arthritis and shoulder injuries Flashcards
hypertrophic arthritis
- bone formation at site of involved joint
- within confines of bone
- protrusion of parent bone
- commonly OA
erosive arthritis
- indicates inflammation
- tiny, irregularly shaped lytic lesions in or around joint surface
- usually RA, gout, psoriasis
infectious arthritis
- joint swelling, osteopenia, destruction of long contiguous segments of articular cartilage
psoriatic arthritis
- 30% of pts with psoriasis
- RF seronegative
- enthesis and marginal bone erosions
- “pencil in cup” deformity
- joint subluxation and interphalangeal ankylosis
ankylosing spondylitis
- chronic and progressive
- RF seronegative
- young males
- symmetric fusion of SI joint and ascending involvement of spine -> decreased ROM and kyphosis
- “bamboo sign” on x-ray
infectious arthritis
- destructive
- d/t seeding of synovial membrane from infectious source
- prompt treatment required
- either septic or nonpyogenic
common causes of septic infectious arthritis
- staph
- gonococcal
common causes of nonpyogenic infectious arthritis
- mycobacterium
risk factors for infectious arthritis
- IV drug use
- chronic steroids
- joint replacement
- recent joint trauma
- DM
symptoms of infectious arthritis
- monoarticular pain and swelling
- decreased PROM and AROM
- fever
- will look VERY ill
- purulent synovial fluid
diagnostic studies for infectious arthritis
- CBC with diff
- ESR, CRP
- cultures
- x-ray
- MRI
treatment of infectious arthritis
- I&D
- abx
- remove infecting source i.e. prosthesis
osteoarthritis
- aka DJD
- most common form of hypertrophic arthritis
- primary, secondary, or erosive
modifiable risk factors for OA
- muscle strength
- physical activity/ occupation
- joint injury
- joint alignment
- leg length inequality
- obesity
- diet
- bone metabolism
non-modifiable risk factors for OA
- age
- sex
- genetics
- ethnicity
treatment for OA
- pain control
- PT
- bracing
- assistive device
- viscosupplemetation
- risk factor modification i.e. weight loss
- surgery- arthroplasty or osteotomy
pain control options for OA
- NSAIDs
- APAP
- steroids
- bracing
- topical options i.e. diclofenac
- narcotics don’t have much of a role- short term use only
why does bracing help with pain in OA?
- reduces muscle co-contractions and joint compression
- improves stability and function
when would you get an MRI for hip arthritis
- if avascular necrosis is suspected d/t pain out of proportion to arthritic changes
viscosupplementation
- hyaluronic acid found normally in synovial fluid and cartilage to act as lubricant and shock absorber
- only FDA approved for knee “lubrication”
- only give to physiologically young pts with less disease
- synvisc or euflexxa
where do most clavicle fx occur?
- middle third of clavicle
- rarely results in NV injury
clinical manifestation of clavicle fx
- +/- deformity
- TTP over fx site
- pain with AROM and PROM especially in abduction and flexion
- doesnt impact flex/ext of wrist
treatment of clavicle fx
- sling
- ice and NSAIDs
- passive ROM at day 3
- PT once fx healed
- if displaced fx need ORIF
AC joint injury
- usually d/t lateral force to lateral aspect of shoulder with arm adducted
- acromion driven inferiorly and medially
- high occurance in hockey
clinical manifestations of AC joint injury
- pain and decreased ROM
- TTP over AC joint
- deformity depends on grade
- cross arm test- elevate affected arm to 90 degrees then adduct; pain is pos
treatment of AC joint injury
- depends on age/life style and grade of injury
- grade I and II conservative tx
- grade III +/- surgery
grade IV-VI - surgery - joint stabilization with fixation at origin/insertion of ligament
grade I AC joint injury
- sprain of AC ligament
grade II AC joint injury
- tear of AC ligament
grade III AC joint injury
- tear of AC and coracoclavicular ligament
sternoclavicular joint dislocation
- uncommon
- usually fall on abducted and extended arm
- SCM pain/spasm
- may not dislocate until days later
- anterior more common than posterior
- posterior requires surgery
proximal humerus fx
- mainly in elderly
- mostly impacted or nondisplaced d/t fall from standing
- anterior or posterior dislocation of humeral head can occur (less common)
clinical presentation of proximal humeral fx
- mod/ severe shoulder pain exacerbated by movement
- swelling and ecchymosis
- hold affected arm adducted
- NV injury can occur if displacement occurs
treatment of proximal humeral fx
- mainly conservative
- sling
- ice, analgesics
- sleep in semi-recumbent chair
- gentle ROM after 2 weeks
- ROM of wrist/ elbow asap
- if unstable ORIF or reverse TSR
what is the most common type of shoulder joint dislocation?
