Download to read offline
Uploaded byBijayendra Singh
Gp update upper limb Jan 2018
This document provides information on common upper limb conditions seen by Dr. Bijayendra Singh, an orthopaedic surgeon. It discusses his background and qualifications. It then outlines the scope of his practice, which includes shoulder, elbow, wrist and hand surgery. The document lists and describes many common orthopaedic conditions involving the shoulder, elbow, wrist and hand, such as rotator cuff tears, osteoarthritis, carpal tunnel syndrome, and Dupuytren's contracture. It provides details on evaluating and managing these various conditions.
More Related Content
Similar to Gp update upper limb Jan 2018
Gp update upper limb Jan 2018
- 1. Common Upper LimbConditions • Prof. Bijayendra Singh • FRCS (Tr & Orth), FRCS, MS, DNB • Consultant Orthopaedic & Upper Limb Surgeon • Medway NHS Foundation Trust • Visiting Professor, Canterbury Christchurch University 1
- 2. My Journey SoFar • Qualified 1992 • Masters 1995 • UK • Higher Training • Fellowship US & Australia • Consultant since 2007 • Professor of Orthopaedics & Chair Orthopaedic Pathway – Canterbury Christchurch University 2
- 3. Scope of Practice •Shoulder: • All aspects – arthroscopy, arthroplasty and fractures • Elbow: • All Aspects – arthroscopy, arthroplasty and fractures • Wrist & Hand • All Aspects Covered • Exceptions: • No microvascular • No Tendon transfers / graft
- 4.
- 5. Shoulder • Cuff Problems •Instability • Stiff Shoulder • Referred Pain
- 6. • Elbow: • InsertionalTendinopathy • Arthritis • Ulnar Nerve Compression • Ligament Injuries
- 7. Wrist & Hand •Carpal Tunnel Syndrome • Thumb Base Arthritis • Ganglion • Dupuytren’s Contracture • Trigger Finger / Thumb • deQuervain’s Tenosynovitis • Wrist Arthritis • SLAC / SNAC / OA • Hand Arthritis • Ulnar Impingement • Ligament Injuries
- 8. History • Age • Occupation •Handedness • Main Complaint • Previous Injury • Previous Surgery • ADL • Specific Activity Related • Exacerbation • Improvement • Frequency • Duration
- 9.
- 10. Red Flag Signs •Trauma pain + weakness = Cuff tear • Any mass or Swelling • Red skin, fever or systemically unwell • Infection • Post epileptic painful & stiff shoulder
- 11. Cuff Pain • Impingement,Cuff Tear, ACJ OA • Often patients point to Deltoid Insertion • Full ROM (ER) • Differential?
- 12. Most common causeof shoulder pain Usually > 40, if > 65 suspect cuff tear Pain Worsening on stretching / overhead activites Difficulty in sleeping on side Problem with other ADL May have weakness 12 If pain worse on bringing arm down - High suspicion of tear
- 13. 13 Impingement is a CLINICALDIAGNOSIS
- 14. • Management: • SubacromialBursa Injection • Physiotherapy
- 15.
- 16.
- 17. • When toRefer: • Acute onset • Severe Pain • Traumatic • Failure of conservative treatment • Over age of 75 - ? CTA
- 18.
- 19. Do we needto fix cuff tears 19
- 20. Natural History ofNon operatively Treated Symptomatic Rotator Cuff Tears in <60 yrs. (5mm or more) Safran et al: Am Jr. Sports Medicine, 39(4), 710 - 714 • F/U: 25 - 39 months • Ultrasonography by same sonographer • 51/61 evaluated – 30 (49%) tears increased in size – 26 (41%) no change – 5 (8%) reduced – 10(25%) found to have new tears • No correlation between change in tear size, – patient age – prior trauma – size of tear at index • Co-relation between considerable pain & increase in tear size 21
- 21. Massive / IrreparableCuff Tears 22
- 22. Introduction ● Massive irreparablerotator cuff - Challenge ● Presents with ‘Pain & Loss of function’ ● Progressive degeneration of the shoulder joint ● The functional status + dynamic stability of shoulder are used as a guide for treatment
- 24. Clinical Presentation • Pain •Stiffness & Adhesive capsulitis • ACJ pain • Disability • Weakness away from body • Pseudoparalysis • Weakness
- 25. • Clinically Anterosuperior escape- static dynamic
- 26. What is theBalloon ●Novel surgical technique ●Use of a bio-degradable material ● L-lactide-co-E-caprolactone ●As sub acromial spacer ( bursa) ●Promoting frictionless gliding / movement between HH & Acromion ●CE marked in July 2010 and in use in Europe
- 27.
