Royal Orthopaedic Hospital! ! Ball and socket joint.! ! Stability PASSIVE ACTIVE GLENOID & LABRUM ! -VE INTRA-ARTICULAR PRESSURE ! CAPSULE & GLENO HUMERAL LIGAMENTS ! ! ROTATOR CUFF MUSCLES vs Mobility.! 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! ! Pain ! Age! ! Occupation! ! Handedness! or Stiffness! ! Instability! ! Functional Site and precipitating features! ! Night pain ! ! Radiation! ! Localisation to ACJ! Problems! ! Weakness! ! History ! of trauma ! history / aspirations! ! Sporting ! Direction of instability! ! Frequency! ! Precipitating ! Lax ! Neck! ! Pancoast factor! joints anywhere else! Tumour! ! Subdiaphragmatic! ! Cardiac! ! 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! TREATMENT! ! ! Look ! ! Feel! ! Move! ! Special Tests! ! ! Non Operative! – – – – Anti inflammatories! Activity modification! Physiotherapy! Steroid Injections ! – – – – Insidious pain! Loss of ext rotation! ! Normal xray! ! ! ! Operative! – Arthroplasty! Reduced joint space! Osteophytes! Subchondral calcification! cysts! Associated with:! – DM ! – -MI! – -Post trauma ! !! ! Natural history! ! Stability vs Mobility! ! Sporting injury! – Anterior 85%! ! Electrocution / Epilepsy! – Posterior 2%! – Self limiting! 6 months worsens! 6 months plateau! ! 6 months improves! ! ! ! ! Probably not true! Treatment:! – injection + physiotherapy + analgesia! – MUA + injection! ! Sensory deficit 12.6% ! Torn Loose ! Born Loose ! Fracture 33% ! Traumatic ! Atraumatic ! Unilateral ! Multidirectional ! Bankart ! Bilateral ! Surgery ! Rehabilitatation ! Inferior Capsular Shift Perron 2003 j emerg med ! Recurrence 60% < 20y 6% > 40y Te slaa 2004 jbjs ! Rotator cuff tear 63% >50y ! Atraumatic: ! 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.! minor trauma ! Multidirectional ! Bilateral: instability may be present asymptomatic shoulder is also loose ! Rehabilitation ! Inferior is the treatment of choice capsular shift: surgery required if conservative measures fail ! Complex of 3 joints:-! ! Humero-ulna! – Complex hinge! ! Radio capitella! ! Bony anatomy leads to inherent stability! ! Complex bony & liamentous anatomy! ! Ulna nerve! ! Radial nerve! ! Median nerve! – pronation/supination! ! Proximal radio ulna! – pronation / supination! ! Pain & stiffness ! ! ! Locking- loose bodies ! ! Olecranon bursitis! Osteoarthritis! ! Cubital Tunnel Syndrome (ulnar nerve compression)! ! ! Pins & needles , hand weakness! Tennis Elbow: lateral epicondylitis (extensor) ! Golfers Elbow: medial epicondylitis (flexor)! ! ! 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! ! Non operative! – – – – – – Activity modification! NSAIDS! Clasp! Physiotherapy! Ultrasound! Streroid injections! ! Inflammation of bursa! ! Often pain free! ! May be infected by inoculation by foreign bodies! ! Operative! – decompression! ! Tennis elbow:! – Pain reproduction on resisted wrist extension (Mills' Test)! ! Golferʼs elbow:! – Pain reproduction on resisted wrist flexion.! ! = “Ulnar neuritis”! Pain/paraesthesia in ulnar nerve distribution! ! Forced elbow flexion! ! Hypothenar wasting! ! Guttering! ! Fromentʼs sign! ! ! MANAGEMENT! – Cubital tunnel decompression! – Transposition! ! 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.! ! 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! ! night pain ! ! pattern of symptoms! – aggravating and relieving factors! – worse after activity / use! ! swelling of the wrist/surrounding tissues! ! Nerve compression Syndromes! – Carpal Tunnel Syndrome! – Cubital Tunnel Syndrome! ! Arthritis! – rheumatoid! – osteoarthritis! ! Trauma! – Tendon injuries! – Chronic injuries! ! Swellings! ! Dupuytrens! ! hand dominance! of previous injury! ! history – e.g. Collesʼ fracture, scaphoid fracture! ! job / occupation! – ability to continue with this! – what does job involve?! ! hobbies! – musical instruments! ! 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 ! lack ! swellings! – rapidity of onset! – soft or hard discrete! – diffuse single or multiple! ! other swellings on bony areas in the body! problems:! – lack of grip strength! – dropping items and “clumsiness”! – triggering of fingers! of ability to straighten fingers! 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! ! Systemic ! Predominantly ! Goals – Hot wax and NSAIDs! ! Arthroplasty ! Fuse ! arthroplasty! Synovitis can lead to: ! Cartilage destruction by pannus! – pannus is granulation tissue! Tendon compression and rupture! ! ! Hyperextended PIPJ! Flexion deformity DIPJ! ! Treatment:! ! – early - splinting! – late – soft tissue correction or fusion! – sometimes treating more proximal problems may resolve the deformity! MCP ulnar drift ! – cause soft tissue stretch and ulnar subluxation of the extensors ! ! ! Nerve compression! Erosion and dislocation of joints! synovial invovement! of treatment! – !1) pain relief !! – ! 2) improved function ! – ! 3) prevent further damage ! – ! 4) cosmesis! (MCP and PIP) ! DIP! ! Interposition autoimmume disorder ! ! Therapy and medical treatment ! Surgical rebalance of muscles and realignment of the extensor tendons ! New MCP joints! ! 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! fusion provides a stable base for hand function! ! Wrist ! ! Early synovitis ! !-medical management! ! Persistent synovitis !-synovectomy! ! Specific deformity !-corrective reconstruction! ! 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)! ! Flexion of DIPJ which corrects passively.! Rupture/avulsion of ectensor tendon from distal phalanx.! Usually treated with mallet splint.! 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! ! Congenital or acquired ! ! Thickening of the flexor tendon such that it does not pass through the sheath.! ! Local injection or release! 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! ! ! ! ! ! ! ! Inflammation affecting EPB and APL.! Women. ! 30-50yrs.! Finkelsteinsʼs test.! Treatment! – Rest and NSAIDʼs.! – Corticosteroid injection (beware of rupture).! – Decompression.! 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!! ! 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! ! signs:! – pain (passive extension)! – flexed position ! – local tenderness along tendon sheath! – swelling! ! ! Elevation, antibiotics, drainage and irrigation! Untreated tendon liquefies! ! ! 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!
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