Upper limb problems

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Upper limb problems

• What to refer and what not to

Roland Pratt Consultant Orthopaedic Surgeon North
Tyneside General
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What can I deal with in primary care?

• vs
• What is best treated in hospital?

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Introduction

• Hexham audit
• What to send in and what to manage in primary
  care
• Common conditions with
• Some examples
• Questions

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Hexham audit

• Discharged after one visit

• Ganglia
• Low back pain
• Knee pain

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Send these in

• Tendon ruptures
• Masses
• Neurology
• (Dislocations / Fractures)
• Exhausted primary care options
• Diagnosis unclear

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Initial management in Primary Care

• Adhesive capsulitis
• Subacromial impingement
• Tendinopathy tennis / golfers
• Osteoarthritis
• Carpal tunnel / cubital
• Ganglia
• Dupuytrens

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Tendon ruptures

• Have variable window of opportunity to treat
  surgically
• Eg flexor tendon rupture / biceps lt4/52
• Rotator cuff 12 months

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Rotator cuff tears

• Acute traumatic, rare under 25 years
• Chronic degenerative, often on background of
  impingement
• Pain features similar to impingement
• Complains of weakness
• Jobes test, External/ Internal rotation lag
  sign, belly press test

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Rotator cuff tears

• If acute treat pain first, reassess once pain
  settled at 3-4 weeks
• If symptoms settle and function improves
  compensated tear
• Refer if not cuff atrophy with time
• Beware weakness in multiple injections
• Beware dislocation in older patients
• Surgery is for pain

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Literature evidence

• With kinematic magnetic resonance imaging,
  Bonutti et al showed that the tense subscapularis
  kept the capsule in contact with the underlying
  bone structures in external rotation, whereas in
  internal rotation the subscapularis became
  redundant and the labrum and the capsule folded
  into the joint in some unstable shoulders.
• Kinematic MRI of the shoulder.Bonutti PM,
  Norfray JF, Friedman RJ, Genez BM. J Comput
  Assist Tomogr. 1993 Jul-Aug17(4)666-9.

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External rotation splint

• Position of external rotation of about 10 degrees
  with arm in adduction
• Worn for 23 hours a day for 3-4 weeks
• Can remove it for shower purposes

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Audit results

• 31 males, 5 females _at_ min 1yr
• recurrent
• lt20 yrs -16 4
• 21-30 yrs -10 1
• 31-40 yrs -10
• 2 non-compliant dislcn group
• 4 non-complaint no dislcn group

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Neurology

• C-spine radicular
• Brachial neuritis
• Peripheral nerves
• Carpal tunnel
• Cubital tunnel
• Suprascapular nerve
• PIN
• Guyons
• Wartenbergs

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Tumours

• Greater than about 5 cm in diameter
• Deep to fascia, fixed or immobile
• Increasing in size
• Painful
• Recurrence after previous excision

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Ganglions / Lumps

• 95 hand tumours are benign
• Incidences unknown
• Many can be diagnosed clinically
• Enlarging and shrinking benign
• Insidious onset, pain, enlarging - ?malignant

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Common lumps / swellings

• Ganglia / Mucous cyst
• PVNS / GCT of tendon sheath
• Enchondroma
• Glomus
• Dermoids, fibroma, schwannomas, Heberdens nodes
  etc
• Trigger finger
• De Quervains / Intersection syndrome

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Ganglia - wrist

• Cosmesis / pain / fear of cancer
• Diagnosis transillumination
• 50 spontaneous resolution (80 children)
• Aspiration reassuring (60 recur, 75
  satisfied)
• Excision 14-40 recur. 15-30 complications

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Ganglia - Hand

• Flexor sheath
• Interferes with grip
• 70 resolve with 2 aspirations
• Surgery

• Mucous cysts
• OA DIPJ
• Can drain / trophic nail changes / pain
• Aspiration 40 recurrence
• Surgery

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PVNS / GCT of tendon sheath

• Second most common
• Firm lobulated digital fibroblastic mass
• Occasionally erosions on XR
• Locally recurrent 10-20

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Enchondroma

• Most common bony lump
• Usually present with fracture
• Single lesion benign
• Olliers
• 2 recur after BG

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Glomus tumour

• Uncommon unusual
• Very tender
• Cold sensitive

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Initial management in primary care

• Subacromial impingement vs adhesive capsulitis
• Osteoarthritis
• Tennis / golfers
• Trigger digits
• Carpal tunnel / cubital
• Dupuytrens

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Impingement

• Middle age onwards
• Onset variable
• Anterolateral shoulder pain / night pain
• Overhead activities / elbow away from side
• Painful arc, Neers, Hawkins vs crossed adduction

