Upper Limb Orthopaedic update Steven Barnes Inverclyde Royal Hospital

Disclosures

Upper limb Cold cases Trauma General orthopaedics

“Shoulder impingement” Supraspinatus tendonitis Supraspinatus tendonitis

Non steroidals 6/52 physio therapy + home exercise regime X-raysInjection(s)Ultrasound Surgery arthroscopy or open?

WC significantly longer to return to work /52 No difference in outcomes WC need to return to higher functional level (Nicholson jbjs am (4) )

Cuff tears Acute traumatic v A natural aging phenomena?

repair

outcomes RepairDebridement

More likely to get adhesive capsulitis Return to pre op work levels 7.6/12 Maximal improvement in heavy 33.6/12 (Bathia et al Arthroscopy (8) ) (Bathia et al Arthroscopy (8) )

Biceps tendon problems SLAP lesions Bicipital tendonitis

Shoulder replacement

Adhesive capsulitis Physiotherapy Pain relief Injections of steroids Manipulation or Operation?

Tennis elbow/Golfers elbow PhysioInjection1-2XSurgery

Do demonstrate consistent improvement benefit from surgery when properly selected Equal outcome Equal outcome fewer workers comp return to former job 65% v 77% 24% WC changed job compared to 4% others (Balk Am JOrtho (3) )

Elbow arthroplasty

Wrist arthritis

DRUJ arthritis

Carpal tunnel syndrome Open v endoscopic The use of questionnaires

Scoring system for CTS Scoring System for CTS Date: Please tick the appropriate box 1. Age: ( ) Sex: Male Female 2. Occupation: Do you have diabetes? Yes No 4. Are you right or left handed? Right Left Both 5. What kind of problems do you have with your hands Are symptoms worse in one hand than the other? Right Left Both 7. Are symptoms worse at any of the following times? During the night (2) First thing in the morning (1)While driving While or after working with hands While holding the phone 8. Which fingers are worse affected? Thumb, index and middle (2) Ring and little, Middle and ring (2) All fingers, not thumb, All fingers 9. If you are woken in the night by the symptoms can they be relieved by shaking the hand or holding it out of bed? Yes No 10. If you have been given a splint to wear on the wrist, does this alleviate the symptoms? Yes oe No oe 11. Do you tend to drop objects or have your hands become more clumsy? Yes No 12. How long have the symptoms been present? 0-3 Months 3-6 months 6-12 months longer than 12 months 13. Have you been exposed to vibrating tools in your work? Yes No THIS PART SHOULD BE FILLED IN BY THE CLINICAL EXAMINER: SIGNS: Paraesthesia in the ulnar nerve distribution: Yes No Evidence of cervical root irritation: Yes No Age: Below 60 years (2 points) ________________ Above 60 years (0 points) ________________ Symptoms: Night pain (2 points) ________________ Paraesthesia median nerve distribution (2 points) ________________ Relief pain by shaking (2 points) ________________ Relief pain by splint (1 point) ________________ Clumsiness (1 point) ________________ Signs: Tinel’s sign (2 points) ________________ Phalen’s test (1 points) ________________ Alteration in sensation in distribution of median nerve (2 points) ________________ Wasting Thenar eminence (2 points) ________________ Total: (17 points) ________________ 670 THE JOURNAL OF HAND SURGERY VOL. 34E No. 5 OCTOBER 2009

Carpal tunnel scores Score Sensitivity Specificity 6> 92% 62% 6> 92% 62% 7> 82% 67% 7> 82% 67% 8> 70% 72% 8> 70% 72%

EMG studies Men in manual occupation Vibration exposure Features of ulna nerve entrapment Features of cervical nerve root irritation Non anatomical distribution/history litigenous

CTD outcomes High patient satisfaction No recovery Scar tenderness RSD

Basal joint arthritis Trapeziectomy +/- tendon interpositions

Dupytrens disease Needle aponeurectomy CollagenaseSurgery

Trauma Locking plates

Locking nails

The Glasgow Pathway “Virtual clinics”

Direct Discharges 5 th metatarsal Fifth metacarpal Distal radius torus Minor radial head/elbow fat pad Mallet finger Childs clavicle

Virtual fracture clinic Consultant lead MultidisciplinaryHistory/examination/xrays Nurse led clinic Telephone discharge Sub Specialty clinic

Journal of Hand Surgery March 2014