Common Queries on Shoulder and Elbow Problems

Dr.Senthilvelan

Consultant Orthopaedic Surgeon

Apollo Hospitals, Chennai

MBBS, MRCS, FRCS (Orth), FEBOT (France)

Specialist in  Shoulder and Elbow.,Foot Ankle,

Apollo Hospitals Ayanambakkam, Chennai, India.

Apollo Clinic, Annanagar.

For appointments Contact 082205009176/velansenthil78@yahoo.com

I have listed some some common Queries on: Shoulder, Elbow and Wrist Problems that patients commonly ask me, so that it can benefit others.The answers apply to each individual so if you have any specific queries contact me on velansenthil78@yahoo.com

S V: I developed a chronic painful shoulder from the day when somebody twisted my shoulder. Along with it my elbow and wrist also started paining . What can be the reason? My other shoulder also has started paining. Both the shoulders cant are not like before, why so? What is the cure?

Shoulder pain after twisting injury could be because of damage to the lining of Shoulder joint socket(SLAP tear) or Tendon injury(rotator cuff tear). To accurately identify the issue you need to consult Specialist shoulder surgeon.You may require further investigations like Xray/USG of shoulder to confirm the diagnosis. Once confirmed it can be addressed by Key hole surgery (Arthroscopy) to relieve symptoms.For further information on SLAP tears kindly look at www.nexusortho.net

T S: My father's hand pains when he raises his hand up straight. I'll be highly obliged if you give me the suggestion regarding the treatment for it.

The clinical history suggests that your father he could have rotator cuff (tendons around shoulder) tear. He should be seen by specialist Shoulder surgeon and he may require further investigations like USG/Xrays to confirm the diagnosis. If rotator cuff tear is confirmed this can be addressed by Key Hole surgery (Arthroscopy) to repair the tendons. If you need further information on rotator cuff tears kindly look at www.nexusortho.net

A S: I'm 22 and have pain in the root of my right hand thumb near the wrist since last 6 months. Mostly when pressurised, the pain becomes unbearable. Doctors have confirmed that it isn't dislocated. Kindly suggest me a way out other than a surgery.

The pain in the region of wrist you are described is commonly due to what is called Dequervains synovitis. The tendons around the wrist reaching the thumb become inflamed and can cause significant pain. You need to consult a specialist Wrist surgeon for further assessment. If the diagnosis is confirmed most often it can be managed conservatively with Wrist splints or injections. Only if doesn’t resolve then surgery is indicated.

N D: In Mid fifties a friend has develop some sort of pain in the entire arm specially the biceps of both arms. They have no strength, for example, while sleeping both the arms start paining as they cannot sustain the weight of the body, while holding the newspaper abone they start paining in less than 30 secs. He cannot dust with a dusting cloth, cannot scrub clothes with a brush as immediately the hands confirm get tired and it  starts paining right from shoulder down to the elbow.

The clinical history of your friend suggest he could have rotator cuff (tendons around shoulder) tear. This could happen bilaterally. He should be seen by specialist Shoulder surgeon and he may require further investigations like USG/Xrays to confirm the diagnosis. If rotator cuff tear is confirmed this can be addressed by Key Hole surgery (Arthroscopy) to repair the tendons. If you need further information on rotator cuff tears kindly look at www.nexusortho.net
           

S M I usually have pain in my shoulders & back of my neck whenever I sit on my desk for a long time & a portion of my shoulder has turned numb. I can't feel anything there when touched. What can be the reason?

Painful shoulder along with neck pain is usually due to problem in your neck. This could be due to trapped nerve secondary to disc prolapse. If you have developed numbness that is constant seek early appointment with Orthopaedic Surgeon. You will require thorough clinical assessment and MRI scan to further assess the cause of the problem.

D T: Is any elbow joint replacement surgery available?

Yes. I carry out Elbow joint replacements for patients who have arthritis of elbow. This relieves pain and restores elbow range of movements. For more details visit www.nexusortho.net

A R what is frozen shoulder?????

Frozen shoulder is condition in which the covering of shoulder undergoes contracture.It happens more in diabetics but can also happen in non diabetics.

The volume of shoulder is reduced and this results in reduced movement and can cause pain.

