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!! Age!! Radial Nerve! Humeral shaft fractures! Wrist drop! 1st wed space sensory loss!! 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!! Neck!! Frequency!! Pancoast Tumour!! Precipitating factor!! Subdiaphragmatic!! Lax joints anywhere else!! 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!! Stability vs Mobility!! Sporting injury! Anterior 85%!! Electrocution / Epilepsy! Posterior 2%!! Treatment:! injection + physiotherapy + analgesia! MUA + injection!! Sensory deficit 12.6%! Torn Loose! Born Loose! Fracture 33% Perron 2003 j emerg med! Traumatic! Atraumatic! Recurrence 60% < 20y 6% > 40y! Unilateral! Bankart! Multidirectional! Bilateral Te slaa 2004 jbjs! Rotator cuff tear 63% >50y! Surgery! 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!! Ulna nerve!! Radial nerve!! Median nerve!! Proximal radio ulna! pronation / supination!! 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!! Flexion of DIPJ which corrects passively.!! Rupture/avulsion of ectensor tendon from distal phalanx.!! Usually treated with mallet splint.!! Severe crippling!!-salvage.!! 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!