Orthopedic Pathology 300 (Upper extremity pathologies) Flashcards
Glenohumeral hypermobility
“Hypermobility is when the humeral head translates to a greater degree” ????
Due to physiological laxity of the CT
Glenohumeral instability
Instability is the inability to maintain the humeral head in the glenoid fossa
instability (and hypoermobility?) can be described as
Can be classified as Anteriorly, Posteriorly, or Multi-directional
instability can also be classified as…
Can be further classified as Traumatic or Atraumatic
Atraumatic is seen as either: Congenital or Repetitive injury (overhead activities)
repetitive stress instability
…
static vs dynamic stabilizers
Static Stabilizers:
Superior Glenohumeral Lig
Middle Glenohumeral Lig
Inferior Glenohumeral lig
Glenoid Labrum
Negative intra-articular pressure
static vs dynamic stabilizers 2
Dynamic Stabilizers:
Rotator Cuff muscles
Deltoid
Long head of Biceps Brachii
negative intraarticular pressure
“is the pressure in the synovial fluid (not that between the contact areas of the articulating surfaces)”
“Negative intra-articular pressure (IAP) is a passive stabilizer during joint movement.”
“In humans, negative intra-articular pressure is a considerable factor in the maintenance of shoulder stability.”
“In particular, it helps to prevent inferior displacement and keep the humeral head positioned in the center of the glenoid.”
gh instability clinical presentation
Clinical Presentation
Pain
Clicking
Dead arm syndrome
Feeling of instability/apprehension/possible dislocation
Sulcus sign (multidirectional instability)
dead arm syndrome
“Description. “Dead Arm” is characterized by a sudden sharp or ‘paralyzing’ pain when the shoulder is moved forcibly into a position of maximum external rotation in elevation or is subjected to a direct blow.”
“Dead arm syndrome is a condition that affects the shoulder. It’s caused by repeated movements, which place stress on the joint.”
“Dead arm syndrome is pain or weakness that occurs in the upper arm when doing a throwing movement.”
sulcus sign
“The sulcus sign tests for inferior glenohumeral instability. With the patient sitting or standing, the examiner grasps the patient’s arm and pulls inferiorly. The test is positive if a dimple or sulcus appears beneath the acromion as the humeral head is translated inferiorly.”
GH instability tx
Rehab; strengthening shoulder stabilizers
Surgery
AC joint separation (shoulder separation)
Separation of the acromioclavicular joint
Technically a dislocation/subluxation
also considered ligament sprain/tear
how ACJ sep
Usually from a traumatic fall/hit to the shoulder
Direct: Hit to acromion; hockey, rugby, football
Indirect: FOOSH, fall on elbow
ACJ sep grades
Graded by the extent of damage to AC jt and surrounding ligaments
Grade 1: tearing of the AC joint capsule
Grade 2: tear of the AC joint capsule and acromioclavicular ligaments
Grade 3: tear of the joint capsule, the acromioclavicular ligaments, and coracoclavicular ligaments (conoid and trapezoid ligaments)
3 grades, other definition (mistake on slides @ previous card???)
“The original grading system had three grades; non-displaced sprain (type 1), partially dislocated joint (type 2) and completely dislocated (type 3).”
GH dislocation
Most commonly dislocated joint in the body
Anterior dislocation
= most common
MOI: excessive abduction and external rotation or hyperextension
GH posterior dislocation
MOI: excessive flexion, adduction and internal rotation
GH dislocation tx
Reduction (tractioning?)
