Transcript Upper limb problems

Upper limb problems
What to refer and what not to
Roland Pratt
Consultant Orthopaedic Surgeon
North Tyneside General
What can I deal with
in primary care?
vs
What is best treated in
hospital?
Introduction
• Hexham audit
• What to send in and what to manage
in primary care
• Common conditions with
• Some examples
• Questions
Hexham audit
• Discharged after
one visit
• Ganglia
• Low back pain
• Knee pain
Send these in:
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Tendon ruptures
Masses
Neurology
(Dislocations / Fractures)
Exhausted primary care options
Diagnosis unclear
Initial management in
Primary Care
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Adhesive capsulitis
Subacromial impingement
Tendinopathy – tennis / golfers
Osteoarthritis
Carpal tunnel / cubital
Ganglia
Dupuytrens
Tendon ruptures
• Have variable window of opportunity
to treat surgically
– Eg flexor tendon rupture / biceps <4/52
– Rotator cuff – 12 months
Rotator cuff tears
• Acute traumatic, rare under 25 years
• Chronic degenerative, often on
background of impingement
• Pain features similar to impingement
• Complains of weakness
• Jobe’s test, External/ Internal
rotation lag sign, belly press test
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
Literature evidence
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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-Aug;17(4):666-9.
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
Audit results
• 31 males, 5 females @ min 1yr
<20 yrs
-16
21-30 yrs -10
31-40 yrs -10
• 2 non-compliant dislcn group
• 4 non-complaint no dislcn group
recurrent
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Neurology
• C-spine – radicular
• Brachial neuritis
• Peripheral nerves
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Carpal tunnel
Cubital tunnel
Suprascapular nerve
PIN
Guyons
Wartenbergs
Tumours
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Greater than about 5 cm in diameter
Deep to fascia, fixed or immobile
Increasing in size
Painful
Recurrence after previous excision
Ganglions / Lumps
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95% hand tumours are benign
Incidences unknown
Many can be diagnosed clinically
Enlarging and shrinking – benign
Insidious onset, pain, enlarging ?malignant
Common lumps / swellings
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Ganglia / Mucous cyst
PVNS / GCT of tendon sheath
Enchondroma
Glomus
Dermoids, fibroma, schwannomas,
Heberdens nodes etc
• Trigger finger
• De Quervains / Intersection
syndrome
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
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
PVNS / GCT of tendon
sheath
• Second most
common
• Firm lobulated
digital fibroblastic
mass
• Occasionally
erosions on XR
• Locally recurrent
10-20%
Enchondroma
• Most common bony lump
• Usually present with
fracture
• Single lesion benign
• Ollier’s
• 2% recur after BG
Glomus tumour
• Uncommon unusual
• Very tender
• Cold sensitive ++
Initial management in
primary care
• Subacromial impingement vs adhesive
capsulitis
• Osteoarthritis
• Tennis / golfers
• Trigger digits
• Carpal tunnel / cubital
• Dupuytrens
Impingement
• Middle age onwards
• Onset variable
• Anterolateral shoulder pain / night
pain
• Overhead activities / elbow away
from side
• Painful arc, Neers, Hawkins vs
crossed adduction
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
Adhesive Capsulitis
• Dupuytrens like capsular
tightness
• Idiopathic assoc diabetes, thyroid
• Secondary trauma
• Diffential –
infection/GH
arthritis/mets or ca
Adhesive Capsulitis
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40-70 years
3 phases
Shoulder pain radiating, dull
Sharp exacerbations with movement
Global loss of ROM – check external
rotation
Adhesive Capsulitis
• Symptomatic treatment
• Many modalities – poor evidence for
all
• MUA under GA is UK norm
Dupuytren’s
• Males, 50+ yrs,
genetic
• Diathesis younger, male,
bilateral, +ve FHx
• History
– rate progression
• ‘table-top’ test
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
Osteoarthritis – ACJ &
Glenohumeral
• Symptomatic treatment
• Distal clavicle excision
• Shoulder hemiarthroplasty / TSR
Osteoarthritis of elbow
Osteoarthritis of elbow
Osteoarthritis – wrist
• Post-trauma –
SNAC & SLAC
• Pain / weakness
• Rest, modification,
splints
• Partial fusion vs
PRC vs full fusion
Osteoarthritis – thumb
base
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CMCJ – v common F>M
Painful grip / twist / weakness
Grind test
Rest, modification, splints
Injection – localising
(pantrapezial)
• Surgery – fusion vs
interposition vs replacement
Osteoarthritis - fingers
• Heberden’s /
Bouchard’s nodes
• Family history
• Pain, stiffness
• NSAIDS, injection
• Fusion is gold
standard
Arthritis – inflammatory
- hand
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
– Thomson’s test
(ERCB)
Treatment
• Rest / ice /
activity
modification
• physio
• Steroid injection
– Max 3
• Surgery
– open
– 70% successful
– stretching /
ultrasound /
acupuncture
• Epiclasp
www.gnulc.com
Carpal Tunnel Syndrome
• F (25-40;60+)> M
• 50% bilateral
• Pregnancy, thyroid,
AI, Colles’
Symptoms
• Pain - night
• Pins and needles
• Clumsiness
Carpal Tunnel Syndrome examination
• Sensation (2 point)
• Wasting / weakness
• Tinels
• Phalens
NB can be negative in advanced
CTS
Carpal Tunnel Syndrome
Nerve Conduction tests
• Mild (sensory slowing)
• Moderate (motor slowing)
• Severe (axon drop out)
CTS treatment
• Splintage
• Steroid injection
– 50% respond but drops off
(POEMS)
– Technique
– Avoid intraneural injection
• Surgery
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
(Guyon’s canal)
Trigger finger /
thumb
• 40-60 years
• Repetitive work
• RhA, gout,
hypothyroidism
• Symptomatic Tx
• Injections
• Surgery
De Quervain’s Disease
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F>M
Mothers
Repetitive movt
Finkelstein’s test
Symptomatic Tx
Injections
Surgery
Intersection
syndrome
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Proximal to De Quervain’s
Direct trauma/repetitive movt
Anatomy
Usually responsive to
conservative measures
Management in Primary
Care summary
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Activity modification
Analgesia is safer than Surgery
Physiotherapy
Aspirations / injections
Refer in – delay may
alter prognosis
• Tendon / ligament
disruption
• Tumours
• Certain Neurology
• ……just had enough
Sources of information
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http://ebmg.wiley.com
http://www.cochrane.org/
http://www.prodigy.nhs.uk
http://www.jr2.ox.ac.uk/bandolier