Royal Orthopaedic Hospital!

! Ball and socket joint.!

! Stability vs Mobility.!

PASSIVE

!  GLENOID & LABRUM !  -VE INTRA-ARTICULAR

PRESSURE !  CAPSULE & GLENO

HUMERAL LIGAMENTS

ACTIVE

!  ROTATOR CUFF MUSCLES

!  Musculo-tendinous cuff.!

!  4 Muscles:-!–  Supraspinatus.!–  Infraspinatous.!–  Subscapularis.!–  Teres minor.!

!  Centres head in glenoid.!

!  Axillary nerve!–  shoulder dislocation!–  Regimental badge!–  Deltoid!

!  Radial Nerve!–  Humeral shaft fractures!–  Wrist drop!–  1st wed space sensory loss!

! Age!

! Occupation!

! Handedness!

! Pain or Stiffness!!  Instability!! Functional Problems!! Weakness!! History of trauma !! Sporting history / aspirations!

!  Site and precipitating features!

!  Night pain !

!  Radiation!

!  Localisation to ACJ!

! Direction of instability!

! Frequency!

! Precipitating factor!

! Lax joints anywhere else!

! Neck!

! Pancoast Tumour!

! Subdiaphragmatic!

! Cardiac!

!  Look !

!  Feel!

!  Move!

!  Special Tests!

!  Pain with overhead activities!

!  Painful arc!

!  Chronic pain and night pain!

!  May develop rotator cuff tear !

!  Haemorrhage and oedema around rotator cuff settles with injection and conservative treatment (young) !

!  Fibrosis and tendinitis (physio, injection and ? operative) !

!  In older persons 40+ cuff tear and AC spur progressive disability !

!  Requires operative decompression and repair of the cuff.!

!  Elderly!

!  Pain & Stiifness!

!  X rays!–  Reduced joint space!–  Osteophytes!–  Subchondral calcification!–  cysts!

TREATMENT!

!  Non Operative!–  Anti inflammatories!–  Activity modification!–  Physiotherapy!–  Steroid Injections !

!  Operative!–  Arthroplasty!

!  Insidious pain!!  Loss of ext rotation!!  Normal xray!

!  Associated with:!–  DM ! !!–  -MI!–  -Post trauma!

!  Natural history!–  Self limiting!

!  6 months worsens!!  6 months plateau!!  6 months improves!

!  Probably not true!

!  Treatment:!–  injection + physiotherapy + analgesia!–  MUA + injection!

!  Stability vs Mobility!

!  Sporting injury!–  Anterior 85%!

!  Electrocution / Epilepsy!–  Posterior 2%!

!  Sensory deficit 12.6%

!  Fracture 33% Perron 2003 j emerg med

!  Recurrence 60% < 20y 6% > 40y Te slaa 2004 jbjs

!  Rotator cuff tear 63% >50y

!  Torn Loose

!  Traumatic

!  Unilateral

!  Bankart

!  Surgery

!  Born Loose

!  Atraumatic

!  Multidirectional

!  Bilateral

!  Rehabilitatation

!  Inferior Capsular Shift

! Traumatic aetiology ! Unidirectional instability ! Bankart lesion is the pathology ! Surgery is required

–  Operative intervention is designed to address the Bankart lesion. !–  May tighten capsule by capsular shift.!

! Atraumatic: minor trauma ! Multidirectional instability may be present ! Bilateral: asymptomatic shoulder is also

loose ! Rehabilitation is the treatment of choice !  Inferior capsular shift: surgery required if

conservative measures fail

!  Bony anatomy leads to inherent stability!

!  Complex bony & liamentous anatomy!

!  Complex of 3 joints:-!

!  Humero-ulna!–  Complex hinge!

!  Radio capitella!–  pronation/supination!

!  Proximal radio ulna!–  pronation / supination!

!  Ulna nerve!

!  Radial nerve!

!  Median nerve!

! Pain & stiffness !

! Locking- loose bodies !

! Pins & needles , hand weakness!

!  Tennis Elbow: lateral epicondylitis (extensor) !!  Golfers Elbow: medial epicondylitis (flexor)!

!  Olecranon bursitis!!  Osteoarthritis!!  Cubital Tunnel Syndrome (ulnar nerve compression)!

!  Often middle aged (35 - 50)!

!  May be recent history of excessive activity involving that elbow (rarely tennis ! dusting sweeping etc)!

!  Golferʼs elbow similar history but medial pain less common than tennis!

!  Tennis elbow:!– Pain reproduction on resisted wrist extension

(Mills' Test)!

!  Golferʼs elbow:!– Pain reproduction on resisted wrist flexion.!

!  Non operative!

–  Activity modification!–  NSAIDS!–  Clasp!–  Physiotherapy!–  Ultrasound!–  Streroid injections!

!  Operative!

–  decompression!

!  = “Ulnar neuritis”!

!  Pain/paraesthesia in ulnar nerve distribution!

!  Forced elbow flexion!!  Hypothenar wasting!!  Guttering!!  Fromentʼs sign!

!  MANAGEMENT!–  Cubital tunnel

decompression!

–  Transposition!

!  Inflammation of bursa!

!  Often pain free!

!  May be infected by inoculation by foreign bodies!

!  Flexor and extensor retinaculum.!–  Median nerve passes deep

to FR with flexor tendons. Except for palmar cutaneous branch which is superficial!!

!  Sensory supply to hand from ulna,median and radial nerves.!

!  Nerve compression Syndromes!–  Carpal Tunnel Syndrome!–  Cubital Tunnel Syndrome!

!  Arthritis!–  rheumatoid!–  osteoarthritis!

!  Trauma!–  Tendon injuries!–  Chronic injuries!

