Under the microscope:

Top news:

Meniscus Repair: Up-to-Date Advances in Stem Cell-Based Therapy

The meniscus is a semilunar fibrocartilage between the tibia and femur that is essential for the structural and functional integrity of the knee joint. Meniscus injuries can lead to pain, knee joint dysfunction, and degenerative changes such as osteoarthritis.

Stem cell-based therapy has recently attracted much attention in repairing meniscus injuries. Mesenchymal stem cells are most explored for their easy availability, trilineage differentiation potential, and immunomodulatory properties. This therapy offers patients the chance to repair damaged and/or degraded meniscal tissue, thus reducing their pain, and restoring function to the knee joint without increasing their risk of additional degenerative effects.

In a review published in Stem Cell Research & Therapy in May 2022, the authors summarize the advances and achievements in stem cell-based therapy for meniscus repair in the last 5 years. They also highlight the obstacles before their successful clinical translation and propose some perspectives for stem cell-based therapy in meniscus repair.

The review explains that the meniscus bears a poor self-healing ability due to its intrinsic avascular characteristics. Only the marginal 10–30% of the meniscus receives blood supply from the synovial membrane directly and can be healed after injuries, while the central meniscus nourished by the penetration of joint fluid lacks self-healing ability. The annual incidence of meniscus injuries reaches 66–70 per 100,000 people, mainly caused by trauma and degenerative diseases. Meniscus injuries lead to multiple clinical symptoms including joint pain, swelling, and locking.

Various surgical therapies have been applied to treat meniscus injuries including meniscectomy, allogeneic meniscus transplantation, and artificial meniscus implantation. However, stem cell-based therapy with potent regenerative properties has recently attracted much attention in repairing meniscus injuries.

1. Stem Cell Therapy for Meniscus Tear – thriveMD Denver & Vail, CO. (n.d.). ThriveMD Clinic. Retrieved from https://thrivemdclinic.com/stem-cell-therapy-meniscus-tear/
2. Bian, Y., Wang, H., Zhao, X., & Weng, X. (2022). Meniscus repair: up-to-date advances in stem cell-based therapy. Stem Cell Research & Therapy, 13(1), 207. doi: 10.1186/s13287-022-02863-7

On the case:

Elderly Patient with Fall on Outstretched Hand

Case study

Background: Samira, a 70-year-old woman presents to the Urgent Care Centre after falling on her outstretched right hand. 

She has a history of type 2 diabetes, osteoporosis, and glaucoma. She lives at home with her husband who has dementia and is his main carer. She is right-handed. Medication history is that she takes metformin, AdCal, and timolol eyedrops. 

Mechanism of Injury:

Samira says she was in a rush and tripped on a rug at home, falling onto her outstretched right hand. She reports immediate pain and swelling in her right wrist. She denies any injury elsewhere and did not bang her head.

Wrist fractures usually occur after a fall on an outstretched hand. When a person puts their hand out to break a fall, they might land on the small bones that make up their hand and wrist. This contact transfers energy to the radius, one of the two lower arm bones.

Examination: Systematic examination of injuries uses the look, feel, move method: 

LOOK - for abnormalities (comparing to the other side when possible). 

FEEL - for circulation and sensation distal to the injury and specific areas of tenderness. Assess the sensory/ motor function of specific nerves. 

MOVE – assess joint movement as appropriate.

Signs and Symptoms:  Samira’s wrist is swollen and bruised, with no open wounds or grazes. She is tender over the distal radius and cannot move her wrist due to pain. A radial pulse is present, and her hand is pink and warm with a normal capillary refill time of 2 seconds. She can move all her fingers and has full sensation to all parts of her hand. There is no apparent wrist deformity.

Common symptoms of a wrist fracture include pain, swelling, bruising, tenderness, numbness and tingling, difficulty in hand/ wrist movement, and there may be an obvious deformity.

Questions:

1. What is the most common type of distal radial fracture seen in elderly patients?

       A- Colles fracture

       B- Barton’s fracture

       C- Smith's fracture

Answer- The correct answer is A

With the mechanism of a fall onto an outstretched hand, the end of the radius near the wrist breaks, causing the broken bone to tilt upward towards the back of the wrist. This may be referred to as a Colles fracture. Colles fractures are the most common type of distal radial fracture seen in elderly patients.

2. What is the most frequently fractured carpal bone after a fall onto an outstretched hand? 

       A- Capitate 

       B- Scaphoid

       C- Lunate

Answer- The correct answer is B

There are 8 carpal bones in the wrist. After a fall onto an outstretched hand, the scaphoid is the carpal bone most likely to be fractured. The scaphoid is important for wrist movement and stability and therefore even though approximately 16% of scaphoid fractures are not seen on the first X-ray (and may eventually need an MRI to diagnose) any suspected scaphoid injury should be referred to the Fracture Clinic. 

Treatment: Treatment options for a Colles fracture depend on the severity of injury, age and a person’s activity level. In the Urgent Care setting a straightforward fracture with no displacement, neurological or vascular compromise will simply require a temporary plaster back-slab for immobilisation, and a routine referral to Fracture Clinic. This allows the swelling to go down before a full cast is applied A fracture that is angulated will require manipulation using adequate analgesia for which the patient may need to attend A&E. 

