REMEMBERING PROF. J.N. KAKKER BY HIS O.P.D TEACHING - WRIST PAIN

 

Prof. J. N. Kakker was our teacher in Orthopedic Surgery in King George’s Medical College, Lucknow. He was always meticulously dressed in a suit and everything about him reflected grandeur and opulence. He was trained in the U.K and he spoke English with a British accent. With patients however, he suddenly metamorphosed into a desi Dacsaab! He was a wonderful teacher and a very sought after thesis guide among post graduates. His lectures were well planned, just enough for M.B.B.S students, and always laced with anecdotes and jokes.

 

However, it was during our posting as undergraduate students in Orthopedics wards that we came to know him better. He would leave his coat in his room, wear a new starched white apron every morning, and come out for rounds. His team of residents, Dr. Shishir Rastogi, Dr. Sanjay Rastogi, Dr. P.K. Jain, to name a few, would accompany him from his room to first the Orthopedics ward, where our ward teaching by one of his residents would be in progress. “Which Batch?” he will enquire. “F Batch, Sir” we will reply in chorus. He would then briefly enquire what was being taught and which patient was being discussed. Then go with his resident team towards his beds to continue with his rounds. Once the round of this ward was complete he would come back to our Batch and start his teaching. We were expected to write the patient history and examination in a case sheet and one of us would present the case. He would then quiz every person in the batch about the case. Looking back today, I don’t think he was testing our knowledge; he was actually interested in knowing whether his resident team was doing a good job with our ward teaching. Physical signs would be meticulously elicited and discussion would be threadbare.

 

Once the ward teaching was over, he would ask us to accompany his team for the rest of his round – to private rooms, and traumatic paraplegia unit. Then our white apron procession will march towards the Administrative Block, turn right and walk towards Sardar Patel Hostel, walk down the slope, cross the gate, turn right and walk towards the Rehabilitation & Artificial Limb Centre (RALC). Invariably a meter gauge train would be crossing the railway over-bridge and our entire white apron procession will wait for it to cross, lest some unthinkable stuff dropped from the train on us! I wonder what would be the spectacle for the onlookers in the Shahmina Road crossing, a bunch of white apron wearing adults, with their hands protecting their eyes from the sun, looking up at a passing train!

 

RALC was the crown jewel of our Orthopedics department. It was way ahead of time, with state of the art rehabilitation facilities. Even in 1978-79 they were providing highest quality Prosthetics and Orthotics and Rehabilitation Care to the physically challenged persons, and it was a pioneer institution of that era. The services offered by RALC were related to musculoskeletal problems, brain injury stroke, spinal cord injury, acute and chronic pain management, amputee, work injuries, orthopedic injuries, sports medicine, pediatric neuromuscular-skeletal problems and the developmental delays, osteoarthritis, metabolic bone diseases, osteoporosis etc. Prof. Kakker had patients in RALC and his round would complete only after greeting these patients and reviewing their progress. Every visit to this place was an eye opener for us and the so called disabled routinely mesmerized us by their ability to do exercises in a swimming pool, practice walking on artificial limbs, and getting wax bath, infra-red heat treatment and electrical stimulations.

 

Prof. J.N. Kakker stayed in River Bank Colony, very near the RALC, but he had place in Aliganj, which he had converted into a nursing home, usually managed by his son, who was not a doctor. I remember having assisted Prof. A.K. Wakhlu and Prof. Sandeep Kumar in that hospital. It was small but nice and cozy and the room which was converted into an operating theatre was big, air conditioned and well illuminated. Prof. Kakker's illustrious teaching career in KGMC, which started way back in 1965, came to an end in 1986.

 

Today I recall a case discussion in Prof. J.N. Kakker’s outpatient. The middle aged lady, who was overweight, presented with pain in her wrist. By then we had been shown a case of Carpal Tunnel Syndrome by Dr. G. Ramakrishna, a Senior Resident in Surgery and so we made the diagnosis. The patient had

• Burning, tingling or numbness, especially between the thumb and ring finger. 
• Needing to take breaks to rest during daily activities like kneeding dough or typing. 
• Sensation in the fingertips when flexing or extending the wrist. 
• Perceptions of swelling or stiffness in the wrist, hands or fingers. 