Treatment is firstly physiotherapy and if this doesnot help Keyhole surgery(arthroscopic) release can be done in resistant cases. For more information look at www.nexusortho.net

G S sir i m feeling pain in the upper part of my right shoulder. It started when i played cricket after many years of gap. When i take rest it isnt felt but when i start playing again it does.

Shoulder pain after sporting injuries usually represent tear in lining of socket of shoulder.This is called SLAP(superior labral anteroposterior tears). The pain typically happens only when you r getting into throwing action or lifting things. These can be addressed by Arthroscopic(Key hole) repair . The diagnosis should be first confirmed by an MRI scan with contrast . Once diagnosis is confirmed SLAP repair can be done. This has to  be carried out by specialist Shoulder surgeon experianced in these . For further information pls look at www.nexusortho.net

JS Please give some signs & symptoms of Tennis Elbow? Please explain medications also for the same?

In regards to Tennis elbow, patients experience pan in outside aspect of elbow . This happens especially with repeated activities of wrist . Pressing on outside aspect of elbow reproduces the symptoms. Initial treatment involves Tennis elbow splints, anti inflammatories. But persistant symptoms can be treated with new modality of Stem cell injections.This involves taking blood from patient (15 ml) centrifuging it and separating the stem cells and injecting into the outside aspect of elbow. Studies have shown favourable results of Stem cell injections in Resistant tennis elbow.

A  C: Sir my mom has a stiff wrist. What should she do?

Wrist pain and stiffness are most commonly due to Wrist arthritis in the elderly. We need to identlfy the cause of stiffness . Xrays of wrist can identify what stage of arthritis is present. If diagnosis is confirmed number of minimally invasive options like Key hole surgery(arthroscopy) of wrist are available now in Apollo which were only available in the west.This surgery involves 2  small scars on front of wrist , and debridement of wrist joint cn be done.  Sometimes if arthritis is advanced  then Wrist replacement can be done to relieve pain and stiffness.This is done only in selected centres and should be done by specialist Wrist surgeon experianced in such procedures

How to deal with Shoulder Arthritis

Article in Deccan Chronicle by
 Dr Senthil Velan Consultant Shoulder Elbow Surgeon

The Link for the article is
http://www.dc-epaper.com/PUBLICATIONS/DC/DCC/2013/05/05/ArticleHtmls/The-shoulder-has-its-reasons-05052013110019.shtml?Mode=1

For queries and appointments contact nexusortho@gmail.com/9566222533

Whats New in Clavicle Fractures ?

Dr Senthil Velan.

MBBS, D Ortho, MRCS(UK) FRCS (Ortho),

FEBOT, Fellow European Board Orthopaedics and Trauma.

Consultant Shoulder, Elbow & Wrist Surgeon

Apollo Hospitals Ayanambakkam, Chennai, India.

Apollo Clinic, Annanagar.

For appointments Contact 082205009176/velansenthil78@yahoo.com

Should we Change our notion of Clavicle fracture treatment?

Although most conservatively treated midshaft clavicular fractures were traditionally thought to unite,recent clinical evidence suggests that nonunion after fractures is rather common. Unfortunately, non-union often causes pain and impaired function of the shoulder girdle.

Recent literature is challenging the traditional belief that midshaft clavicle fractures

uniformly heal without functional deficit. This paradigm shift is supported by several prospective studies by members of the Canadian Orthopaedic Trauma Society, who reported higher nonunion rates and functional deficits after nonsurgical treatment of midshaft clavicle fractures when compared with internal fixation

Pre op Xray of Mid third Clavicle fracture with 2 cm displacement

Post op Xrays showing Clavicle fixation

Recent studies have shown that long-term results from conservative, or non-operative, management of clavicular fractures are not as favourable as previously considered:

•             42% of people still had sequelae at 6 months in one study. The same study suggests the exploration of alternative treatment options, including surgery, for certain clavicular fracture types.[7]

•             A recent multicentre randomised controlled trial in Canada showed that displaced clavicle shaft fractures treated by surgical plate fixation had improved functional outcome and a lower rate of malunion and nonunion when compared with nonoperative treatment at one year.

•             Another study into nonoperative treatment of displaced mid-clavicular shaft fractures detected significant residual deficits in shoulder strength and endurance.

