232 ‒ Shoulder, elbow, wrist, and hand: diagnosis, treatment, and surgery of the upper extremities

KEYPOINTS

• 01

  The shoulder trades stability for mobility.

  Alton Barron, an orthopedic surgeon specializing in the shoulder, elbow and hand (and the surgeon who operated on Attia), explains that the shoulder is a shallow ball-and-socket that relies on the labrum, capsule and rotator cuff for stability. That makes it the most mobile and among the least stable joints, which is why rotator cuff, labral and dislocation injuries are so common.

• 02

  History, mechanism and exam beat imaging alone.

  Barron says if you compulsively take the history, mechanism of injury and symptoms and do a careful physical exam, you'll be about 95% accurate before the MRI. MRIs of people over 50 often show degenerative labral tearing that isn't the pain generator; he describes a woman in her early 60s told she needed surgery for such a tear, which is often the wrong call.

• 03

  Anatomy predisposes some people to injury.

  The acromion comes in types: type 1 is flat (most people), while the hooked type 3 is far from rare (Barron estimated perhaps 30% for types 2–3) and predisposes to impingement mainly in overhead athletes and lifters. Spinal stenosis and other variants also change risk, so screening can be useful in contact sports.

• 04

  Frozen shoulder is common and often misread.

  Adhesive capsulitis, which Barron sees two or three new cases of weekly in one office, shows as a stiff, tight capsule that blocks motion (for example external rotation stopping at about 30 degrees with pain). Its cause is unknown and multifactorial, worse with diabetes, and it can mimic or conflate other diagnoses. Neck problems can also refer pain to the shoulder, so the exam includes the cervical spine.

• 05

  Arthroscopy and better anchors transformed repair.

  Barron started practicing in 1996, when most work was open surgery and early arthroscopic techniques were judged retrospectively, with high failure rates in some series. Modern repairs use heavy sutures and anchors into bone to reinforce healing, and age alone is not a barrier: he has repaired rotator cuffs in people in their 90s who healed fully.

• 06

  PRP and stem cells: plausible in places, oversold overall.

  Barron uses PRP selectively in his Manhattan office for things like lateral epicondylitis and some tendon injuries, and thinks cells may help muscle tears, but says stem cells won't regrow a labrum. Many studies justifying these treatments are poorly designed, a lot of money is involved, and patients fly abroad (including Germany) for unproven injections.

• 07

  AC joint separations are graded by displacement.

  Up to about 30% widening is grade 2; 100% or more is grade 3, with higher grades beyond. Many grade 3 injuries can be managed without surgery; a study of NFL athletes about 20 years ago supported this. Hockey players and quarterbacks hit by '300-pounders' are classic cases.

• 08

  Throwers' elbows depend on their shoulders.

  Pitchers develop asymmetric shoulders, gaining roughly 45 degrees more external rotation on the throwing side; losing 10–15 degrees can add torque on the elbow. Tommy John (UCL) reconstruction revolutionized baseball, and throwers live with 15–20-degree elbow contractures and stay functional, since a 100-degree arc covers most daily needs.

• 09

  The hand is neurologically enormous.

  More than half of higher cortical neurons (Barron says over 60%) map to the hand in the homunculus. Splinting a wrist in too much flexion or extension raises pressure on the median nerve and can cause acute carpal tunnel syndrome, so neutral positioning is safest. Hand fractures are finicky too: the average adult bone heals in about six weeks, but some wrist bones take 10–12 weeks.

• 10

  Thumb-base arthritis is extremely common.

  Barron says about half of people will experience osteoarthritis of the thumb's basal joint in their lifetime, and perhaps a quarter of those (around 12.5% overall) may need surgery. Tennis elbow's sweet spot is ages 40–60, increasingly into the 70s as people stay active.