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Cumulative Trauma Disorders

Cumulative Trauma Disorders

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Cumulative Trauma Disorders

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  1. Cumulative Trauma Disorders MUN ORTHOPEDICS

  2. CUMULATIVE TRAUMA DISORDERS CLINICAL EXAMPLES: UPPER EXTREMITY MUN ORTHOPEDICS

  3. CUMULATIVE TRAUMA DISORDERS • Carpal tunnel syndrome • Dequervain’s tenosynovitis • Tennis elbow • Impingement syndrome shoulder MUN ORTHOPEDICS

  4. CARPAL TUNNEL SYNDROME • DEFINITION • DIAGNOSIS • INVESTIGATIONS • TREATMENT • CONTROVERSY MUN ORTHOPEDICS

  5. Carpal Tunnel Syndrome • Definition • Compression neuropathy of the median nerve at the wrist • Most common diagnosis for WCC claims in the U.S. • In France CTS is not an allowable diagnosis MUN ORTHOPEDICS

  6. CARPAL TUNNEL Palmar aponeurosis Median nerve MUN ORTHOPEDICS

  7. Carpal Tunnel Syndrome • Pain and Paresthesias on palmar-radial aspect of hand • Often worse at night • Risk factors • Intrinsic • extrinsic MUN ORTHOPEDICS

  8. Carpal tunnel syndrome MUN ORTHOPEDICS

  9. Carpal Tunnel Syndrome • Intrinsic risk factors • Anatomic variants • Either decreased dimension of carpal tunnel or increased volume of its contents • Physiologic variants • Diabetes , alcoholism , smoking , pregnancy , rheumatoid arthritis , myxedema • All associated with edema MUN ORTHOPEDICS

  10. Carpal Tunnel Syndrome • Extrinsic factors • Hand position • Forceful use of hand • Repetitive motion • Vibration MUN ORTHOPEDICS

  11. Carpal Tunnel Syndrome • MRI has shown that wrist flexion compresses the median nerve between flexor retinaculum and tendons • Minimizing wrist flexion/extension by redesign of tools helps reduce CTS MUN ORTHOPEDICS

  12. Carpal Tunnel Syndrome • Forceful use of hand has not been well established as a risk factor in epidemiologic studies • Repetitive motion is a risk factor for hand pain BUT not specifically for CTS • No correlation between hours of keyboard work and CTS MUN ORTHOPEDICS

  13. Carpal Tunnel Syndromeand Vibration • Hand-arm vibration syndrome • Raynaud’s , sensory changes & sclerodactyly • Digital nerves mainly • Often misdiagnosed as CTS • Definite dose-response relationship • >50% incidence with >8000 hrs. • Carpal tunnel release does not help MUN ORTHOPEDICS

  14. Carpal Tunnel SyndromeRole of Work • Difficult to extrapolate epidemiologic studies to individuals • Epidemiologic studies have major flaws • Nonrigorous diagnosis • Time relationship to starting job • Background exposure (79% of time is not at work) • Intrinsic risk factors not measured MUN ORTHOPEDICS

  15. Carpal Tunnel SyndromeDiagnosis MUN ORTHOPEDICS

  16. Carpal Tunnel Syndrome • Electrodiagnostic tests • Commonly done • May not be as sensitive as clinical signs MUN ORTHOPEDICS

  17. CARPAL TUNNEL ANATOMY MUN ORTHOPEDICS

  18. Carpal Tunnel Syndrome MUN ORTHOPEDICS

  19. Carpal Tunnel Release MUN ORTHOPEDICS

  20. Dequervain’s Tendonitis • Tendon entrapment not tenosynovitis • Analogous to trigger finger • APL & EPB tendons • Originally described in 1895 and blamed on “housework” • Peritendinous fibrosis not inflammation MUN ORTHOPEDICS

  21. Dequervain’s Tendonitis MUN ORTHOPEDICS

  22. Dequervain’s Tendonitis • No reports that relate incidence of Dequervain’s to frequency or intensity of repetitive work • Tender over radial styloid • Finklestein’s test MUN ORTHOPEDICS

  23. Finklestein’s test MUN ORTHOPEDICS

  24. Dequervain’s TendonitisTreatment • Splinting • Rest • NSAIDS ? • Steroid injection - 80% success • Surgery MUN ORTHOPEDICS

  25. Dequervain’s tendonitis MUN ORTHOPEDICS

  26. Tennis elbow Lateral epicondylitis • Angiofibroblastic tendinosis • Not inflammatory • ?avascular or degenerative etiology • ECRB origin MUN ORTHOPEDICS

  27. Tennis elbow Lateral epicondylitis MUN ORTHOPEDICS

  28. Tennis elbow Lateral epicondylitis • Associated with repetitive use • Occupational • Sports • Musicians • Tender over lateral epicondyle • Pain on resisted wrist extension MUN ORTHOPEDICS

  29. Tennis elbow Treatment • “comfort and cure” • NSAIDS • Steroid injection • Rehab program – 4 months !! • Rest • Clasps MUN ORTHOPEDICS

  30. Tennis elbow Lateral epicondylitis • Surgery when all else fails • Literature suggests 80% success rate • Optimistic • Post-op rehab is 6 months ! MUN ORTHOPEDICS

  31. Tennis elbow MUN ORTHOPEDICS

  32. Tennis elbow MUN ORTHOPEDICS

  33. ROTATOR CUFF MUN ORTHOPEDICS

  34. ROTATOR CUFF • Classic example of overuse • Prolonged or repetitive overhead use of arms • Neer – impingement abrades tendons • Continous cycle of overuse without adequate repair MUN ORTHOPEDICS

  35. Overuse syndromes MUN ORTHOPEDICS

  36. Impingement Syndromes • Subacromial bursitis • Rotator cuff tendonitis • Bicipital tendonitis • AC arthritis • Rotator cuff tear MUN ORTHOPEDICS

  37. Impingement Syndrome MUN ORTHOPEDICS

  38. Shoulder Anatomy MUN ORTHOPEDICS

  39. Acromion Morphology MUN ORTHOPEDICS

  40. Impingement :Hx & Px • Repetitive overhead use of arm • Swimmers,pitchers • painful arc • impingement signs • decreased ROM active vs. passive • pain with resisted motion MUN ORTHOPEDICS

  41. Impingement : treatment • Avoidance of offending activity • Physiotherapy • NSAIDS • Corticosteroid injection • Surgery : Subacromial decompression MUN ORTHOPEDICS

  42. Impingement :Surgery • Arthroscopic vs open decompression • Cuff repair • Excision outer end of clavicle MUN ORTHOPEDICS

  43. Acromioplasty MUN ORTHOPEDICS

  44. MUN ORTHOPEDICS

  45. Rotator Cuff Tear MUN ORTHOPEDICS

  46. MUN ORTHOPEDICS