Indications for acute surgical treatment may include younger, active patients with clavicle shortening greater than 1.5 to 2 cm, significant cosmetic deformity, or multiple-trauma situations.

The Clavicle has many functions including acting as strut to hold the scapula away from body, serves as attachment for muscles, provides protection for underlying blood vessels and nerves. It also helps in transmitting the forces to the scapula.

The clavicle also assists with the external, upward, and posterior rotation of the scapula. This has been supported by number of Cadaveric and clinical studies.

Upward scapular rotation elevates the lateral acromion, whereas its posterior tilting elevates the anterior acromion; thus, by influencing scapular motion, the clavicle may assist the motion of the glenohumeral joint and decrease subacromial pressure

Shoulder dyskinesia affects surrounding muscles of scapula and the entire kinematic chain from the trunk to the upper extremity. Clavicular discontinuity changes the shoulder girdle kinematics, resulting in decreased external rotation, upward rotation, and posterior tilting of the scapula. This in turn can lead to secondary impingement of shoulder.

Trigger Finger

Dr Senthil Velan.

MBBS, D Ortho, MRCS(UK) FRCS (Ortho),

FEBOT, Fellow European Board Orthopaedics and Trauma.

Consultant Shoulder, Elbow & Wrist Surgeon

Apollo Hospitals Ayanambakkam, Chennai, India.

Apollo Clinic, Annanagar.

For appointments Contact 082205009176/velansenthil78@yahoo.com

Trigger Finger

What is it?
The tendons that bend your fingers run through a tunnel or sheath. Trigger finger is caused by a thickening on the tendon, which causes it to catch as it runs in and out of the sheath. You can often feel this swelling in the palm as you move the finger. Patients complain of pain in the palm at the base of the affected finger and episodes of the finger being stuck, bent down. This can be relieved by pushing the finger out straight, causing a snap which can be painful. Patients often wake in the morning with the finger stuck down.

Picture showing Evidence of Trigger Right Ring Finger

What can be done?

There are two ways of treating the problem.

1. Steroid Injection - A small amount of steroid is injected around the tendon. This flattens out the swelling on the tendon allowing it to glide freely in and out of the sheath once more. A single injection is all that is needed in 50% of cases. A further 25% will respond to another injection (i.e. three-quarters of cases can be successfully treated in this way). The steroid injection does not work immediately. It causes no general side-effects but occasionally the skin around the injection-site can be made a little thinner. Thus two injections are the maximum.

   

   Steroid Injection into triggering site.

2. Surgery - This is needed if the steroid injections do not work. It involves a small procedure usually under local anaesthetic. A slit is made in the mouth of the sheath to prevent the tendon catching at this point. The condition can occur in the affected or any other finger again in the future. Surgey is more common in patients with multiple trigger fingers and in Diabetic patients.

Picture showing released Tendon from constriction.

Post-operative care

After the operation, you will be in a big bandage, but the fingers will be free to move. It is important to move all fingers and thumb straight away, as well as keep the hand raised (above the level of your heart) for at least 72 hours to help with swelling and stiffness.

This bulky dressing can be taken down at 72 hrs and a light sticky dressing applied to the wound. There will initially be some swelling and bruising, however, if you have any worries contact your G.P (i.e increasing pain, swelling, redness) The stitches are usually dissolvable. You will be reviewed in the Orthopaedic clinic at 2- 6 weeks. Timing of your return to work is variable according to your occupation and you should discuss this.

Infection

Any operation can be followed by infection and this would be treated with antibiotics.

Scar
You will have a scar on the palm. This will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with moisturizing cream.

Stiffness
About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (Complex regional pain syndrome).This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Nerve
The nerves running to the fingers can be damaged during the surgery and cause numbness in part of the finger. This is very rare.

Recurrence
As mentioned above, the triggering can recur. However this is rare.

Carpal Tunnel Syndrome

Dr Senthil Velan.

MBBS, D Ortho, MRCS(UK) FRCS (Ortho),

FEBOT, Fellow European Board Orthopaedics and Trauma.

Consultant Shoulder, Elbow & Wrist Surgeon

Apollo Hospitals Ayanambakkam, Chennai, India.

Apollo Clinic, Annanagar.