!  Swellings!

!  Dupuytrens!

! Wrist pain !– specific wrist pathology or generalised

condition!– onset!

!  rapid: trauma or infection!! slow: degenerative!

– association with other joint problems!– other obvious conditions e.g. RA!

! hand dominance!! history of previous injury!

– e.g. Collesʼ fracture, scaphoid fracture!!  job / occupation!

– ability to continue with this!– what does job involve?!

! hobbies!– musical instruments!

! night pain !! pattern of symptoms!

– aggravating and relieving factors!– worse after activity / use!

! swelling of the wrist/surrounding tissues!

! Hand pain!– Many similar features to wrist pain!– Specific location e.g. base of thumb!– Neurological origins!

! pain distribution!–  carpal tunnel syndrome!–  ulnar neuritis!

! precipitating events!– holding paper up!– night time symptoms !– other medical conditions Thyroid, RA, DM!

! Functional problems:!–  lack of grip strength!– dropping items and “clumsiness”!–  triggering of fingers!

!  lack of ability to straighten fingers!

! swellings!–  rapidity of onset!– soft or hard discrete!– diffuse single or multiple!

! other swellings on bony areas in the body!

Look !

Feel!

Move !

Special tests!

! very common!!  females often!! may not be

symptomatic!! symptoms donʼt

correlate with x-rays!

Treatment:!!  !splint + analgesia!!  ! injection!!  !excision!!  !arthrodesis!!  ! replacement!

! Other changes DIP joint arthritis (Heberdenʼs nodes)!

! mucous cysts.!! Treat hand therapy!

– Hot wax and NSAIDs!! Arthroplasty (MCP and PIP) !! Fuse DIP!!  Interposition arthroplasty!

! Systemic autoimmume disorder !

! Predominantly synovial invovement!! Goals of treatment!

–  !1) pain relief !!–  !2) improved function !–  !3) prevent further damage !–  !4) cosmesis!

!  Synovitis can lead to: !

Cartilage destruction by pannus!–  pannus is granulation tissue!

Tendon compression and rupture!

Nerve compression!

Erosion and dislocation of joints!

!  MCP ulnar drift !–  cause soft tissue stretch

and ulnar subluxation of the extensors !

!  Therapy and medical treatment !

!  Surgical rebalance of muscles and realignment of the extensor tendons !

!  New MCP joints!

!  Hyperextended PIPJ!!  Flexion deformity DIPJ!

!  Treatment:!–  early - splinting!–  late – soft tissue correction or fusion!–  sometimes treating more proximal problems may

resolve the deformity!

!  Dorsal capsular attrition and central slip rupture!

!  Lateral bands migrate in a palmar direction and act as flexors of the PIPJ!

!  Therapy and splintage!!  Soft tissue procedures!!  Fusion!

! Synovitis!– synovectomy!

! Subluxation and collapse!! Wrist fusion provides a stable base for

hand function!

!  Early synovitis ! !-medical management!

!  Persistent synovitis !-synovectomy!

!  Specific deformity !-corrective reconstruction!

!  Severe crippling ! !-salvage.!

!  Flexion of DIPJ which corrects passively.!

!  Rupture/avulsion of ectensor tendon from distal phalanx.!

!  Usually treated with mallet splint.!

!  Fibrosis of longitudinal structures in palmer fascia !

!  Contractures of MCPJ & PIPJ!

!  Also associated with!–  penile fibrosis (Peyronieʼs)!–  sole of feet (Ledderhosenʼs)!

!  Thick knuckle pads (Garrodʼs)!

Risk factors!!  Northern European Races!!  Chronic alcoholism!!  Liver disease!!  Smoking!!  Diabetes!!  Epilepsy / Antiepileptics !!  Family history

(Dupuytrenʼs diathesis)!

!  Consider surgery if effecting function!–  Washing face - poking eye!–  Hand shake!–  Canʼt put hand in pocket!–  Work place risks!

!  Complications!–  nerve and vessel damage!–  Joint stiffness !–  Haematoma !

!  Congenital or acquired !

!  Thickening of the flexor tendon such that it does not pass through the sheath.!

!  Local injection or release!

!  Congenital or acquired !

!  Thickening of the flexor tendon such that it does not pass through the sheath.!

!  Local injection or release!

!  Thick fluid surrounded by synovium.!

!  Develop around joints or tendon sheaths, but rarely communicate with the joint.!

!  Most common around the wrist.!

!  Treatment, beware of recurrence!!

!  Inflammation affecting EPB and APL.!

!  Women. !!  30-50yrs.!!  Finkelsteinsʼs test.!!  Treatment!

–  Rest and NSAIDʼs.!–  Corticosteroid injection

(beware of rupture).!–  Decompression.!

! Causes (ICRAMPS)!•  Idiopathic !•  Colles, Cushings !•  Rheumatoid !•  Acromegaly, amyloid !•  Myxoedeoma, mass, (diabetes) mellitus !•  Pregnancy !•  Sarcoidosis, SLE !

!  Signs:!–  Tinelʼs sign!–  Phalenʼs sign!–  Direct compression sign!–  APB weakness!–  sensory disturbance!

!  Consider nerve conduction tests!

!  Non-surgical treatment:!–  splint/analgesia/injection!

!  Decompression!

!  Paronychia infection of nailfold!

!  Fight bite!–  MCPJ inoculation with oral

organisms!–  Human bites complicated

group of organisms treat with considerable seriousness!

!  Web space and palmar space infections!

!  signs:!–  pain (passive extension)!–  flexed position !–  local tenderness along

tendon sheath!–  swelling!

!  Elevation, antibiotics, drainage and irrigation!

!  Untreated tendon liquefies!