Diagnostic accuracy of pre-operative clinical examination in Zone V flexor injuries

Abstract

Background: Zone V flexor injuries can be devastating with significant morbidity. The pre-operative clinical examination not only assists surgeons with preparation but also with efficiency of limited theatre utilisation. Our study aimed at analysing the demographic data of patients who presented to the casualty unit at Chris Hani Baragwanath Academic Hospital (CHBAH) with zone V flexor injuries and also to assess the diagnostic accuracy of pre-operative clinical examination of orthopaedic registrars in these injuries. Methods: This was a prospective study of patients with zone V flexor injuries who presented to the casualty unit at CHBAH from 1st March 2018 to 30th April 2019. The demographic data were analysed, and the pre-operative clinical examination findings were compared to the definite intra-operative findings. The latter was to assess the accuracy of the pre-operative clinical examination findings of the orthopaedic registrars. One-sample test for proportion was used to assess if the difference between the pre-operative clinical examination findings and definite intra-operative findings was statistically significant. Results: Zone V flexor injuries occur predominantly in males and in people less than forty years of age. The leading causes of these injuries in our setting were homicide and accidental injuries. These injuries occurred mainly in the employed, contract workers and students. Furthermore, they occur on the right upper limb and dominant side of the patients. Alcohol intake was a significant factor for the causes of these injuries. Forty-eight percent and thirty-six percent of the zone V flexor injuries in our study were spaghetti wrists injuries and ulna triad injuries respectively. Concurrent injuries to the radial and ulna arteries were rare but lacerations of either of these arteries were common. The overall accuracy of pre-operative clinical examination of zone V flexor injuries by orthopaedic registrars was 77.8%. The missed diagnosis of lacerated tendons, nerves and arteries were high. The accuracy of diagnosing partial injuries of tendons, nerves and arteries was very low. The rate of inaccurate diagnosis of flexor digitorium superficialis (FDS) tendons was higher than that of flexor digitorium profundus (FDP). Flexor carpi ulnaris (FCU) tendon, ulnar nerve and ulna artery had the highest rate of inaccurate diagnosis of pre-operative examination among the tendons, nerves and arteries, respectively. CONCLUSION: There was a significant difference between pre-operative clinical examination and intra-operative findings. The accuracy of the clinical examination can be improved by enhancing the adequate knowledge and clinical skills of the examining doctor as well as carrying out the clinical examination in a pain-free, calm and co-operative patient. There should be a high index of suspicion for exploring zone V flexor injuries