For appointments Contact 082205009176/velansenthil78@yahoo.com

What is Carpal Tunnel Syndrome? Carpal Tunnel Syndrome is caused by compression of the median nerve in the wrist. The median nerve controls some of the muscles in your hand, as well as relaying sensation from the skin. The median nerve lies in a tunnel in your wrist, this is the carpal tunnel. Any swelling or inflammation in this small space can cause compression on the median nerve, and symptoms occur in the hand. Who gets Carpal Tunnel Syndrome? Carpal tunnel syndrome occurs most often in people 30 to 60 years old, and is more common in women than men. Other factors that may lead to carpal tunnel syndrome include: Alcohol Abuse. Bone fractures and arthritis of the wrist. Obesity. If your body keeps extra fluids during pregnancy or menopause. Rheumatoid arthritis. What are the symptoms of Carpal Tunnel Syndrome? Patients experience clumsiness when gripping objects and may experience numbness and tingling in thumb and next two or three fingers. There also could be pain extending upto the elbow. Problems with fine finger movements (coordination) and Wasting away of the muscle under the thumb (in advanced or long-term cases) can also happen. Areas of Numbness and Tingling in Carpal Tunnel Syndrome What tests are required to diagnose Carpal Tunnel Syndrome? The clinician would carry out clinical test to identify the condition.Some of the tests include Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand (this is called Tinel's sign)One other test is done by bending the wrist forward all the way for 60 seconds will usually result in numbness, tingling, or weakness (this is called Phalen's test) Further tests like nerve conduction  studies sometimes may be necessary to confirm the diagnosis What is the Management of Carpal Tunnel Syndrome? There are a number of ways of treating the condition including modifying activities, splinting, steroid injections and surgery. Surgery is recommended if you have had the problem for a long time, your symptoms are severe, non surgical treatments have failed or if the doctor detects weakness of muscles. What is involved in Carpal Tunnel Decompression surgery? The median nerve and the tendons that flex (or curl) your fingers go through a passage called the carpal tunnel in your wrist. This tunnel is narrow, so any swelling can pinch the nerve and cause pain. A thick ligament (tissue) just under your skin (the carpal ligament) makes up the top of this tunnel. The surgery for Carpal Tunnel release is mostly done under Local Anaesthesia without you needing be put to sleep(General Anaesthesia) First, you will receive numbing medicine (anaesthesia) so that you will not feel pain during surgery. You may be awake but you will also receive medicines to make you relax. In carpal tunnel release, the surgeon will cut through this ligament to make more space for the nerve and tendons. First your surgeon will make a small surgical cut in the palm of your hand near your wrist. Then your surgeon will cut the carpal transverse ligament to ease the pressure on the median nerve. Sometimes, tissue around the nerve is removed as well. Your surgeon will then close the skin and tissue underneath with sutures (stitches).   Intra operative picture showing release of Median Nerve What are the possible complications? With all surgery there is a risk of complications: Infection - Any operation can be followed by infection and this would be treated with antibiotics Nerve Damage - Nerves running in the region can be bruised or damaged during the surgery and form a painful spot in the scar or numbness. The most commonly involved areas are the heel of the hand or the space between the middle and ring fingers. This complication is rare (2%) but may require a further operation to correct Recurrence - If you continue to have attacks of tingling and numbness, it might mean that not all the ligament has been cut. This is rare (1%) but the operation would need to be repeated to correct this Grip - You will find that your grip is weaker than previously and slightly painful, causing discomfort in the heel of the hand. Leaning on the heel of your hand can be uncomfortable (pillar pain). This will gradually improve over six months.

What is the long term prognosis after this surgery?

Carpal tunnel release decreases pain, nerve tingling, and numbness, and restores muscle strength. Most people are helped by this surgery

Elbow Arthritis

Dr Senthil Velan.

MBBS, D Ortho, FRCS (Ortho),

FEBOT, Fellow European Board Orthopaedics and Trauma.

Consultant Shoulder and Elbow Surgeon

Apollo Hospitals Ayanambakkam, Chennai, India.

Apollo Clinic, Annanagar.

For appointments Contact 082205009176/velansenthil78@yahoo.com

What is it?

