An Update of Upper Limb Conditions Dr. Gavin Nimon Head of Upper Limb and Hand - QEH Senior Lecturer- University of Adelaide MBBS FRACS (Orth) FRCS (Ed) Orthopaedic Surgeon Shoulder, Hand & Knee Injuries
Profile Gavin Anthony Nimon University of Adelaide- intern 1990 bst 91-93 Edinburgh/ Newcastle Orthopaedic Registrar 1994 Advanced Trainee Orthopaedics 1995-1998 Senior Registrar Year 1999 QEH Senior Registrar/ Consultant PMR Edinburgh Consultant DGRI 2000-2005 Senior Lecturer University of Adelaide- QEH Head of Hand & Upper Limb Specialty- The Queen Elizabeth Hospital
Factors leading to Cuff Tendinopathy
History Age of patient Length of symptoms Trauma? Site of pain Family history Smoking / Diving/ Alcohol Loss of function and ROM
Assessment:- History:- Age Site of pain Occurrence Past history ( same shoulder or other) Examination:- Exclude neck Tenderness Range of motion Arc of motion Crepitus Specific tests Neurology neer s and hawkins impingement ER power and IR power, gerbers Adduction/ scarfe / Cross arm Speeds/ Yergason s
Investigations:- X-rays (Ap, axillary and lateral scapular) Exclude oa (see state of ac joint and G-H subluxation) 15 degree uptilt view for ac joint Ultrasound- confirm impingement- less important MRI- more accurate for above and cuff tear Injection as diagnostic For fracture CT with 3d reconstructions useful
Secondary bony Abnormalities Spur Os acromiale
Cuff Degeneration Normal Cuff Degenerative cuff ( smoker )
Acromioplasty- Decompression Side on view demonstrating Subacromial Spur Spur being excised Spur excised, bone now flat
Post-op Surgery X-rays AC joint excised arthroscopically Spur excised, not flat undersurface of acromion Opposite AC joint- Not Normal
Arthroscopic Cuff Repair
Arthroscopic techniques allow repair of small tears that may have previously been not treated with open techniques
Arthritis and shoulder replacement Anatomic Total Shoulder Replacement Anatomic Cuff Deficiency Reverse Total Shoulder Replacement
Its very important to be aware of the implant being recommended and that its long term results are within recommended result
Wrist Pain- some common diagnoses Global- Radial- Ulnar- OA (x-ray changes) Tendinitis ( crepitus ) Radial styloid oa (xray) scaphoid fracture / Scapho-lunate (xray) dequervains (u/s) CMC OA (xray) ECU tendinitis (u/s) TFCC (clinical) pisiform / triquetral oa (xray/ ct/ bone scan) Neurological - Carpal tunnel (ncs) Cubital tunnel (ncs) Referred from neck ( spurling s test )
Acute Treatment of Displaced Scaphoid fractures Acute:- screw Fixation Chronic:- ORIF and Bone Graft
Scaphoid fracture- oa Arthritis and scaphoid Non-union can be treated with scaphoid excision and partial fusion of wrist
CMC Osteoarthritis Very common Degenerative (female> male) Grind test +ve CMC Fusion performed for arthritis Tx Splint/ physiotherapy Steroid Injection Trapezectomy +/- suspensoplasty vs fusion K wire and plaster 4-6 weeks
CMC Fusion
Dequervain s Tenosynovitis 1 st Extensor Compartment Finkelstein s test Physio Brace Inject Release
Carpal Tunnel Syndrome Very Common Performed Under Local Anaesthesia Wide awake surgery Self- funded - cheaper as no assistant or anaethetist required Safe Quick recovery
Cubital Tunnel Syndrome Exclude Cervical C8 Bigger Incision Required protect in sling for 2-4 weeks Good Results Can be Day Surgery
Distal Biceps Rupture Previously Rare ( but must have existed?? ) Complete rupture - literature says better with repair But older male with achy arm and u/s partial tear? Latter just aging Same principles as cuff tear Tricky procedure, best done by specialist Upper Limb Surgeon Difficult after 1st 6 weeks after injury
OA and myxoid cysts
Dupuytren s Contracture Very common in United Kingdom Nordic Genes (Vikings) Requires committed patient, for splinting, physiotherapy and wound care High risk of recurrence But results very good from surgery Risks Nerve damage Infection
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