- anterior (95% of the time)
shoulder joint dislocations
- can lead to chronic instability (usually in younger pts)
- atraumatic dislocations usually d/t laxity and repetitive
- if it is posterior dislocation d/t fall from height, epileptic seizures, electric shock
imaging for shoulder dislocations
- AP
- Axillary
- Scapular Y
clinical presentation of shoulder dislocations
- deformity with humeral head dislocated anteriorly
- shoulder adducted and IR
- shoulder loses roundness
- axillary nerve assessment
treatment for shoulder dislocation
- reduce ASAP
- sling immobilization X 2 weeks with gentle ROM
early PT to maintain ROM and strengthen RTC
impingement syndrome
- RTC tendonitis
- pain d/t compression of tissues btwn humeral head and coracoacromial arch
- usually recent hx of over activity
- onset of pain with AROM, overhead movement
- partial RTC tear is one of the most common reasons
clinical presentation of impingement syndrome
- pain sleeping on shoulder
- pain with IR
- TTP over greater tuberosity
- +/- atrophy of supraspinatuous m
hawkins test
- tests for impingement syndrome
- have pt in 90/90 flexion
- stabilize top of shoulder while internally rotate shoulder
- positive= pain
imaging for impingement syndrome
- AP
- Lateral
- Grashey
- Scap Y
- usually appears normal
treatment for impingement syndrome
- activity modification and PT
- NSAIDs
- steroids
- surgery- arthroscopic acromioplasty with coracoacromial ligament release, bursectomy, debridement, RTC repair
partial RTC tear
- damaged RTC but not completely severed
- often heal by scarring
full thickness RTC tear
- separates all of tendon from bone
- dont heal well
- increase in size with time
- usually require sx
muscles of RTC and functions
- supraspinatous- abduction
- infraspinatous- ER
- teres minor- ER
- subscapularis- IR
etiology of RTC tears
- acute- FOOSH or pulling on shoulder
- chronic- repetitive over head movement or lifting
clinical presentation of RTC tear
- full thickness tear more symptomatic
- weakness** or pain with overhead mvmt
- pain at rest and night
- crepitus
- limited AROM
- acute tears cause intense pain
most commonly torn muscle of RTC
supraspinatous
imaging for RTC tears
- AP
- Lateral
- grashy
- Scap Y
- MRI
partial RTC tear tx
- 80% are nonsurgical
- PT
full thickness RTC tear tx
- usually sx
- PT for older sedentary pts
indications for RTC sx
- sx 6-12 mo
- pt does overhead work/sports
- large tear > 3 cm
- significant weakness and loss of fn
- tear d/t recent acute injury
rehab after RTC sx
- immobilization with no AROM 4-6 weeks
- PROM at PT with start of AROM
- strengthening 8-12 weeks
- functional ROM and adequate strength usually by 4-6 months
slap lesions
- injury of glenoid labrum at point of attachment of long head of biceps
- usually d/t FOOSH or throwing sports
- type I- usually asymptomatic
- type II and III- requires surgery
study of choice for slap lesions
- MRI
adhesive capsulitis
- minimal/ no trauma
- pain out of proportion to clinical findings during inflammatory phase
- stiffness during freezing phase
- usually perimenopausal women
- common with endocrine disorders
clinical presentation of adhesive capsulitis
- pain and decreased PROM and AROM
- strength is normal but may appear decreased d/t pain
- lasts about 24 mo
treatment of adhesive capsulitis
- NSAIDs
- frequent PT
- intra-articular steroid inj
- +/- PO prednisone
