Royal Orthopaedic Hospital! Ball and socket joint.! Stability vs Mobility.!

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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