upper limb musculoskeletal surgery
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Upper Limb Musculoskeletal Surgery. Lisa Tourret MBChB.MSc.FRCS . FRCS (T&O) Nuffield Hospital Teaching Program. Aim. Introduction Scope of talk Selected conditions Shoulder Elbow Wrist Hand Questions and Answers. Who am I?. Lisa Tourret ( www.shoulder2hand.com )

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upper limb musculoskeletal surgery

Upper Limb Musculoskeletal Surgery

Lisa Tourret MBChB.MSc.FRCS. FRCS (T&O)

Nuffield Hospital Teaching Program

slide2
Aim
  • Introduction
  • Scope of talk
  • Selected conditions
  • Shoulder
  • Elbow
  • Wrist
  • Hand
  • Questions and Answers
who am i
Who am I?
  • Lisa Tourret ( www.shoulder2hand.com )
  • Higher surgical training in Northern Region
  • Fellowships in New Zealand
  • North Shore Hospital
  • Middlemore Hospital
  • Consultant at SRH since 2006
  • Relocated to Brighton August 2012
scope of talk
Scope of Talk
  • Common conditions of upper limb
  • Traumatic – accidental/sports injury
  • Degenerative – joint disease/ soft tissues
  • Neoplastic
shoulder pain

Rotator cuff tear

Calcific tendinopathy

Impingement

Cervical spine

Shoulder Pain
clinical presentation history
Clinical Presentation - History
  • Shoulder pain - severity
  • Diffuse
  • Radiation?
  • Night pain
  • Aggravating factors
  • Relieving factors
  • Duration
  • Onset spontaneous or post trauma?
  • Age of patient
clinical presentation examination
Clinical Presentation - Examination
  • Observe (symmetry, posture, muscle bulk…)
  • Palpation
  • Active movements (range, pain, scapulohumeral rhythm…)
  • Passive movements
  • Power against resistance
  • Impingement signs
  • Scarf and Obrien’s test
  • Stability
jobe test and hawkins sign
Jobe test and Hawkins sign

Beware the patient with MDI presenting with impingement pain

partial thickness tears
Partial thickness tears
  • “Not a singular condition…rather a common outcome of a variety of insults to the rotator cuff.” AAOS vol 7 Jan 1999
  • Aging (<40 yrs do not have tears, 25% of >60yr old do)
  • Anatomic impingement
  • Repetitive microtrauma
partial thickness tears1
Partial thickness tears
  • Articular surface (2-3 times more common)
  • Bursal surface
  • Within tendon substance
  • Supraspinatus tendon most commonly involved
  • ?Progression ?Healing
  • 40 PTRCT at 1 year re-’scoped 11 progressed and 4 had healed Clin Orth 1994, 304
full thickness rotator cuff tear
Full Thickness Rotator Cuff Tear
  • Small <1 cm
  • Moderate 1-3 cm
  • Large >3 cm
  • Massive > 5 cm
  • Surgery more successful in <4 cm
calcific tendonitis1
Calcific Tendonitis
  • Common disorder
  • Unknown aetiology
  • Multifocal cell mediated calcification
  • Spontaneous phagocytic resorption
  • Acute Pain during resorption phase
  • Not purely degenerative as it peaks in 5th decade and fully heals
  • Surgical removal is the exception not the rule

(AAOS vol 5, no 4 1997)

treatment
Treatment

Physiotherapy, NSAID, Injections, Arthroscopy, Debridement, Repair, Reconstruction, Replacement

dislocation of shoulder
Dislocation of Shoulder
  • First time traumatic
  • Recurrent
  • When is it recurrent?
  • What do we do?
  • Arthroscopic stabilisation – in whom?
  • Open stabilisation – in whom?
  • Bony reconstruction?
frozen shoulder
Frozen Shoulder
  • Adhesive capsulitis
  • Onset
  • Age
  • Duration
  • Natural time course (freezing/Frozen/Thawing)
  • When do we intervene? Distension or capsular release
  • IDDM?
elbow
Elbow
  • Tennis elbow
  • Ulna nerve compression or cubital tunnel syndrome
  • Loose bodies – locking
  • Stiffness – post traumatic? Arthritic?
  • Olecranon bursitis
tennis elbow
Tennis elbow
  • Lateral epicondylitis
  • Radial tunnel syndrome
  • Resisted supination?
  • Middle finger test?
  • Injection site?
  • Surgical intervention <20% of initial presenters
ulnar nerve compression
Ulnar nerve compression
  • Cubital Tunnel Syndrome
  • 2nd only to Carpal Tunnel Syndrome
  • When to treat?
  • Non-operative measures
  • Operative – decompression vs transposition
elbow arthroscopy
Elbow Arthroscopy
  • Loose bodies
  • Arthrolysis
  • Tennis elbow
  • Osteochondritis
  • Synovectomy
wrist and hand
Wrist and Hand
  • Carpal tunnel syndrome
  • Dupuytrens disease
  • Ganglions
  • Trigger finger
  • OA
  • Tendon sheath tumours – GCT, pea ganglions
when to treat
When to treat?
  • Mature cords
  • MCP 30º
  • PIP 30º
  • Tabletop test
ganglions
Ganglions
  • Symptomatic?
  • Lump or scar?
  • Recurrence rate
  • Complications
trigger finger
Trigger finger
  • Pathology?
  • Treatment
  • A1 pulley release
  • Recurrence?
  • Tendon slip excision
hand tumours
Hand tumours
  • More than 95% Benign
  • Occasional rare site for metastasis eg breast, lung
  • Primary malignant tumour very, very rare
  • Commonest are ganglia then Giant cell tumour of tendon sheath
incidence of oa of the hand
Incidence of OA of the Hand
  • Commonest form of OA
  • <40 yrs - 50 new cases per 1000 person-years at risk
  • 40 - 59 yrs - 65 new cases per 1000 person-years at risk
  • >60 yrs - 110 new cases per 1000 person-years at risk

(Kallman et al. 1990, Arth Rheum 33,1323 - 1332)

surgical intervention
Surgical intervention
  • When non-operative methods fail
  • Fusion
  • Excision arthroplasty
  • Joint replacement
  • Interpositional arthroplasty
distribution
Distribution
  • DIPJ – fusion
  • 1st CMC –Trapeziectomy
  • PIPJ – fuse or replacement
  • MCPJ - replacement
  • Others - Sesamoid, Trapezial Scaphoid/trapezoid, Pisiform-triquetral OA
other conditions
Other conditions

Scaphoid non-union

SNAC or SLAC wrists

TFCC tears

DRUJ injury/ OA

the list goes on
The list goes on!
  • Partial wrist fusion
  • Total wrist fusion
  • Partial replacements
  • Total replacements
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