Orthopaedic - Upper Limb Flashcards
Outline the precautions in 0-4/52 following moderate to large RC repair (with entry through the deltoid)
For a moderate to large rotator cuff (RC) repair where surgery involved an incision through the deltoid, precautions focus on protecting the repair site, controlling pain, and preventing re-injury. Key points include:
Movement Restrictions:
- No active shoulder movements.
- Avoid shoulder extension, horizontal adduction, and internal rotation.
- No lifting, pushing, or pulling actions.
- Avoid overhead motions and excessive stretching.
Positioning:
- Keep the arm in an abduction sling for up to 6 weeks.
- Remove the sling for elbow and wrist movement (3-4 times daily) but avoid shoulder movement.
- Avoid sleeping on the affected side; instead, sleep in a semi-reclined position.
Therapeutic Exercises:
- Begin passive range of motion (PROM) with exercises like pendulums and gentle PROM in flexion and scapular plane.
- Start scapula depressions early to support proper scapulo-humeral rhythm and avoid compensatory shoulder hiking.
Other Considerations:
- Maintain wound hygiene and keep incisions dry.
- Cryotherapy may be used to manage pain and inflammation
Outline the conclusions for surgery using the papers included in the Masterclass (in the same detail as the masterclass)
The masterclass reviewed several studies on the effectiveness of surgery for rotator cuff-related shoulder pain. Key conclusions include:
Subacromial Decompression:
- Surgery groups showed some benefit over no treatment in terms of pain and function scores (e.g., Oxford Shoulder Score). However, the improvements were not clinically significant.
- No significant difference between subacromial decompression and diagnostic arthroscopy alone, suggesting limited additional benefits from decompression surgery
Progressive Resistance Exercise (PRE) vs. Corticosteroid Injections and Advice:
- PRE did not significantly outperform best-practice physiotherapy advice alone.
- Corticosteroid injections did not provide long-term benefit when used as an adjunct to either PRE or advice-based management
You may be provided (within the exam) the Mean difference, 95% confidence intervals and clinically worthwhile effect of a particular surgery vs sham or physiotherapy and you must provide an explanation of the result
In academic language OR;
In patient centred language to a patient that would like to know the difference in outcome between surgical and physiotherapy management.
To a patient: “Studies comparing surgery to physiotherapy show small differences in pain relief and movement. Surgery may lead to faster relief for some, but over time, physiotherapy alone often works just as well for most people. So, you can expect good outcomes from physiotherapy without the risks of surgery, but surgery might be worth it if your symptoms are severe and other treatments haven’t helped.”
List and briefly describe the causes for RC injury
- Acute Trauma: Falls or sudden, high-force impacts can lead to tears.
- Degenerative Changes: Age-related degeneration from repetitive shoulder movements causes wear and tear over time.
- Impingement Syndrome: Repeated rubbing of the RC tendons against the acromion can lead to inflammation and eventual tearing.
- Overuse: Chronic, repetitive overhead activities (e.g., sports, heavy lifting) stress the RC.
- Anatomical Variations: A hooked acromion can increase tendon compression, predisposing the RC to injury
List and briefly describe the factors that affect rehabilitation following RC repair (12 factors). Note that you may be asked about this in relation to a different joint
- Surgical Approach: Open surgery with deltoid detachment may require longer recovery.
- Size of Tear: Larger tears (especially >5cm) require more conservative rehab.
- Tissue Quality: Poor-quality tendon or muscle (e.g., fatty degeneration) can slow progress.
- Fixation Method: Stronger fixation (e.g., double row sutures) allows for more stable recovery.
- Location of Tear: Tears involving the posterior cuff need restricted internal rotation.
- Type of Tear: Complex or retracted tears are challenging to repair, requiring careful rehab.
- Mechanism of Injury: Acute tears may heal differently than degenerative ones.
- Timing of Surgery: Early surgery can lead to faster recovery.
- Surrounding Tissue Quality: Healthy adjacent tissue supports better outcomes.
- Patient Characteristics: Factors like age, smoking, diabetes, and fitness level affect healing.
- Access to Care: Regular physiotherapy often leads to better outcomes than home programs alone.
- Surgeon’s Philosophy: Some surgeons prefer conservative rehab, while others support more aggressive protocols
Describe why scapula exercises are important and understand when you would use these/advise these in rehabilitation
- Support Shoulder Mechanics: The scapula provides a stable base for the RC to function, ensuring optimal arm movement.
- Promote Scapulo-Humeral Rhythm: Proper scapular positioning reduces strain on the RC and shoulder joint.
- Prevent Compensations: Strengthening scapular muscles helps avoid shoulder hiking, which can lead to impingement or re-injury.
Scapular exercises, such as scapula depressions and controlled scapular movement, are introduced early (1 week post-op) to set a stable foundation before active RC exercises begin
Outline the factors that result in better and worse outcomes following TSR surg
Better Outcomes:
- No prior shoulder surgeries.
- Higher preoperative function.
- Minimal RC pathology.
- Primary osteoarthritis as the surgery indication.
- Overall good health before surgery.
Worse Outcomes:
- Underlying conditions like rheumatoid arthritis or trauma.
- Severe loss of preoperative range of motion.
- Multiple comorbidities.
- Significant RC pathology and fatty degeneration in the RC muscles