And she would wake up at night with wrist pain.

We showed him that only the sensory part of Median nerve was involved and there were no motor sighs. We planned a Nerve Conduction Velocity test to prove the diagnosis and then release the transverse carpel ligament to treat it.

 

Prof. Kakker was very impressed with our F Batch and then he started his teaching. The wrist may be only a small part of your musculoskeletal system, he said, but it’s one of the most complex and delicate structures in the human body. The wrist anatomy consists of several joints, eight bones, tendons, ligaments, nerves, and blood vessels all crammed in a very narrow area.  That’s why diagnosing wrist pain can be quite tricky. And, we use our wrists a lot - from grabbing and holding onto objects to complex movements like writing and typing. Therefore, wrist pain can be quite debilitating and certainly interferes with one’s daily life. 

 

Depending on the underlying cause, the type of wrist pain one can experience varies from tightness and lack of mobility to sharp pain. So we can expect

     ·        Sharp and sudden pain in the hand
·        Difficulty moving the wrist or gripping objects
·        Swollen wrist or fingers
·        Redness or warmth around the wrist
·        Numbness or a pins and needles sensation in the hand

These symptoms often get worse at night. But, we should not go away with the impression that all pains around the wrist are because of Carpel tunnel Syndrome, he cautioned. So let us understand the differential diagnosis of wrist pain:

1. Arthritis

Arthritis refers to joint inflammation that leads to swelling, stiffness, and pain. It's a very widespread issue, and contrary to popular belief, arthritis can affect adults of any age. There are many types of arthritis, but three particular forms known to affect the wrists are:

Rheumatoid arthritis – This is an autoimmune disease that damages and wears down the joints, typically in both wrists. Painful swelling and reduced mobility are common symptoms.

Gout - a form of arthritis where sharp uric acid crystals build up in joints and cause pain and swelling.

Osteoarthritis - the degenerative type of arthritis associated with wear and tear and advanced age. When the cartilage that surrounds the joints degrades, bones rub against each other, leading to pain and swelling.

Depending on the form of arthritis, causes and treatments vary tremendously. 

 

2. Carpal tunnel syndrome

Carpal tunnel syndrome is an extremely painful disease that affects 5% of the population. Anyone, particularly office workers, artists, and manual laborers can be affected by the condition. Carpal tunnel syndrome occurs when the median is compressed as a result of friction or inflammation. Symptoms can develop in one or both wrists and tend to get worse at night. One can experience pain, weakness, numbness, or a pins and needles sensation in the palms and fingers (except for the little finger).

Mild cases of carpal tunnel syndrome are treated by wearing a wrist brace, applying hot or cold compresses, and taking over-the-counter anti-inflammatory (NSAID) medications (e.g. ibuprofen, asperin) to reduce the pain.

More serious cases may require surgical release of the transverse carpel ligament and neurolysis of Median nerve.

Some people advocate steroid injections, but we don’t think it helps.

I have written a blog on Carpal Tunnel Syndrome in the past and if you wish to read it, please click: https://surajitbrainwaves.blogspot.com/2022/04/carpel-tunnel-syndrome.html

 

3. Ganglion

Ganglion cysts are benign lumps filled with fluid. These cysts typically appear on the back of the wrist or hand, and they can either be painless or quite bothersome. The cause of these cysts is unknown, but the American Academy of Orthopedic Surgeons points out that they appear more often in individuals aged 15-40, women, and gymnasts. Ganglion cysts can sometimes go away on their own. The most constant book in an English household is the Bible. The English try to squish their ganglion by repeatedly striking it with the Bible – the Bible treatment.. Wearing a splint, draining the ganglion cyst, or surgically excising it are other options.

 

4. Carpal boss

A bump on the dorsum of wrist that’s accompanied by wrist pain may also be a sign of a carpal boss. Also known as a carpometacarpal boss, this is a bony lump that forms where the carpal bones meet the radius. Unlike a ganglion cyst that’s mobile and somewhat squishy, carpal bosses are firm and immobile bumps. The exact cause is unknown, but they are believed to be caused by degenerative changes, repetitive stress, prior injury, or localized joint instability that leads to bone spur formation in this area. It usually occurs in younger adults - between 20 and 40 years of age. It tends to appear near the base of the index or middle finger. A carpal boss doesn’t need treatment unless it causes symptoms. Conservative treatment like splints, and analgesics are tried initially. Surgically it can be burred down to shape.

