Common upper limb pathologies 2 Flashcards
what is adhesive capsulitis
formation of excessive scar tissue or adhesions across the GHJ, leading to stiffness, pain, dysfunction, and ligaments affected
Primary (idiopathic)_ spontaneously, secondary- often after trauma
adhesive capsulitis - statistics
3-5% in general population, 20% with diabetes, 40-50% bilateral involvement, resolve in 1-3 years
adhesive capsulitis risk factors
female>male- females respond better to female, age over 40, trauma, HLA-B27- positive blood test- shows higher change of autoimmune disease, diabetes- worse symptoms, cerebrovascular disease, coronary artery disease
adhesive capsulitis- stage 1 and 2
1- primary complaint of shoulder pain- especially at night, arthroscopically- evidence of synovitis without adhesions, inflammatory cells infiltrate synovium
2- patient begins to experience stiffness, arthroscopically- synovitis, some loss of axillary fold- early adhesions, synovial proliferation- more dense fibrous tissue
adhesive capsulitis- stage 3 and 4
3- profound global loss of ROM, pain at ER, Arthrosocpically- synovitis is resolved, significant adhesions- axillary fold obliterated, dense collagenous tissue within capsule
4- chronic stage- persistent stiffness, minimal pain, synovitis resolved, advanced adhesions
adhesive capsulitis- clinical presentation
usually present first with pain, followed by gradual loss of A/PROM- LR- most affected, PROM with firm, painful end feel, imaging not necessary for diagnosis but can rule out other conditions- pancrose tumor
adhesive capsulitis- pancose tumor
type of lung cancer at apex of lung- 25% have delayed diagnosis, 1% of patient with frozen shoulder have this
adhesive capsulitis- management
physio- early mobilisation, education
NSAIDs. corticosteroid injection, hydrodilation- large volume of fluid injected into shoulder capsule to tear adhesions and stretch out shoulder,
surgery- MUA, capsular release- involves CH lig and rotator interval, contractor capsule, safer and more effector
fractures- clavicle fracture
most result from fall, neuro/vascular structures near by, mid-shaft>lateral>medial
management- conservative- sling use, physiotherapy- early mobilisation of shoulder girdle, then loading, surgery
fractures- proximal humerus
3 most common fracture in elderly, more common in women (2:1), classified depending on how many fragments are displaced (0- 1 part, 1- 2 part), usually occur due to a fall
management- collar and cuff- 2-3/52, followed by progressive active management physio, surgery older they are progress slowly- left with reduce ROM
fractures- distal radius fracture
colles facture- most common- extra articular, dorsally displaced distal radius fracture, smiths fracture- anterior displacement of distal radius, bartons fracture- intra articular fracture with associated dislocation of the rcj, occur due to FOOH
fractures-distal radius fracture- management
splints, casts, K-wires, MUA, physio following period of immobilisation- 6 weeks- increase mobillity/ strength/ function
fractures- scaphoid fracture
most common fractured carpal bone (70%), often occurs from a FOOH, waist> prox pole- if waist fractured, blood cant get to it AN> distal pole, risk of non- union (5%), pain over anatomical snuff box
management- cast, surgery, physio, after immobilisation perioid
osteoarthritis
most common form of arthritis, can develop in synovial joint, most common in knees, hips and small joints of hand
osteoarthritis- management
management- physio- exercises for strength and mobility/ hands on technique/ hydrotherapy/ education, corticosteroid injection
surgery- joint replacement (concave prosthesis replaced socket convex head of humerus replaced ball, debridement)
rheumatoid arthritis
systemic autoimmune disease characterised by inflammatory arthritis with extra articular involvement, synovium infiltrated by immune cells, systemic inflammation and autoimmunity in RA begin long before onset of inflammation
rheumatoid arthritis- epidemiology and risk factors
most prevalent in northern America and Europe, female>male 1-3:1, increases with age, paediatric population- juvenile idiopathic arthritis
risk factors- genetic factors, smoking, air pollution, obesity, low vit D
rheumatoid arthritis- management
goal of treatment is symptom management, pharmacological management- disease managing anti-rheumatic drugs (DMARDs), nutrition, physio
shoulder dislocation-
shoulder stability provided by ligament, labrum- static stablisers, and RC and scapular musculature- dynamic stablisers, can be anterior or posterior (<5%)
shoulder dislocation- anterior
often caused by the arm being position in abduction and LR (apprehension position), humeral head displaced anterior inferior, concurrent RC injuries can occur- slap lesion, haggle, alpsa, vascular/neural structure at risk- axilla and brachial plexus
shoulder dislocation- lesion
hills sachs lesion- cortical depression on posterolateral head of humerus, caused by impaction of humeral head on roof of glenoid
bankrupt lesion- damage to attachment point of anterior labrum to the glenoid
shoulder dislocation- posterior
usually caused by a blow to the front of the shoulder, can only occur during seizures, can easily be overlooked in AP X-ray, concurrent injuries to RC (subscap) and posterior labrum
shoulder dislocation- recurrence rates
