Managing upper limb presentations – A microcosm of healthcare
Strength to your arm, then.1
This month’s issue of Australian Journal of General Practice explores a region of great functional importance, characterised by complex anatomy and physiology. Consequently, the history, examination and management are also complex and highly varied. Although managing patients with presentations focused on the upper limb can be time consuming, these presentations are also satisfying opportunities for the general practitioner (GP) as diagnostician, proceduralist, advocate and therapeutic touchstone.
Injuries often provide an immediate insight into the patient’s lived experience. Take, for instance, the relatively simple presentation of a pulled elbow in a toddler. By the end of the consultation, one is likely to have reduced the elbow while unintentionally acquiring information on childcare arrangements, recent illnesses and favourite songs. It is common to consult with another family member in the weeks ahead. Sporting injuries, such as the acute tear to the ulnar collateral ligament of a skier’s thumb, are predicated on having access and capacity to participate. Consider another seemingly similar injury to the ulnar collateral ligament: gamekeeper’s thumb, a chronic work-related injury caused by repetitive use in an occupation that has long disappeared.
The forearm, elbow, wrist and hand appear to be common sites of lacerations, fractures, sprains and tears. These require excellent examination, interpretive and diagnostic skills to ensure appropriate management with multidisciplinary input and avoid long-term dysfunction. Curiosity about the exact mechanism of an injury can uncover drug and alcohol use, sensory defects, metabolic bone disease and more.
Availability and accessibility of appropriate imaging services can be a barrier to management in primary care, as can accommodating the ‘walk-in’ need for suturing or application of plaster cast. There is also the question of keeping up a sufficient skill base:2 given the tremendous variety in any given clinic session and the varying scopes of practice, how do interested GPs ensure they are confidently maintaining their techniques?
A significant proportion of upper limb injuries are work related, with common sites among Australian patients being the shoulder and wrist.3 The rise of sedentary jobs has posed its own challenges. Mouatt and Kamper discuss conservative management of shoulder girdle and neck pain that may result as a worker accommodates to longer hours of screen time and sitting down.4 Various protections given to today’s employees stand in contrast to the sporadic social safety nets available to yesterday’s gamekeeper or housemaid. GPs, who play a pivotal part in assessing and rehabilitating workers via various compensation schemes, will readily recognise that the diagnosis of a workplace-related injury does not always encapsulate other impairments and consequences the patient sustains to their self-image and relationships.
De Quervain’s tenosynovitis5 and frozen shoulder6 are addressed in this issue as examples of two conditions for which the diagnosis remains clinical as they are largely treatable in primary and community care.
Other upper limb presentations reflect the body as an irreducible whole. A myocardial infarct, or ischaemic or haemorrhagic stroke are common examples of this. Signs in the hands and arms may have global significance, such as swollen metacarpophalangeal joints indicating an autoimmune disorder, or the pallor of anaemia.
One of the discussions in medicine is the pressure towards specialism and the associated increased fragmentation of patient care.2,7 The rewards, frustrations and challenges of presentations of the upper limb are a microcosm of broader tensions in the healthcare system. But if a passionate, patient-centred application of our clinical competencies is to remain at the heart of generalism, GPs can thoughtfully resist erosions to our collective scope of practice. We can remain careful to value the comprehensive, accessible and appropriate care that general practice offers.