TRIGGER THUMB

(Syn. Stenozing Tenosynovitis of Flelexor Pollicis Longus Tendon)

Trigger Thumb is a painful clinical condition in which the terminal phalanx if the thumb gets locked in a state of flexion. Sometimes it is bilateral i.e. involving both hands. Big toes of the feet are usually not involved. The condition at some stage may become painless. It is more common in diabetics.

Trigger thumb is caused as a result of inflammation of the tunnel of the thumb in which the (Flelexor Pollicis Longus) tendon moves. As a result the tunnel gets narrowed, usually at the metacarpo phalangeal joint and arrests the gliding movement of the tendon. Sometimes there is a nodule formation in the tendon at the same place producing obstruction to the tendon movement.

Treatment

Non steroid anti inflammatory drugs help in reducing pain and swelling. Physiotherapy helps in regaining movements of the joint. Sometimes in local infiltration with steroids gives relief. However long term effects of steroids are not desirable.

Surgical Treatment if the medical treatment does not succeed, then surgical release of the tendon should be undertaken. It a one stitch surgery which can be done under local anesthesia with constantly good results.

Congenital Trigger Thumb some children are born with it. The congenital variety is usually bilateral. In these cases the treatment is surgical only. It should be done early otherwise the terminal phalanx of the child will not grow and remain small in size.

PULLED ELBOW

(Syn. Subluxation of Superior/Inferior Radio ulnar Joint)

This is a painful condition of the elbow affecting children below the age of 5 years. It is caused by a pull on the arm with the forearm in a state of internal rotation. It is not the fall but the prevention of fall that causes the problem. Usually it occurs when the mother pulls the child by arm to put him on the other side while turning in bed. Sometimes when the child has a tendency to fall from the bed he, holds the bed sheet to prevent the fall, the whole body weight gives the momentum to internal rotation at the elbow joint and the upper/lower radio ulnar joint is partly dislocated.

It is a very painful condition the affected limb appears to be paralyzed

It is an orthopaedic emergency and the child should be taken to an orthopaedic surgeon or to the casualty department of a hospital immediately.

The X-ray usually does not show any abnormality.

Reduction of the joint displacement is easy. A cuff and collar sling is usually adequate.

If the condition becomes recurrent, a plaster may have to be applied for 2-3 weeks.

No medicine is required.

A chocolate is usually sufficient to bring a smile on the face of the child and parents.

RHEUMATOID ARTHRITIS

Rheumatoid Arthritis is a self limiting condition. But, by the time it leaves, the patient is crippled due to deformities & contractures & is demoralised.  Medicines help in controlling the pain & inflammation. Physiotherapy maintains join mobility, prevents contractures & deformities & helps in locomotion.

Keep your moral up.

God bless you

TENNIS ELBOW

(Syn. Lateral, Epicondylitis)

Technically Tennis Elbow is a misnomer, since most often it occurs in non tennis players. Less than 5% of patients of tennis elbow play tennis (Ludwig Ombregt et al)

Tennis elbow is a clinical condition where patient feels pain on the outer side of elbow while attempting to lift any object with palm facing downwards but the same act can be done with the palm facing upwards. Pain is also produced in any rotatory movement at the wrist e.g. opening a tap or wringing the clothes.

This is due to the internal swelling (inflammation) on the outside (Lateral Side) of the lower end of arm bone (Humerus, Lateral Epicondyle). It is at this place that all the muscles of the fore arm that lift the wrist upwards (Common Extensors) are attached. Any attempt to move these muscles cause pain.

Tennis Elbow is usually caused by a direct hit on the lateral epicondyle. Other diseases like Koch’s or metastatic deposits should be ruled out. Sometimes Cervical Spondylosis may present as tennis elbow. It is more common in diabetic and obese people.

Treatment is simple.

Diabetes must be ruled out and controlled.

Avoid painful acts and activities.

Fomentation with warm water or paraffin wax bath helps.

Pressure bandage during the day gives relief; it should be avoided at night as it can cause swelling of the fore arm.

