1. Upper Limb Musculoskeletal Surgery Lisa Tourret MBChB.MSc.FRCS. FRCS (T&O) Nuffield Hospital Teaching Program

2. Aim • Introduction • Scope of talk • Selected conditions • Shoulder • Elbow • Wrist • Hand • Questions and Answers

3. 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

4. Scope of Talk • Common conditions of upper limb • Traumatic – accidental/sports injury • Degenerative – joint disease/ soft tissues • Neoplastic

5. Rotator cuff tear Calcific tendinopathy Impingement Cervical spine Shoulder Pain

6. Clinical Presentation - History • Shoulder pain - severity • Diffuse • Radiation? • Night pain • Aggravating factors • Relieving factors • Duration • Onset spontaneous or post trauma? • Age of patient

7. 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

8. Jobe test and Hawkins sign Beware the patient with MDI presenting with impingement pain

9. Anatomy

10. Impingement

12. Impingement

13. Impingement SyndromePartial Thickness Tear?

14. 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

15. 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

16. Full Thickness Rotator Cuff Tear • Small <1 cm • Moderate 1-3 cm • Large >3 cm • Massive > 5 cm • Surgery more successful in <4 cm

17. Initial tear

18. Enlarging tear

19. Enlarging tearlateral slips sublux“Bald humeral head”

20. Chronic tear

21. Plain X-ray

22. Biceps Tendon

23. Calcific Tendonitis

24. 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)

25. Ultrasound Scan

26. MRI

27. Arthroscopy

28. Treatment Physiotherapy, NSAID, Injections, Arthroscopy, Debridement, Repair, Reconstruction, Replacement

29. 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?

34. Frozen Shoulder • Adhesive capsulitis • Onset • Age • Duration • Natural time course (freezing/Frozen/Thawing) • When do we intervene? Distension or capsular release • IDDM?

35. The Elbow

36. Elbow • Tennis elbow • Ulna nerve compression or cubital tunnel syndrome • Loose bodies – locking • Stiffness – post traumatic? Arthritic? • Olecranon bursitis

37. Tennis elbow • Lateral epicondylitis • Radial tunnel syndrome • Resisted supination? • Middle finger test? • Injection site? • Surgical intervention <20% of initial presenters

38. Ulnar nerve compression • Cubital Tunnel Syndrome • 2nd only to Carpal Tunnel Syndrome • When to treat? • Non-operative measures • Operative – decompression vs transposition

39. Elbow Arthroscopy • Loose bodies • Arthrolysis • Tennis elbow • Osteochondritis • Synovectomy

40. Wrist and Hand • Carpal tunnel syndrome • Dupuytrens disease • Ganglions • Trigger finger • OA • Tendon sheath tumours – GCT, pea ganglions

41. When to treat? • Mature cords • MCP 30º • PIP 30º • Tabletop test

42. Ganglions • Symptomatic? • Lump or scar? • Recurrence rate • Complications

45. Trigger finger • Pathology? • Treatment • A1 pulley release • Recurrence? • Tendon slip excision

47. 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

48. 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)

49. Surgical intervention • When non-operative methods fail • Fusion • Excision arthroplasty • Joint replacement • Interpositional arthroplasty

50. Distribution • DIPJ – fusion • 1st CMC –Trapeziectomy • PIPJ – fuse or replacement • MCPJ - replacement • Others - Sesamoid, Trapezial Scaphoid/trapezoid, Pisiform-triquetral OA