Ortho Flashcards
What do rotator cuff tears refer to
Injury to tendons of the rotator cuff muscles
Muscles of the rotator cuff
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Action of supraspinatus
Abducts the arm
Action of infraspinatus
Externally rotates the arm
Action of teres minor
Externally rotates the arm
Action of subscapularis
Internally rotates the arm
Typical presentation of rotator cuff tears
Shoulder pain
Weakness and pain with specific movements relating to the site of the tear
Patients may find it difficult to get comfortable at night due to pain the shoulder, disrupting sleep
IX for rotator cuff tears
X-rays will not show soft tissue injuries such as rotator cuff tears. They may be helpful for excluding bony pathology, such as osteoarthritis.
Ultrasound or MRI scans can diagnose a rotator cuff tear.
Management of rotator cuff tears
Surgery
Non-surgical options include physiotherapy, rest, adapted activities and analgesia(NSAIDs)
Main surgical option for rotator cuff tear
Arthroscopic rotator cuff repair, where the tendon is reattached to the bone during an arthroscopy(keyhole surgery)
What is frozen shoulder
Inflammation and fibrosis in the glenohumeral joint leads to adhesions(scar tissue)
The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint
Key risk factor for adhesive capsulitis
Diabetes
What are the three phases of frozen shoulder
Painful phase
Stiff phase
Thawing phase
Entire illness lasts 1-3 years before resolving but patients can have persistent symptoms
What is the painful phase of adhesive capsulitis
Shoulder pain is often the first symptom and may be worse at night
What is the stiff phase of adhesive capsulitis
Shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase
What is the thawing phase of adhesive capsulitis
There is a gradual improvement in stiffness and a return to normal
What is primary adhesive capsulitis
Occurs spontaneously without any trigger
What is secondary adhesive capsulitis
Occurs in response to trauma, surgery or immobilisation
What is supraspinatus tendinopathy
Involves inflammation and irritation of the supraspinatus tendon, particularly due to impingement at the point where it passes between the humeral head and the acromion.
Which test can be used to assess for supraspinatus tendinopathy
Jobe test
How can acromioclavicular joint arthritis be demonstrated clinically
Tenderness to palpation of the AC joint
Pain is worse at the extremes of the shoulder abduction, from around 170 degrees onwards when the arm is overhead
Positive scarf test – pain caused by wrapping the arm across the chest and opposite shoulder
Non-surgical options for management of frozen shoulder
Continue using the arm but don’t exacerbate the pain
Analgesia (e.g., NSAIDs)
Physiotherapy
Intra-articular steroid injections
Hydrodilation (injecting fluid into the joint to stretch the capsule)
Surgical options for management of frozen shoulder
Manipulation under anaesthesia – forcefully stretching the capsule to improve the range of motion
Arthroscopy – keyhole surgery on the shoulder to cut the adhesions and release the shoulder
What is subluxation
Partial dislocation of the joint
What type of dislocations occur in most shoulder dislocation cases
Anterior dislocations(head of the humerus moves anteriorly in relation to the glenoid cavity)
What are posterior shoulder dislocations associated with
Electric shocks and seizures
Potential nerve damage complication associated with anterior shoulder dislocation
Axillary nerve damage
What does axillary nerve damage result in
Loss of sensation in the “regimental badge” area over the lateral deltoid. It also leads to motor weakness in the deltoid and teres minor muscles.
What is the apprehension test
Supine position
Shoulder abducted to 90 degrees and the elbow is flexed to 90 degrees
Shoulder is then slowly externally rotated
As arm approaches 90 degrees of external rotation, patients with shoulder instability will become anxious and apprehensive
IX for shoulder dislocations
X-rays
MRI
Arthroscopy
Acute management of shoulder dislocation
Analgesia, muscle relaxants and sedation as appropriate
Gas and air (e.g., Entonox) may be used, which contains a mixture of 50% nitrous oxide and 50% oxygen
A broad arm sling can be applied to support the arm
Closed reduction of the shoulder (after excluding fractures)
Dislocations associated with a fracture may require surgery
Post-reduction x-rays
Immobilisation for a period after relocation of the shoulder
Ongoing management of shoulder dislocations
Physiotherapy
Shoulder stabilisation surgery
What does epicondylitis refer to
Inflammation at the point where the tendons of the forearm insert into the epicondyles at the elbow(type of repetitive strain injury)
Function of tendons that insert into the medial epicondyle
Act to flex the wrist
Function of tendons that insert into the lateral epicondyle
Act to extend the wrist
What is lateral epicondylitis often called
Tennis elbow
Presentation of tennis elbow
Causes pain and tenderness at the lateral epicondyle(outer elbow)
The pain often radiates down the forearm and can lead to weakness in grip strength
What does Mill’s test involve
Involves stretching the extensor muscles of the forearm while palpating the lateral epicondyle
Elbow is extended, the forearm supinated, and the wrist and fingers are extended. The examiner holds the patient’s elbow with pressure on the lateral epicondyle. If this causes pain, the test is positive, indicating lateral epicondylitis.