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Impingement Treatment

• Activity modification avoid activity with elbow
  away from side work, computer etc
• Stretching
• NSAIDs
• Steroid Injection short term
• Physical Therapy effective in up to 70
• Surgery

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Adhesive Capsulitis

• Dupuytrens like capsular tightness
• Idiopathic assoc - diabetes, thyroid
• Secondary trauma
• Diffential infection/GH arthritis/mets or ca

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Adhesive Capsulitis

• 40-70 years
• 3 phases
• Shoulder pain radiating, dull
• Sharp exacerbations with movement
• Global loss of ROM check external rotation

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Adhesive Capsulitis

• Symptomatic treatment
• Many modalities poor evidence for all
• MUA under GA is UK norm

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Dupuytrens

• Males, 50 yrs, genetic
• Diathesis - younger, male, bilateral, ve FHx
• History
• rate progression

• table-top test

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Treatment

• ?Injection of collagenase
• Fasciotomy (cut the cord)
• for MCPJ contracture, elderly
• Limited fasciectomy (cord excision)
• if PIPJ involved (1.5 chance digital nerve
  injury) /- FTSG

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Osteoarthritis Glenohumeral

• 60 years
• Gradual onset
• Dull aching pain
• Night pain
• Activity related
• Reduced active and passive movement, glenohumeral
  crepitus

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Osteoarthritis ACJ Glenohumeral

• Symptomatic treatment
• Distal clavicle excision
• Shoulder hemiarthroplasty / TSR

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Osteoarthritis of elbow
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Osteoarthritis of elbow
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Osteoarthritis wrist

• Post-trauma SNAC SLAC
• Pain / weakness
• Rest, modification, splints
• Partial fusion vs PRC vs full fusion

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Osteoarthritis thumb base

• CMCJ v common FgtM
• Painful grip / twist / weakness
• Grind test
• Rest, modification, splints
• Injection localising (pantrapezial)
• Surgery fusion vs interposition vs replacement

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Osteoarthritis - fingers

• Heberdens / Bouchards nodes
• Family history
• Pain, stiffness
• NSAIDS, injection
• Fusion is gold standard

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Arthritis inflammatory - hand
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Tennis elbow (lateral epicondylitis)

• What is it?
• Differential
• lateral compartment OA
• radial tunnel syndrome

• Tests
• tender over extensor origin
• pain passive wrist flexion / active extension
• Thomsons test (ERCB)

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Treatment

• Rest / ice / activity modification
• physio
• stretching / ultrasound / acupuncture
• Epiclasp

• Steroid injection
• Max 3
• Surgery
• open
• 70 successful

www.gnulc.com
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Carpal Tunnel Syndrome

• F (25-4060)gt M
• 50 bilateral
• Pregnancy, thyroid, AI, Colles
• Symptoms
• Pain - night
• Pins and needles
• Clumsiness

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Carpal Tunnel Syndrome - examination

• Sensation (2 point)
• Wasting / weakness
• Tinels
• Phalens
• NB can be negative in advanced CTS

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Carpal Tunnel Syndrome

• Nerve Conduction tests
• Mild (sensory slowing)
• Moderate (motor slowing)
• Severe (axon drop out)

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CTS - treatment

• Splintage
• Steroid injection
• 50 respond but drops off (POEMS)
• Technique
• Avoid intraneural injection
• Surgery

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Cubital tunnel syndrome

• Most common site entrapment ulnar nerve
• numbness ulnar 1 1/2 digits AND dorsum hand
• muscle wasting
• examine elbow
• Tinels

• Differential
• T1 nerve root entrapment
• cervical rib
• low entrapment (Guyons canal)

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Trigger finger / thumb

• 40-60 years
• Repetitive work
• RhA, gout, hypothyroidism
• Symptomatic Tx
• Injections
• Surgery

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De Quervains Disease

• FgtM
• Mothers
• Repetitive movt
• Finkelsteins test
• Symptomatic Tx
• Injections
• Surgery

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Intersection syndrome

• Proximal to De Quervains
• Direct trauma/repetitive movt
• Anatomy
• Usually responsive to conservative measures

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Management in Primary Care summary

• Activity modification
• Analgesia is safer than Surgery
• Physiotherapy
• Aspirations / injections

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Refer in delay may alter prognosis

• Tendon / ligament disruption
• Tumours
• Certain Neurology
• just had enough

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Sources of information

• http//ebmg.wiley.com
• http//www.cochrane.org/
• http//www.prodigy.nhs.uk
• http//www.jr2.ox.ac.uk/bandolier