- 28.
- 29.
- 30.
- 31.
- 32. Biceps Labral ComplexLesion 33
- 33.
- 34. Tests 35 ★ O'Brien ActiveCompression ★ Speed ★ Dynamic Labral Shear (Mayo Shear) ★ Biceps Load II (Kim) ★ Resisted Supination External Rotation (Labral Tension) ★ Upper Cut ★ Kibler Anterior Slide ★ Compression Rotation
- 35. Instability • Traumatic • Firsttime - nonoperatively • Immobilization? • If recurrent • Atraumatic • Refer early on
- 36.
- 37. Physical Demonstrate dislocation/subluxation ? Laxitytests Stability tests 38 Laxity tests Drawer Sulcus Push - pull Stability tests Fulcrum Apprehension (crank ) Jerk Strength tests
- 38. Stiff Shoulder • ThreeCauses • Arthritis • Frozen Shoulder • Dislocated Shoulder • ER??? • Plain Radiographs • 2 Views
- 39. • If notdislocated – try injection / physio • Frozen Shoulder – physio typically makes pain worse in early stages. • When to refer: • Early in frozen shoulder esp in diabetic • Disabling symptoms esp night pain • Pts with Inflammatory Arthropathy
- 40.
- 41. Enthesopathies • Commonest causeof elbow pain • Tendinopathies most common • Lateral >>>>> Medial • Conservative • Steroid Injection • Brace • PRP Injection • Physiotherapy • Extracorporeal Shockwave Therapy
- 42. Surgical Options • Open •Arthroscopic
- 43. OA Elbow • Pain •Stiff • Ulnar Nerve Symptoms
- 44. • Ulnar NerveCompression • Muscle Wasting • Clumsiness • Small Object Surgery
- 45. Management • Arthroscopic Debridement •Ulnar Nerve Transposition • Elbow Replacement
- 46.
- 47. Why is theHand so Important
- 48. Pubmed Search • Foot& Ankle: 156859 + 63234 • Knee: 146141 • Hip: 140650 • Shoulder: 94936 • Hand: 1343600
- 50. Dr. Wilder Penfield's monograph"The Cerebral Cortex of Man."
- 51. Objectives • Review theAnatomy, History and Physical Examination of the wrist and hand • Formulate a pathoanatomic diagnosis in the clinical setting • Discuss common clinical conditions that can be elicited from the physical exam
- 52. • Least protectedjoints • Extremely vulnerable to injury • History can be vague • Difficult & Complex examination • Compare with other side
- 53. 29 bones • Phalanges:14 • Sesamoids: 2 • Metacarpals: 5 • Carpals: • Proximal Row: 4 • DIstal Row: 4 • Radius / Ulna
- 54. • Muscles /Tendons (29) • Volar Wrist - 6 • Dorsal Wrist - 9 • Volar Hand - 10 • Dorsal Hand Interossei • Nerves: 3 • Arteries: 2
- 55.
- 56. History • Age • Occupation •Handedness • Main Complaint • Previous Injury • Previous Surgery • Specific Activity Related • Exacerbation • Improvement • Frequency • Duration
- 57. History Often the firstsymptom will clinch the diagnosis
- 58. Tingling / PinsNeedles / Numbness • Thumb Side - Carpal Tunnel • Little Finger - Ulnar Nerve Compression • Starting above elbow ? Cervical spine
- 59. Pain • Thumb /Radial • de Quervains’ • CMCJ OA • Triggering • Fracture scaphoid? • Wrist OA
- 60. • Ulnar Side: •TFCC Tear • Ulnar Impingement • Tendinitis
- 61. Swelling / Lump •Dorsal: Ganglion unless proven otherwise • Volar: Ganglion, Aneurysm • Fingers: • Ganglion, GCT, Degenerative Conditions • Rheumatoid Nodule / Bursa
- 62. Examination • Inspection • Palpation •Range of Movements • Neurologic Exam • Special Tests
- 63. Inspection • Can givelot of information & help diagnosis • Attitude • Muscle wasting • Finger Nails • Deformities of joint
- 65. •Tear or stretchof the central extensor tendon at PIP •Note: unopposed flexion at PIP •Extension at DIP •Trauma or inflammatory arthritis
- 68. • Heberden’s Nodes:DIPJ • Bouchard’s Nodes: PIPJ
- 70.
