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


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





Impingement syndrome partial thickness tear
Impingement SyndromePartial Thickness Tear?


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




Enlarging tear lateral slips sublux bald humeral head
Enlarging tearlateral slips sublux“Bald humeral head”






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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