Non steroid, anti inflammatory drugs (NSAIDS) have a definite role to play in the management of tennis elbow they take away pain and swelling at the common extensor origin. There is effect is potentiated by anti oxidants like omega three fatty acids, methyl, cobalamine and other vitamin supplements.

FROZEN SHOULDER

(Syn. Periarthritis Shoulder, Adhesive Capsulitis)

Frozen Shoulder Syndrome usually presents as a limitation of shoulder movements associated with pain. It usually presents around the age of 40 years equally affecting males and females. Diabetic and obese people are more prone to it. Bilateral frozen Shoulder is almost always found in Diabetics. It usually starts with minor trauma, often ignored by the patient. The patient often claims it to have insidious, spontaneous onset.

On many occasions the patient may have been confined to bed rest for some medical problem, does not do any shoulder movements, and hence gradually slips into shoulder stiffness. Cervical Spondylosis when causes pain in neck and around shoulder, may initiate and precipitate frozen shoulder.

Treatment is simple.

Diabetes must be ruled out in all the patients and treated well in those who are suffering from it.

No treatment will ever succeed unless diabetes is controlled.

X-ray should be done to rule out other associated disorders

 E.g. Koch’s, metastatic deposits

Patient needs anti inflammatory drugs (NSAIDS) to control the inflammatory process going on inside.

Muscle relaxants are needed to relieve the spasm of the muscles. They facilitate the shoulder movements.

Neurotropics, antioxidants and omega three fatty acids are needed to improve the general metabolism and health of the patient. They also potentiate the analgesic effect of NASAIDS.

Sometimes manipulation of the shoulder under General Anaesthesia may have to be undertaken.

With advancement of surgical technology, arthroscopic fibrinolysis of the shoulder joint is undertaken with good results.

In the end, it is the active physiotherapy that is the sheet anchor of treatment, until the patient makes a wilful determined effort no treatment will succeed.

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is an autoimmune disorder affecting the joints, symmetrically (usually). The joints become swollen, red, hot, painful & tender. The joint movement becomes limited due to pain & swelling

It starts with inflammation of the synovial membrane but may involve the joint capsule and other surrounding soft tissues.

It is a self limiting disease. But by the time it leaves, the patient is crippled due to contractures & deformities.

Acute phase can be managed with medicines.

                                         

Commonly used medicines are Ibuprofen/Paracetamol/Aspirin in therapeutic doses. They help to control symptoms of pain and swelling of the joints in most of the cases by their anti inflammatory properties. Fever is also controlled. 

Vitamins, minerals, anti oxidents & other supportive medicines are also needed. Omega 3 fatty acids have a very definite role to play in improving the response to the treatment.

Physiotherapy helps in preventing contractures & deformities.

The patient should do general exercises & keep active.

He may have to be further investigated

  

In established cases of Rheumatoid arthritis DMARD (disease modifying drugs) e.g. METHOTREXATE, HCQ, LEFLUNOMIDE, SAAZ etc. have to be used.

They all are toxic drugs & can cause bone marrow depression along with other side effects. They should be taken under medical supervision.

Sometimes steroids may have to used.

The dose of these medicines should be adjusted to the minimum required, to control the symptoms.

Blood, urine Tests & other investigative procedures should be done periodically to rule out any side effects.

X rays of the affected part should be done to confirm diagnosis & assess the extent of damage.

Diabetes, vitamin D deficiency or any other metabolic disorder should be ruled out. Sometimes they mimic the symptoms & create confusion in diagnosis. Associated disorders like these, most certainly affect recovery adversely.

It should be ascertained that the patient is not allergic to any of the medicines that he is going to take.

Rheumatoid arthritis is a chronic disorder that lasts over many years with acute exacerbation & remissions. The earning capacity of the family is adversely affected. The cost of medical treatment is high. If the patient needs surgery, it is further escalated. Most of the population in India is not covered by any medical insurance. All these factors put together create an atmosphere of depression in the family. Patient feels morally degraded & may even develop suicidal tendency.

In a situatation like this it becomes essential that a moral support is provided to the patient by his friends & relations. Treating doctor has a very definite role to play in keeping up the moral of patient.