Dislocations and collateral ligament injuries of the first metacarpophalangeal joint are important complications of trauma that can be easily overlooked. A sudden valgus stress applied to the metacarpophalangeal joint of the thumb may cause a disruption of the ulnar collateral ligament and often is associated with a fracture of the proximal phalanx. This injury, if left untreated, may result in early degenerative joint disease of the first metacarpophalangeal joint.
The typical history involves a patient who injures his thumb on the ski slopes; the patient may or may not remember a specific event. Physical examination will usually demonstrate instability in the first metacarpophalangeal joint, if the patient is examined before much swelling has occurred.
Initially, radiographs may be negative, although small avulsed fragments from the base of the proximal phalanx can be delineated in some instances. These fragments may be displaced proximally and rotated from 45 to 90 degrees. Radiographs obtained with radial stress applied to the first metacarpophalangeal joint can reveal the luxation of the joint. It is important to stabilized this joint in order to prevent instability. This injury may take several months to heal and stress to the joint should be avoided.
Diagrams from Greenspan, A., Orthopedic Radiology, Gower Medical Publishing 1988, and Resnick and Naiwayama, Diagnosis of Bone and Joint Disorders, Sauders, 1981.
While cervical disc pathology can unquestionably produce radiculopathy, many patients presenting with arm pain, paresthesia or perceived weakness do not exhibit the clinical behavior of true nerve-root compromise. In these cases, failure to differentiate the primary pain generator may lead to unnecessary spinal injections, nerve ablation procedures or surgical consultation despite limited likelihood of benefit.
The New Jersey Board of Chiropractic Examiners has made a precedential decision, concurring with the Association of New Jersey Chiropractors' (ANJC) position paper on chiropractic X-ray guidelines. In plain terms, the board ruled, consistent with the ANJC position, that insurance companies cannot use medical X-ray rules or recommendations, like those written by the American College of Radiology (ACR), to decide whether a chiropractor's X-ray was necessary.
For decades, chiropractors have been told the answer to more professional referrals is simple: educate medical doctors about chiropractic. There is some truth in that advice; but it is also incomplete. The modern challenge is not simply getting another healthcare professional to know that chiropractors exist. It is becoming the kind of clinician (and building the kind of professional relationship) that makes collaboration easy and sustainable.
