1. Upper limb problems What to refer and what not to Roland Pratt Consultant Orthopaedic Surgeon North Tyneside General

2. What can I deal with in primary care? vs What is best treated in hospital?

3. Introduction Hexham audit What to send in and what to manage in primary care Common conditions with Some examples Questions

4. Hexham audit Discharged after one visit Ganglia Low back pain Knee pain

5. Send these in: Tendon ruptures Masses Neurology (Dislocations / Fractures) Exhausted primary care options Diagnosis unclear

6. Initial management in Primary Care Adhesive capsulitis Subacromial impingement Tendinopathy – tennis / golfers Osteoarthritis Carpal tunnel / cubital Ganglia Dupuytrens

7. Tendon ruptures Have variable window of opportunity to treat surgically –Eg flexor tendon rupture / biceps <4/52 –Rotator cuff – 12 months

8. 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

9. 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

10. Literature evidence 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.

11. 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

12. Audit results 31 males, 5 females @ min 1yr recurrent <20 yrs -164 21-30 yrs -10 1 31-40 yrs -10 2 non-compliant dislcn group 4 non-complaint no dislcn group

13. Neurology C-spine – radicular Brachial neuritis Peripheral nerves –Carpal tunnel –Cubital tunnel –Suprascapular nerve –PIN –Guyons –Wartenbergs

14. Tumours Greater than about 5 cm in diameter Deep to fascia, fixed or immobile Increasing in size Painful Recurrence after previous excision

15. Ganglions / Lumps 95% hand tumours are benign Incidences unknown Many can be diagnosed clinically Enlarging and shrinking – benign Insidious onset, pain, enlarging - ?malignant

16. Common lumps / swellings Ganglia / Mucous cyst PVNS / GCT of tendon sheath Enchondroma Glomus Dermoids, fibroma, schwannomas, Heberdens nodes etc Trigger finger De Quervains / Intersection syndrome

17. 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

18. 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

19. PVNS / GCT of tendon sheath Second most common Firm lobulated digital fibroblastic mass Occasionally erosions on XR Locally recurrent 10-20%

20. Enchondroma Most common bony lump Usually present with fracture Single lesion benign Ollier’s 2% recur after BG

21. Glomus tumour Uncommon unusual Very tender Cold sensitive ++

22. Initial management in primary care Subacromial impingement vs adhesive capsulitis Osteoarthritis Tennis / golfers Trigger digits Carpal tunnel / cubital Dupuytrens

23. Impingement Middle age onwards Onset variable Anterolateral shoulder pain / night pain Overhead activities / elbow away from side Painful arc, Neers, Hawkins vs crossed adduction

24. 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

25. Adhesive Capsulitis Dupuytrens like capsular tightness Idiopathic assoc - diabetes, thyroid Secondary trauma Diffential – infection/GH arthritis/mets or ca

26. Adhesive Capsulitis 40-70 years 3 phases Shoulder pain radiating, dull Sharp exacerbations with movement Global loss of ROM – check external rotation

27. Adhesive Capsulitis Symptomatic treatment Many modalities – poor evidence for all MUA under GA is UK norm

28. Dupuytren’s Males, 50+ yrs, genetic Diathesis - younger, male, bilateral, +ve FHx History –rate progression ‘table-top’ test

29. 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

30. Osteoarthritis – Glenohumeral 60 years + Gradual onset Dull aching pain Night pain Activity related Reduced active and passive movement, glenohumeral crepitus

31. Osteoarthritis – ACJ & Glenohumeral Symptomatic treatment Distal clavicle excision Shoulder hemiarthroplasty / TSR

32. Osteoarthritis of elbow

34. Osteoarthritis – wrist Post-trauma – SNAC & SLAC Pain / weakness Rest, modification, splints Partial fusion vs PRC vs full fusion

35. Osteoarthritis – thumb base CMCJ – v common F>M Painful grip / twist / weakness Grind test Rest, modification, splints Injection – localising (pantrapezial) Surgery – fusion vs interposition vs replacement

36. Osteoarthritis - fingers Heberden’s / Bouchard’s nodes Family history Pain, stiffness NSAIDS, injection Fusion is gold standard

37. Arthritis – inflammatory - hand

38. 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)

39. Treatment Rest / ice / activity modification physio –stretching / ultrasound / acupuncture Epiclasp Steroid injection –Max 3 Surgery –open –70% successful www.gnulc.com

40. Carpal Tunnel Syndrome F (25-40;60+)> M 50% bilateral Pregnancy, thyroid, AI, Colles’ Symptoms Pain - night Pins and needles Clumsiness

41. Carpal Tunnel Syndrome - examination Sensation (2 point) Wasting / weakness Tinels Phalens NB can be negative in advanced CTS

42. Carpal Tunnel Syndrome Nerve Conduction tests Mild (sensory slowing) Moderate (motor slowing) Severe (axon drop out)

43. CTS - treatment Splintage Steroid injection –50% respond but drops off (POEMS) –Technique –Avoid intraneural injection Surgery

44. 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)

45. Trigger finger / thumb 40-60 years Repetitive work RhA, gout, hypothyroidism Symptomatic Tx Injections Surgery

46. De Quervain’s Disease F>M Mothers Repetitive movt Finkelstein’s test Symptomatic Tx Injections Surgery

47. Intersection syndrome Proximal to De Quervain’s Direct trauma/repetitive movt Anatomy Usually responsive to conservative measures

48. Management in Primary Care summary Activity modification Analgesia is safer than Surgery Physiotherapy Aspirations / injections

49. Refer in – delay may alter prognosis Tendon / ligament disruption Tumours Certain Neurology ……just had enough

50. Sources of information http://ebmg.wiley.com http://www.cochrane.org/ http://www.prodigy.nhs.uk http://www.jr2.ox.ac.uk/bandolier