Arthritis of Elbow joint can be of two types .Primary Osteoarthritis or Rheumatoid arthritis. Arthritis means wear and tear of the cartilage of joint. Normal joint has cartilage which provides lubrication for smooth gliding of joint. In arthritis this cartilage wears away resulting in roughening of joint surface .The body forms new bone around the worn joint and these are called “osteophytes” and these can reduce movements of joint

CT scan showing Elbow arthritis Changes.

What is its cause?

The most common cause of elbow arthritis is due to ageing. There is wear and tear of joint and this is called “Primary Osteoarthritis”. Sometimes arthritis can occur in this joint after a previous Elbow fracture or dislocation. This type of arthritis is called “Secondary Post traumatic arthritis”. In case of Rheumatoid arthritis the body’s own immune system mistakenly forms cells that damage joint cartilage.

What are the symptoms and how is elbow arthritis diagnosed?

The early symptom is stiffness of elbow and pain gradually worsens as arthritis becomes worse. Some patients develop symptoms of “locking” which is caused by loose bodies which get dismantled from arthritis bone and get lodged inside the joint.

The pain gradually worsens and causes limitation to day to day activities. The pain is especially worse after lifting activities. Sometimes the nerve around the funny bone (medial epicondyle) can get compressed and the patient can experience tingling/weakness of hand.

Will further tests or investigations be needed?

X rays are usually needed to assess extent of arthritis. MRI Scan/CT scan would be needed to plan treatment. Sometimes a Nerve conduction study would be required to assess whether the nerve is compresses at elbow.

CT scan showing evidence of Elbow arthritis

h

What is the treatment?

1. Initial conservative management include Pain Killers, Physiotherapy and splinting. If the nerve is compressed it requires surgery to release the pressure at the level of elbow even at early stages. This is to prevent further deterioration secondary to compression of nerve.

2. Key Hole Surgery(Arthroscopy)- If the patients predominant symptoms are “locking”  and loss of movement , this can be helped by doing a key hole operation to remove loose bodies from joint. This immediately alleviates the symptoms.

Arthroscopic (Key Hole Surgery)  involves two small stab incisions are made in the elbow through which small telescope and instruments are used to remove loose bodies, inflammatory tissue or bony spurs.

Elbow Arthroscopy

3. Elbow debridement (OK procedure): This type of surgery is advised for marked

arthritis that is causing significant loss of movement and pain. An incision of about

10cm is needed on the back of the elbow. At surgery all loose bodies and bony

spurs that are blocking movement are removed. A fenestration is made in the

distal humerus (end of the arm bone) and loose bodies or spurs in the front of the

elbow are also removed. The elbow is put in a splint, in an extended position, at

night only, for 2-3 weeks. Physiotherapy after surgery is critical.

4. Total elbow replacement: Joint replacement of the elbow is usually a successful

operation. The pictures below show x-rays of the replacement in a patient who

has rheumatoid arthritis. Replacement is usually avoided in young people but is a

good option for patients with rheumatoid arthritis or those having low demands on

the elbow. The operation will lead to significant pain relief and improved functional

range of movement. The elbow in put in splint, in an extended position, at night

only, for 2-3 weeks. Physiotherapy after surgery is critical.

X ray showing Total Elbow Replacement

What happens if it is not treated?

Some patients are able to cope with pain and conservative measures are usually enough to alleviate symptoms. Some patients have progression of arthritis and the pain worsens with limitation of range of movements.

What is the success of surgical treatment?

Arthroscopic removal of loose bodies will nearly

always stop symptoms such as locking. More than 80% patients will achieve a better

range of movement and significant improvement in their pain after debridement of the

elbow. In more than 95% of patients, the elbow replacement will lead to a pain free

elbow with a good functional range of movement.

What are the complications of surgical treatment?

Scar tenderness, Nerve damage, Persistant symptoms are all possible complications after surgery. In the long term, the elbow joint replacement may fail and will need to be revised. However, it is expected that nearly 90% of elbow replacements will still be successful after 10 years, in low demand patients.

Any surgical intervention has the risk of developing complications / setbacks

which are unpredicted. These complications may have the potential to leave the

patient worse than before surgery..

When can I do various activities?

• Following arthroscopic surgery, patients should be able to return to a desk job

within 7 days. 