 

5. Wrist injuries

A wrist injury is one of the most widespread causes of wrist pain. We often fall on outstretched hand and use the hand and wrist to protect our body from the fall. Swelling, bruises, or disfigured joints can result from injury. But remember that an injury can occur even if pain following the fall is the only symptom; this is because nerves and other soft tissues can become injured too.  Sprains are a common ligament injury of the wrist. When a ligament is overly stretched or partially torn, your patient will experience pain while moving the wrist, and may also have swelling, bruising, or tingling.

Wearing a splint, keeping ther wrist elevated, resting, cold compresses, and taking NSAIDs to relieve pain can all help heal the sprain faster. That being said, we highly recommend an X-ray of the wrist so that we do not miss fractures around the wrist. Missing a wrist injury – bony or soft tissue, can be fatal because if the bones or ligaments don’t heal well, we may be left with chronic wrist pain.

 

6. Wrist tendonitis

Inflammation of the tendons, also known as tendonitis, is another extremely common cause of wrist pain. In the wrist area, tendons connect the muscles of the forearms with the hand and finger bones. It is these tendons that allow the hands to open and close a fist. When any of these tendons become inflamed, the result is tendonitis. The symptoms of tendonitis are:

     ·        Morning stiffness
·        Dull pain
·        Grinding sensation when moving the wrist
·        Warmth or swelling in some cases.

Tendonitis usually occurs with overuse of the wrists. This can happen with repetitive wrist movements (like typing, writing, playing golf, or tennis) or as a result of injury.

The domiciliary care of tendonitis is similar to other conditions that cause wrist pain: rest, immobilization with a splint, icing, hand exercises, and taking NSAIDs. When these home treatments are not effective, a professional may advise you to get steroid injections directly into the wrist or, in rare cases, surgery.

 

7. Cubital tunnel syndrome

Just like carpal tunnel syndrome we ca have cubital tunnel syndrome or ulnar neuropathy. This condition occurs when the ulnar nerve, while passing from upper arm to forearm gets pinched at the bend right behind the elbow, behind the medial condyle of humerus. Sufferers describe the pain they experience when the ulnar nerve is compressed as “being hit in the funny bone,” but the pain may also extend downward and cause pain, numbness, and tingling in the wrist or even the ring and little fingers.

There are many causes of cubital tunnel syndrome. These include:

     ·        Arthritis of your elbow.
·        Bending elbow for a long time.
·        Bone spurs.
·        Cysts near elbow joint.
·        Past elbow dislocation.
·        Past elbow fracture

The treatment is mainly symptomatic: rest, immobilization with a splint, icing, hand exercises, and NSAIDs. Those suffering from cubital tunnel syndrome are advised against leaning on the affected elbow, as this may increase the pain. Padding the elbow with a soft cushion may also be helpful. Depending on the severity of the condition, symptoms may go away quickly. But in some cases, they never fully resolve on their own, and surgery is required.  

 

Then Prof. Kakkar added that there are several less common causes of wrist pain too. Here are just a few: 

1.      De Quervain’s tenosynovitis - a painful condition caused by inflammation in the tendons surrounding the thumb.

2.      Kienbock's disease - an illness that affects young adults and triggers the destruction of Lunate, a carpal bone. It loses its blood supply, leading to bone  death, pain, stiffness, and potential arthritis.

3.      Benign or cancerous tumors in the wrist. - Most tumors are benign. The most common tumor types are osteoid osteoma, osteoblastoma, and giant cell tumor. Metastatic carpal tumors are most commonly from lung carcinoma. Chondrosarcoma and hemangioendothelial sarcoma are the most common primary malignancies.

4.      Wrist bursitis - the inflammation of the liquid-filled sacs that protect the joints.

5.      Systemic lupus erythematosus - a systemic autoimmune disease that can affect the joints.

 

Such case discussions and bed-side and OPD teachings were hallmark of our Orthopaedic posting. Orthopaedics always attracted graduates very high merit for post-graduation and was essentially a male domain with only one female resident.