when regional anesthesia is planned in cases of upper extremity reconstruction, the possibility always exists that general anesthesia and tracheal intubation will be necessary. Preoperative evaluation of cervical spine stability will allow appropriate precautions to be taken and potentially devastating complications to be avoided.[31]
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Contributor Information and Disclosures
Author

John A McAuliffe, MD  Consulting Surgeon, Department of Orthopedics, Section of Hand Surgery, Broward General Medical Center

John A McAuliffe, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, and American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph E Sheppard, MD  Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Orthopaedics Overseas

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

N Ake Nystrom, MD, PhD  Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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Typical appearance of the hand following rupture of the extensor tendons of the ring and small finger.
Intraoperative image of a ruptured extensor tendon with the hand to the left. Note that the tendon ends cannot be reapproximated despite maximum tension.
Anteroposterior radiograph of the wrist following wrist arthrodesis and resection of the distal ulna displays the scallop sign, which is the term used to describe the scooped-out appearance of the sigmoid notch of the radius that results from synovial proliferation and bone erosion.
Radiograph of a rheumatoid hand with metacarpophalangeal joint dislocations. These joints are incapable of extension.
 
 
 
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