most likely to have shoulder stabilization surgery, 19.6% recurrence rate- mostly in first 2 years, higher rate in men, higher recurrence in young (10-19 aged 49.2%
shoulder instability
characterised by disruption of the dynamic and static stabilizers of the GHJ leading to dislocation, subluxation or apprehension
static shoulder stablisers
articular conformity, negative, intra articular pressure labrum, GH lig, damage to this can effect proprioception, cause delay in muscle respond
shoulder instability- traumatic and atraumatic
traumatic- due to dislocation, results in damage to both static and dynamic stabilizers
atraumatic- congenital- secondary to hypermobility, can be due to chronic recurrence use- cause change in mobility of shoulder- ant, post, inf, multidirectional- leads to laxity/instability
shoulder instability- clinical presentation
clicking/ pain, possible sub-acromial signs (painful arc, pain on rotation), possible RC signs (resisted tests, pain on rotation), positive apprehension test/ relocation test (anterior), increase accessory motion at GHJ, positive sulcus sign
shoulder instability- management
physio- education, motor control, strength training- deltoids, proprioception training- train dynamic stablisers
surgery- depending on structural impairments- labreal tears- repair labral tears, physio starts after 4 weeks
Dupuytren disease
Hypertrophy and contracture of the superficial palmer fascia, flexion contracture of MCP and PIP joints leading to loss of function, occurs slowly, typically progress over the course of several years, typically occurs bilaterally
Dupuytren disease- progression
begins with thickening of the skin, then bands of fibrotic tissue form in palmer area, eventually leading to affected fingers being pulled into flexion
Dupuytren disease- aetiology
most common in north europe, males>females, average onset age 60- incidence increases with increased age, strong genetic component, environmental factors- alcohol intake, smoking, manual labour, low body weight/ BMI, use of anticonvulsant drugs
associated with diabetes, epilepsy, HIV, AC, cancer
Dupuytren disease- surgical management
is the mainstay of treatment, simple fasciotomy- early stage, contracted cord is cut but not surgically removed- least invasive,
fasciectomy- partial or total removal of the diseased palmer fascia including the cord/ nodule
dermo fasciectomy- also removes overlying skin and fat, then required a full thickness skin graft to cover the surgical site- severe, recurrent dupuytren, amputation of the digits may be considered
Dupuytren disease- physiotherapy
main role is post op
splinting, exercises- passive stretching active exercise, function-restore mobilisation to digits, education and advice, oedema and scar management, recurrent of dupuytren disease.is common
impingement
caused by the tendons of the RC becoming trapped as they pass through the shoulder joint
internal- inner aspect of the tendon compressed
external- outer aspect of the tendon compressed
primary- mechanical impingement resulting from pathological narrowing/crowding of subacromial space
secondary- mechanical impingement resulting in narrowing due to dynamic/functional instability of the shoulder and pectoral girdle
impingement classification- stage 1
oedema and inflammation to sub-acromial tissues
pt normally <25
overuse
P along anterolateral shoulder, described as deep dull ache, sharp with elevation, full A/PROM
P arc (60-120)
impingement classification- stage 2
fibrosis of GH capsule, bursae and tendinotis of relevant tendons
pt >20, <40, +ive capsular pattern, reduced A/PROM
impingement classification- stage 3
disruption to involved tissues
typically >40, muscle weakness ER and ABD, visible atrophy of deltoid, RC, weakness/ drop arm
AC joint injury
traumatic AC injury- occurs when the joint is disrupted. the ligaments that hold the two bones of joint together get stretched too far this is called a shoulder seperation
overuse AC joint- this type of injury occurs over time due to repeated and too much stress on the joint. Cartilage at the end of the acromion and clavicle bones protect joint from daily wear and tear
bicep tendinopathy
traumatic (FOOSH) or insidious
Pain localised to LHB and muscle belly
bony sputs, instability of tendon, poor scap, stability/posture, result from RC tear
bicep rupture
rupture at one of 2 places- proximal or distally, M?F 35+ years
localised px and swelling with bruising
retracted muscle, distal common in deadlifts
proximal forced GH ext, elbow ext, and pronation and dislocation
shoulder bursitis- causes
trauma- due to an accident, the bursa could become irritated and inflamed,
inflamed joint when the whole joint is inflamed, the bursa can become inflamed as well as other structures
overload- the reps of a certain motion too often can lead to the inflammation of the bursa becasue of the friction between the bursa on the one hand and another structure on the other hand (e.g. tendon, bone lig)
other causes- degeneration of tendon, calcium deposition, adjacent inflammation of the supraspinatus tendon
clinical presentation shoulder bursitis
shoulder pain and decreased ROM for longer than 1 month but less than year (becomes chronic bursitis), the presence of pain in atleast 1 activity (sleep, dress, work)
a loss of 10° or more in 1 or more ROM, patients with subacromial bursitis should have a GH abd greater than 45° from patients with frozen shoulders