• Following elbow debridement or replacement, patients should be able to return to

a desk job within 4-6 weeks of the operation and perform reasonable tasks with

the limb by that time. 

• Manual work after surgery should be avoided for 8-12 weeks. 

 References:

1. Master Techniques in Orthopaedic Surgery: The Elbow, 2nd Edition

Copyright ©2002 Lippincott Williams & Wilkins

Cubital Tunnel Syndrome

Dr Senthil Velan 

MBBS, D Ortho, FRCS (Ortho), FEBOT, Fellow European Board Orthopaedics and Trauma.

Fellowship in Shoulder Elbow Surgery (Bournemouth, UK)

Consultant Shoulder Elbow,Hand Surgeon

Apollo Hospitals ,Ayanamabakkam, Chennai, India

Apollo Clinic Annanagar.

For appointments contact 09566222533/velansenthil78@yahoo.com

What is it?   

A nerve called ulnar nerve supplies the index and ring fingers.It runs underneath the inside part of bone in the elbow(medial epicondyle) and tip of elbow(olecranon).It can get compressed in this tunnel and this is known as Cubital tunnel syndrome..

Picture showing Ulnar nerve and Cubital Tunnel(1)

What is the cause?         

In most of cases no underlying cause can be found. In some patients it is due to sustained stretch , or pressure on inside of elbow for prolonged periods of time which can cause thickening of tissue over the tunnel(Osborne’s ligament). This can cause compression of nerve.

This condition is also found more in people who have diabetes, Rheumatoid arthritis, elbow arthritis, or previous elbow fracture.

What are the symptoms and how is the condition diagnosed?    

Patients usually complain of pins and needles in ring and little fingers .This is because of compression of nerve in tunnel at the elbow. The tingling is worse when the elbow is bent and for this reason most people experience worse symptoms at night time.(as most people keep their elbow bent over had while sleeping)    

In later stages patients notice weakness in grip, and may drop things frequently. Muscle weakness in hand muscles can occur if left untreated and can cause deformity.

How is it diagnosed?

Testing of hand muscles and Elbow will be done by Specialist Elbow surgeon and he can determine whether the compression is minimal or severe. The diagnosis is mostly made on clinical examination but usually supplementary nerve testing is required.

Will further tests or investigations be needed?   

          

The diagnosis of cubital tunnel syndrome is made clinically but you will nearly always be referred for electrical tests (nerve conduction studies). The tests may be to confirm the diagnosis in patients in whom the symptoms and signs are not typical and also to confirm that the nerve is not compressed elsewhere (usually in the neck from where it begins or rarely on the front of the wrist).  Other medical conditions like diabetes or thyroid disease need to excluded using lab investigations.

What is the treatment?         

Initial treatment consists of Splints to elbow to help in reduction of symptoms. Night time splinting is achieved with a custom made long arm splint that the patient will wear at night time and as often as possible during the day. Unfortunately it is cumbersome to keep the arm out straight all the time and therefore this is usually used only at night.

If symptoms persist even after conservative measures Surgery can be done to relieve the symptoms.

The procedure is described below

                       

Decompression of the ulnar nerve: This is a standard operation advised and is an open

surgical release of the cubital tunnel. A skin incision of 5 cm is required and at surgery the  roof of the cubital tunnel is opened, thereby decompressing the ulnar nerve. The  procedure can be carried out under local or general anaesthesia, as a day case. After the  operation, a sticky dressing is applied over the surgical wound. A bulky supportive cotton wool dressing then goes on top of that. This supportive dressing is reduced after a couple  of days. The small sticky dressing should be left for 10 -12 days when the stitches will  need to come out.

Light use of the limb should be  possible immediately after the day of surgery. Active movements of the fingers/ wrist/  shoulder are recommended soon after surgery. 

Other surgical procedures like transpositions of Ulnar nerve or medial epicondylectomy are done for resistant  cases.

When certain other conditions like (rheumatoid) arthritis are present, clearing of the soft  tissue lining (synovectomy) or excision of any bony spurs, may be needed.   

What happens if it is not treated?  

            

If left untreated the tingling and numbness may become progressively worse. Compression of nerve for prolonged time can result in weakness of  hand muscles, wasting and can result in deformity.

What is the success of surgical treatment?          

