common upper limb problems

Common Conditions occurring due to

Desk jobs

Dr. Deepthi Nandan Adla

MS(Orth)osm, MSc (Orth eng.) UK, FRCS, FRCS(Tr&Orth), CCT UK

Consultant Orthopaedic Surgeon (Upper limb)

Apollo Hospitals, Hyderabad

Repetitive strain

Conditions occurring due to repeated use of a certain movement

Forceful exertions

Repetition

Awkward postures

Mostly affects office workers

Sedentary jobs

Conditions Musculoskeletal

Cervical spondylosis

Shoulder impingement

Tennis elbow/Golfers elbow

Trigger finger/ DeQuervain’s tenosynovitis

Nerve related

Carpal tunnel syndrome

Cubital Tunnel syndrome

Nerve root compression

Symptoms

Muscle/tendon problems

Pain

Swelling

Weakness

Nerve related

Tingling/altered sensation

Weakness

Tendon problems:Dequervain’s History

New, repetitive activity

Pain over thumb side of the wrist

Pain on making a fist, grasping or holding objects

Examination

Swelling

Thickening

Tenderness

Treatment Activity modification NSAID Splintage – thumb widely abducted

Some reports of low success rates Most reports suggest ineffective

Steroid Injection 60 – 80% improved

Soluble steroid

One or two injections

depigmentation

fat atrophy

Surgical Release Day case procedure

Local anaesthesia

Transverse incision

Release tendon

Tennis/Golfers elbow

First described by Runge in 1873

‘Schreibers Krampfes’ (writers cramps)

Incidence

General population: 0.6% Tennis players: 9%

Age:

35 and 50 years, with an equal distribution between males and

females Associated Rotator cuff problems: 20-40%

Etiology

Multiple microtraumatic events

Disruption of the internal structure of the tendon and degeneration of the cells and matrix JBJS 81:259-278 (1999)

Hypovascular zones

Eccentric tendon stresses

Microscopic degenerative response

Presentation Pain

outer aspect (Tennis elbow )of elbow/ inner aspect (Golfers)

Increases with activity Lifting objects Sometimes pain at rest

Palapation

Tenderness

Special test

Resisted wrist extension Elbow flexion Elbow Extension

Investigation

X ray

Bony spur Calcification Arthritis

Ultrasound

Tendon integrity Synovitis of Elbow

Non- Operative Treatment options

Topical NSAIDs

Oral NSAIDs

Orthotic devices

Physiotherapy

Autologous blood injection-79% had improvement of Nirschl scores

J Hand Surg [Am]. 2003 Mar;28(2):272-8

Literature: Steroid/Physio/wait

RCT

6 weeks Pain/function improved in:

92% (57) of steroid group 47% (30) for physiotherapy 32% (19) for wait-and-see

One year:

69% (43) for injections 91% (58) for physiotherapy 83% (49) for a wait-and-see policy Lancet 2002

Operative treatment Surgery to repair the tendon

Conclusion

Confirm diagnosis

Need assessment by surgeon to confirm diagnosis

NSAIDs

Physio

Surgey if:

Unresolved after non op treatment

H/O trauma and pain after injury

Tear in the tendon

Carpal Tunnel Syndrome

Incidence: 1-3 cases per 1000 persons per year

Prevalence: 50 cases per 1000 persons

aged in their 30s and 50s

Women are affected 2-3 times more often

Association of CTS in computer workers

BMC Musculoskeletal Disorders 2008, 9:134

Symptoms Pins and needles

Pain

The pain may travel up the forearm.

Numbness of finger

Dryness of the skin

Weakness of muscles

AnatomyContents:Nine flexor tendons

Tendons

Median Nerve

Cause of carpal tunnel syndrome

Nerve function v/s pressure in tunnel (healthy people)

Tingling @ 40mmhg

Complete motor and sensory block at 50 mmHg

Carpal tunnel pressure:

5.3 mmHg during rest

16.8–18.7 mmHg static on the mouse

28.8–33.1 mmHg while dragging mouse

Examination

Dry pulps

Wasting of Thenar muscles

Tinels

Investigations Nerve conduction test

Confirm Diagnosis

Assess nerve function

Double crush/Polyneuropathy

Prognosis

Base line, if recurrence

Non-operative Night splint

(good for patients with nocturnal symptoms)

Activity modification (avoid aggravating activity)

NSAIDs

Treatment NSAIDS

Physiotherapy

Activity modification

Surgery

Operative treatment

Indications:

Failed non-operative treatment

Motor weakness

Procedure:

Local anesthesia.

Shoulder Impingement syndrome

Pain in shoulder

Increases with activity

Clicking sensation in shoulder

Pain with overhead activities/ reaching for seat belt, changing gears/wearing cloths

Assessment

Shoulder surgeon to assess to confirm diagnosis

Complex joint

Needs thorough knowledge

Understanding poor among general orthopedic surgeons

Newer techniques available to help improve pain

Treatment

Pain medication

Activity modification

Physio

To improve scapular position

Strengthen a specific group of muscles

Injection into shoulder

To be done by shoulder specialist

If not treated

Continued rubbing of tendon in shoulder

Tear of tendon

Arthritis

Procedure

General anaesthetic

Key hole/arthroscopic surgery

2-3 small cuts around shoulder

Assess shoulder and the tendons

Shaving of the boney spur

Results

90-95% good results

Pain (sharp catching pain) improves

If wear/tear changes in tendon some residual pain is possible

Conclusion

Prevention better than cure

Regular exercises

Try activity modification

Physiotherapy

If still not better: Surgery

Exceptions: Nerve compressions: carpal/ cubital tunnel

Tendon tear in shoulder (Rotator cuff tear)

Thank youContact:deepthi.adla@gmail.com 7893844800