What is the cozen’s test
Starts with the elbow extended, forearm pronated, wrist deviated in the direction of the radius and hand in a fist.
The examiner holds the patient’s elbow with pressure on the lateral epicondyle.
The examiner applies resistance to the back of the hand while the patient extends the wrist. If this causes pain, the test is positive, indicating lateral epicondylitis.
What is medial epicondylitis often called
Golfer’s elbow
Presentation of golfer’s elbow
Medial epicondylitis causes pain and tenderness at the medial epicondyle (inner elbow). The pain often radiates down the forearm. It can lead to weakness in grip strength.
What does a golfer’s elbow test involve
Involves stretching the flexor muscles of the forearm while palpating the medial epicondyle.
The elbow is extended, forearm supinated and wrist and fingers are extended.
The examiner holds the patient’s elbow with pressure on the medial epicondyle. If this causes pain, the test is positive, indicating medial epicondylitis.
Management of epicondylitis
Often self-limiting
Rest Adapting activities Analgesia (e.g., NSAIDs) Physiotherapy Orthotics, such as elbow braces or straps Steroid injections Platelet-rich plasma (PRP) injections Extracorporeal shockwave therapy
What is DeQuervain’s tenosynovitis
Swelling and inflammation of the tendon sheaths in the wrist
Type of repetitive strain injury and results in pain on the radial side of the wrist
what are the two tendons primarily affected by DeQuervain’s tenosynovitis
Abductor pollicis longus(APL)
Extensor pollicis brevis(EPB) tendon
Action of abductor policis longis
Acts to abduct the thumb and abduct the wrist
The tendon inserts into the base of the first metacarpal bone(at the base of the thumb)
Action of extensor policis brevis
The extensor pollicis brevis also acts to abduct the thumb and abduct the wrist. The tendon inserts into the base of the proximal phalanx of the thumb.
What is the extensor retinaculum
Is a fibrous band that wraps across the back (dorsal side) of the wrist.
The APL and EPB pass underneath the extensor retinaculum. Repetitive movement of the APL and EPB under the extensor retinaculum result in inflammation and swelling of the tendon sheaths.
Presentation of DeQuervain’s tenosynovitis
Pain, often radiating to the forearm Aching Burning Weakness Numbness Tenderness
Special tests for DeQuervain’s tenosynovitis
Finkelstein’s test
Eichoff’s test
What is the finkelstein’s test/eichoff’s test
Involves the patient making a fist with their thumb inside their fingers. Then, the wrist is adducted (ulnar deviation), causing strain on the APL and EPB tendons. If this movement causes pain at the radial aspect of the wrist, the test is positive, indicating De Quervain’s tenosynovitis.
Management of DeQuervain’s tenosynovitis
Rest and adapting activities Using splints to restrict movements Analgesia (e.g., NSAIDs) Physiotherapy Steroid injections
Rarely, surgery may be required to release (cut) the extensor retinaculum, releasing the pressure and creating more space for the tendons.
What can bursitis be caused by
Friction from repetitive movements or leaning on the elbow
Trauma
Inflammatory conditions(eg. rheumatoid arthritis or gout)
Infection(septic bursitis)
Presentation of olecranon bursitis
Swollen
Warm
Tender
Fluctuant (fluid-filled)
Features of septic bursitis
Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)
When should septic arthritis be considered instead of olecranon bursitis
Swelling in the joint (rather than the bursa)
Painful and reduced range of motion in the elbow
Management of septic bursitis
Aspiration(before antibiotics)
Antibiotics(fluclox first line, clarithromycin as an alternative)
Hospital admission if systemically unwell
General management of olecranon bursitis
Rest
Ice
Compression
Analgesia (e.g., paracetamol or NSAIDs)
Protecting the elbow from pressure or trauma
Aspiration of fluid may be used to relieve pressure
Steroid injections may be used in problematic cases where infection has been excluded
IX for adhesive capsulitis
MRI gold standard - thickening of joint
HbA1c - more common in diabetics
When should conservative mx be advised for rotator cuff tear
If presenting within 2 wks
Main complication of rotator cuff tear
Adhesive capsulitis
Bony injuries associated with shoulder dislocations
Bankart lesion
Hill Sachs lesion
Which sign on an X-ray is associated with posterior shoulder dislocation
Lightbulb sign
Which type of radial fracture always requires surgery
Essex-lopresti fracture
Which nerve is typically injured in supracondylar fractures
median nerve
anterior interosseous branch
Test for anterior interosseous branch
OK sign