      

The operation has a very good success rate in the early stages. It results in good resolution of  night pain and tingling within a few days. However if the condition has been present for a long  time, then recovery from symptoms of constant numbness and muscle weakness is unpredictable. However one of the aims and benefits of surgery is to stop the nerve from  deteriorating due to constant compression. Thus even if the procedure does not reverse the  symptoms, it will help to prevent progressive worsening of the nerve function.   

What are the complications of surgical treatment?

1. Infection of the wound is possible and in the early stages can be successfully treated with antibiotics.  If pain increases after surgery infection needs to be ruled out. 

2. Damage to the ulnar nerve is possible but very rare when the open surgical technique is used

When can I do various activities?

Return to work depends on many factors including the nature of the job and hand dominance. 

Generally patients can return to a desk job within a few days and perform reasonable tasks with the hand. 

References

1.Linda D Det al. Radiographics2010;30:1373

Development and Morphology of Shoulder

Development and Morphology of Shoulder

Dr.Senthil VelanMBBS, MRCS (Edin), FRCS (Tr & Orth), FEBOT(France), D Orth, Dip SicoT.
Fellowship in Shoulder Elbow Surgery (Bournemouth, UK)
Fellowship in Knee Surgery (Bournemouth, UK)
Consultant Orthopaedic Surgeon.
Apollo Hospitals Ayanambakkam
Apollo Clinic Annanagar, First Med Hospitals.
For Shoulder problems /Appointments contact 09566222533/nexusortho@yahoo.com

Evidence points to the  development of  upper limb evolutionarily , from  from the folds of epidermis in fish species Rhipidistian crossopterygian. The pectoral part developed in to the upper limb and the pelvic fin has developed into lower limb.(1)

As these pre historic fish evolved to become amphibians, they adapted to living on land without the buoyancy of water. This eventually led to freeing up of pectoral and pelvis parts to considerable distance away from central part of the body.

Evolutionary development of Shoulder Girdle(1)

As mammals developed evolutionarily, they developed a well-developed clavicle and sternal medially (more central to body) and wide scapula laterally (peripheral aspect of body).The coracoid and scapular spine parts of scapular bone developed during this period of evolutionary development in mammals.

A number of variations happened in development of clavicle and scapula as functional demands of different mammals differed. Mammals which adapted to running and swimming lost the clavicle to further mobilise the scapula and thereby increase the thrust provided by shoulder to aid movements. Loss of clavicle in mammals,  allowed the scapula to move forwards and backwards with the limb and thereby increased the stride length.Mammals adapted for swimming developed a wider scapula to allow for varied movements.

Animals cheetah have small clavicle which increases stride length and mobility

Finally, shoulders modified for brachiating (including those of humans) developed a strong clavicle, a large coracoid, and a widened, strong scapula. The size of the infraspinous fossa has gradually enlarged over time relative to the length of the scapular spine. This adaptation allows the infraspinatus and teres minor to be more effective in their roles as depressors and external rotators of the humeral head.

Picture showing increase in infraspinous fossa enlargement with evolution. into Humans.(2)

In animals the acromion process is not well developed but whereas in humans it is a massive structure. This development is a reflection of increasing role of deltoid muscle in shoulder function. As the deltoid attachment on acromion has broadened and its attachment shifted distally in humerus the mechanical advantage of deltoid has increased (2)

Fetus showing early evidence of Upper limb development

In humans by 13 weeks of gestation, the rotator cuff tendons, coracoacromial ligament (CAL), and coracohumeral ligament are present. The acromion is cartilaginous and consistently has a gentle curve that conforms to the superior aspect of the humeral head, similar to a type II acromion. These data suggest that variations in acromial morphology are acquired.(2)

Histological studies have shown that curved acromion implicated in impingement syndrome shows evidence of traction phenomena establishing that these changes are acquired.

Acromial morpological patterns.(2)

References :

1. http://www.philvaz.com/apologetics/p15.htm

2.  Rockwood and Matsen's The Shoulder: Expert Consult - Online and Print, 4e (Shoulder (Rockwood/Matsen)(2 Vol.))

3. The First Humans – Origin and Early Evolution of the Genus Homo

Vertebrate Paleobiology and Paleoanthropology 2009, pp 65-75