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