- 71.
- 72. Common Problems • FingerDeformities • Peripheral Nerve Entrapment • Painful Joints • Rupture tendons • Dislocated Joints
- 74.
- 75. Radial Side Pain •CMCJ OA • deQuervains Tenosynovitis • STTJ OA • Scaphoid Fracture
- 76. Palpation - UlnarSide Pain • Ulnar Abutment / Impingement • TFCC Tear • Tendonitis - ECU / FCU
- 77.
- 78.
- 79.
- 80.
- 81.
- 82.
- 83.
- 84. One Stop CarpalTunnel Clinic
- 85. Cubital Tunnel Syndrome •Clumsiness • Small Change, Buttons, Shoe Lace • Worse on driving / resting arm on hard surface
- 87.
- 89. ✦Palpable nodule atlevel of MCPJ ✦1ml 0.5% chirocaine + 40 mg Kenalog ✦Inject around the A1 pulley, not sheath ✦If injection sheath, needle movement to confirm placement - withdraw
- 90. de Quervain’s Disease •Swiss surgeon, Fritz de Quervain, –thickened first dorsal compartment at the wrist • Tenosynovitis of 1st extensor compartment • APL / EPB • More common in females • Fluid retention –Pregnancy
- 91.
- 92. CMCJ OA • Commonestjoint OA - CMC • Often Bilateral • About 1/3 women > 45 (9:1) • Majority asymptomatic
- 93. • Unable togrip • Opening jar / bottle •Squaring of palm • Adduction contracture • Tenderness at base of thumb • Thumb Grind Test
- 95. • Trapeziectomy -Gold standard • Advantages –Good pain relief –Improved function • Problems –in younger & high demand –Why •thumb shortening •weak grip
- 96. Ulnar Impingement / Abutment •Common cause of ulnar sided wrist pain • Worse on gripping / loading • May be precipitated by trauma
- 97. Physical Examination • Ballottementtest • Ulnar Stress Test (Nakamura) – What I call as the ulnar grind test • Grip Test • Weakness
- 99.
- 100.
- 101. Dupuytren’s Contracture • Palmaror digital fibromatosis • Flexion contracture • Painless nodules near palmar crease • Male > Female • Family History, Epilepsy, diabetes, pulmonary dz, alcoholism
- 102. • Xiapex –Collagenase •Injectable formof 2 collagenase enzymes –Isolated from the bacterium Clostridium histolyticum –Work in in a complementary fashion • Small Volume injected in cord •Administration involves an injection and a finger extension procedure 24 hours later
- 104. Carpal Tunnel Syndrome •Commonest Entrapment Neuropathy • Symptoms & Signs • Bad Prognostic Signs: • Permanent Numbness • Muscle Wasting
- 105. • Referral: • Aftersplints / injections failed • Early if Numbness / Muscle wasting • EMG Studies
- 106. Ganglion • A smallcystic tumour connected either with a joint membrane or tendon sheath
- 107. Arthritis • Thumb Base •DIPJ / PIPJ • Wrist • MCPJ
- 108. • NSAID’s • Splints •Hand Therapy • Steroid Injection
- 109. Thumb Base Arthritis •Commonest joint OA - CMC • Often Bilateral • About 1/3 women > 45 (9:1) • Majority asymptomatic • Symptoms: • Unable to grip • Opening jar / bottle • Adduction contracture • Tenderness at base of thumb • Thumb Grind Test
- 110. Triggering / deQuervain’s •Always try injection • May repeat at 3 months if improvement • Refer otherwise
- 111. Dupuytren’s Contracture • GeneticCondition • Men >>> Women • Referral: • MCPJ – 30 • PIPJ – Any
- 112. Dupuytren’s • Xiapex –Collagenase •Injectable formof 2 collagenase enzymes –Isolated from the bacterium Clostridium histolyticum –Work in in a complementary fashion • Small Volume injected in cord •Finger extension 24 - 48 hours later
- 116.
- 117. Ulnar Impingement • Ulnarsided wrist pain • Worse on gripping / strength activities • Splints / NSAIDs
- 118. What’s Changed inShoulder • More Arthroscopic Surgery • Advantages • More Total & Reverse Shoulders • Reverse Shoulder Replacement for trauma
- 119.
- 120.
- 121.
- 122.
- 123.
- 125.
- 126.
- 127.
- 128.