Fracture Clinic treatment includes applying a full plaster cast and further follow-up until the bones are healed. Fracture healing usually takes around 6 weeks but may take longer depending on factors such as underlying medical conditions and nutrition. Other treatment options include closed reduction (moving the bone into position without making an incision on the skin), open reduction (making an incision on the skin to position the broken bones), internal fixation (holding the broken bones in place with metal pins, plates, screws or external fixator), physical therapy (done after the cast is taken off to restore normal movement), and medication (such as paracetamol/ ibuprofen to relieve pain).

    3. What non-medical issues need to be addressed before this patient can be discharged?

      A- Permanent admission for Samira’s husband to a nursing home.

      B- Measures and support systems that need to be in place for Samira to be able to live at home with her husband. Hospital admission option to be explored. 

      C- Measures and support systems available for Samira to move permanently into her son’s house.

Answer – The correct answer is B

Samira is right-handed and will now need a plaster back-slab to immobilise her right lower arm. She is unlikely to be able to look after herself and her husband without support. It will be necessary to find out if she has family/ friends who can supply adequate support and an urgent referral to social services referral should be made immediately. If care cannot be arranged, her care should also be discussed with the Orthopaedic team in case she or her husband need to be admitted to hospital. 

Additional notes:

It is vital to ascertain the exact mechanism of injury including the reason why the patient had a fall. In this case Samira says she tripped on a rug so this is a mechanical fall. A non-mechanical fall (e.g., pt felt dizzy/ had chest pain/ lost consciousness) would require further evaluation in the Emergency Department.

In any case a full set of vital signs observations should be carried out including blood glucose, blood pressure, pulse, and respiratory rate. 

During examination, it is also necessary to examine the joints above and below the injury. In Samira’s case as she has osteoporosis, her fingers, elbow, humerus, shoulder, clavicle and neck should also be assessed to rule out associated injuries.

If Samira had fallen onto a back of her wrist, she may have sustained a fracture that is angled the opposite way - towards the front of the wrist. This may be referred to as a Smith’s fracture. This type of fracture would require urgent Orthopaedic assessment as it may require surgery to stabilise it and it may be putting pressure on the median nerve in the carpal tunnel of the wrist. 

Ask PDUK: 

Kam Datta, ENP answers your questions.

Question: What advice should I give my patients on the initial treatment for first-degree burns?

Answer: As an advanced practitioner, I would advise patients to immediately immerse the burn in cool tap water or apply cold, wet compresses for about 20 minutes.  

After cooling the burn, they can apply either petroleum jelly, aloe vera gel or after sun lotion two to three times daily.  They should never use ice on a burn . If they have any clothing or jewellery near the burn, they should be removed unless they are stuck to the burn. If they have any further concerns, it’s always a good idea to consult with a healthcare professional.

Note: A burn can still develop into a deeper injury for up to 3 hours. If blistering occurs, the patient should seek medical advice, as the blisters may need deroofing, dressing and a review. 

https://www.lsebn.nhs.uk/website/X13911/files/
LSEBN%20Initial%20Management%20of%20Burn%20Wounds.pdf  
accessed 02/06/23

Question:  Does a wound need to be sutured within a certain time frame?

Answer: Yes, a wound needs to be sutured within a certain period of time.  Recommendations for primary closure of wounds that are clean and have no signs of infection can be anywhere between six to 18 hours of the injury. Size of the injury, where the wound is, and patient risk factors all need to be considered. 

Wounds to areas with an extensive vascular supply (e.g., head, face) may be closed up to 24 hours from the time of injury. Because of the high risk of infection, bite wounds are typically left open unless they are on the face and are potentially disfiguring. Clinicians should always follow guidelines per workplace protocol as recommendations may vary. 

Ref- Common Questions About Wound Care | AAFP accessed 31/5/23

deLamos, DM (2022) https://www.uptodate.com/contents/skin-laceration-repair-with-sutures- accessed 7/6/23

Brancato, JC (2022) https://www.uptodate.com/contents/minor-wound-evaluation-and-preparation-for-closure?topicRef=6319&source=see_link. Accessed 7/6/23

Question: What is the best advice to give patients who ask if they should use water or antiseptic to cleanse a wound?

Answer: For most simple wounds, it is recommended to rinse them under cool running water. If they are going to use an antiseptic, it should only be used once to initially clean and never chronically. When they clean the wound again after a day or so, use water. Don’t ever use rubbing alcohol or peroxide to clean an open wound. They can gently rub off any foreign material using a piece of gauze soaked in water.

If they are out and about and don’t have running water, they can always use bottled water.

About our expert

Kam Datta has worked as nurse for over 30 years and her qualifications include Intensive Care and Accident and Emergency Nursing and MSc Physiology, She has been working as a Nurse Practitioner in Urgent Care since 2009.

Don't forget to check out our selection of scheduled minor injury courses, including our:

• RCN Accredited Minor Injuries Essentials-  Face to Face or Online.
• Acute Wound Management for Urgent & Primary Care Practitioners
• X-ray interpretation of minor injuries- includes Red Dot- Online - AR07

Additional programs can be found in our in-house section.