- surgery- manipulation and arthroscopic release
calcific tendonitis
- d/t deposition of calcium hydroxyapatite within tendon
- usually middle aged women
- diabetics at higher risk
- most often in supraspinatus
clinical presentation of calcific tendonitis
- VERY painful shoulder
- minimal/ no trauma
- acute onset
- pt looks in pain and tired
imaging for calcific tendonitis
- AP
- Grashey
- Scapular Y
treatment for calcific tendonitis
- analgesics/ anti- inflammatory
- local steroid injection
- PT
- arthroscopy with aspiration of Ca deposit
midshaft humerus fx
- bimodal age distribution
- males in 30s d/t high velocity trauma
- females in 70s d/t low velocity falls
- typically d/t direct blow or bending force
clinical presentation of midshaft humerus fx
- severe pain in mid arm
- must assess for other injuries “distracting injury”
- may have referred pain to shoulder/ elbow
- swelling and ecchymosis
- shortening of UE
- assess for radial N
radial nerve injury
- weakness of wrist, finger, thumb ext
- weakness of elbow supination
- sensory loss on dorsum of hand
- test motor fn by thumbs up and resisted thumb test
treatment of midshaft humerus fx
- may be nonsurgical in older pts- functional bracing
- ORIF if displacement or young pt
elbow fx
- usually d/t FOOSH
- radial head fx, olecranon fx, or supracondylar humerus fx
- marked by pain and decreased ROM
- fat pad or sail sign on xray
radial head fx
- FOOSH with abducted arm and flexion of elbow joint
radial head fx views
- AP
- external oblique
- lat
treatment for radial head fx
- long arm splint 3-4 days
- sling 1-2 weeks and gentle ROM
- analgesics
- serial xray 2 weeks post
- PT
olecranon fx
- bimodal age distribution
- high energy injury in young
- low energy injury in old
- direct blow -> comminuted fx
- direct blow from FOOSH -> transverse or oblique fx
olecranon fx presentation
- pain in posterior elbow with palpable defect
- unable to extend elbow
olecranon fx tx
- ORIF with tension band
- plate and scrw
elbow dislocation
- mostly closed and posterior
- usually d/t FOOSH with hyperextension or posterolateral rotary mechanism
treatment for elbow dislocation
- simple- closed reduction
- complex fx dislocation- ORIF
- long arm posterior splint/ sling for 1-2 weeks
- analgesia
- PT
lateral epicondylitis
- tennis elbow
- extensor tendons
- pain with resisted wrist ext
medial epicondylitis
- golfer’s elbow
- flexor tendons
- pain with resisted wrist flexion
epicondylitis clinical presentation
- extra- articular elbow pain
- insidious onset
- pain can be minimal to debilitating
treatment for epicondylitis
- rest
- ice massages
- brace
- NSAIDs
- PT
- cortisone
both bones forearm fx
- ratio of open to closed very high
- direct trauma- protecting head
- indirect trauma- MVA, fall from height, sports
- gross deformity, pain and swelling
treatment of both bones forearm fx
- sugar tong splint in ED
- casting if non-displaced (not common)
- ORIF
colles fx
- fx of distal radial metaphyseal region
- dorsal angulation
- d/t FOOSH
- extra-articular
conservative tx for colles fx
- closed reduction
- sugar tong splint immobilization
- long or short arm cast 4-6 weeks
surgical tx for colles fx
- ORIF then splint/cast 4-6 weeks
smith fx
- fx of distal radius with volar angulation
- extra-articular transverse fx
- reverse colles
- d/t fall on flexed wrist
- volar (cock- up) forearm splint