Rest/sling
Rehab
reduction define
“the action of remedying a dislocation or fracture by returning the affected part of the body to its normal position.”
bicipital tendinitis (bicep tendinitis)
Degenerative changes in the tendon of the long head of the biceps muscle
Common with overhead activities
bicep tendinitis – SSx
Local tenderness in the groove
Resisted elbow flexion
Pain with passive abduction
(LONG HEAD DOES ABD)
rupture of biceps tendon
Due to pre-existing degenerative changes in the proximal tendon of the long head of the biceps muscle
(COULD ALSO BE DISTAL TENDON)
how rupture (bb tend)
May rupture during active flexion against a resistance
bb tendon rupture – SSx
Immediate pain and “give away”
Long head of the BB contract into a ball that is more distal than normal
—> (IN PROXIMAL TENDON RUPTURE)
—> in distal tendon rupture, ball is more proximal
frozen shoulder (adhesive capsulitis)
A painful and significant restriction of active and passive range of motion at the shoulder joint.
which movement most affected (adhesive capsulitis)
Usually affects all movements of the shoulder
Most significant are abduction and external rotation
adhesive capsulitis – who?
2 - 3% of the population may experience frozen shoulder
10 – 20% of the diabetic population
adhesive capsulitis – gender
Women are more likely to be affected than men
adhesive capsulitis – age?
Most commonly occurs between 40 – 70 years of age
adhesive capsulitis – etiology
Largely unknown/unclear
adhesive capsulitis – primary vs secondary
Can be classified as Primary or Secondary
Primary:
idiopathic
secondary adhesive capsulitis
Secondary:
Intrinsic: impingement, bursitis, rotator cuff pathology, etc.
Extrinsic: myocardial infarction, pulmonary disorders, breast surgery
Systemic: Diabetes, Thyroid disease
secondary adhesive capsulitis and blood flow (?)
may have something to do with reduced bloodflow ??
E.g.
diabetes, MI, impingement
why breast cancer and frozen shoulder?
“Why would breast cancer treatment predispose women to frozen shoulder syndrome? Because inactivity predisposes patients to developing frozen shoulder, and inactivity is common in breast cancer patients: Patients are recommended to limit use of the arm following surgery.”
why limit movement of arm in breast cancer patients?
“Protecting the arm on the side of the surgery is very important after breast surgery. Poor drainage of the lymphatic system can cause that arm to be more at risk of infection and less sensitive to extreme temperature. Be aware of activities that put too much pressure on the affected arm.”
frozsen shoulder vs collagen production?
“The exact cause of frozen shoulder is unknown. However, the condition is thought to be related to an overproduction of collagen in the shoulder”
“It is thought to be caused by scar-like tissue (adhesions) forming in the shoulder joint.”
adhesive capsulitis pathogenesis
Disagreement over underlying pathological condition:
—> Inflammatory, fibrosis, neurological (?)
frozen shoulder — which structures invovled
Joint capsule is primarily involved with secondary involvement of surrounding structures
Affects the anteriosuperior joint capsule, axillary recess and coracohumeral ligament
Contracture of rotator cuff interval
frozen shoulder phases
acute, subacute, chronic
acute frozen shoulder phase
aka freezing phase or painful phase
This stage can last 2 – 9 months
Gradual onset of pain
—> @ Lateral area of shoulder
Pain may be more severe at night; can’t lay on that side.
Inflammation is present in joint capsule
Muscle spasms may be present in rotator cuff
subacute frozen shoulder phase
aka frozen phase or stiffening phase
This stage can last 4 – 12 months
Severe pain begins to diminish and stiffness becomes the main complaint
—> Pain is still present at the end ranges of motion.
Atrophy may be seen in surrounding muscles d/t disuse
—> Deltoid, rotator cuff
chronic frozen shoulder phase
aka thawing phase or resolution phase
May resolve spontaneously after two years
Some studies show as long as 5 – 10 years
Full range of motion is not always regained
Length of the acute phase corresponds to the length of the overall recovery time
chronic phase prognosis/resolution (?)
Motion and function gradually return to normal
Lateral shoulder pain and night pain continue to diminish
adhesive capsulitis Treatment (MEDICAL MANAGEMENT)
Corticosteroids
Manipulation under anesthetic (E.g. high velocity chiropractic adjustments)
—> can lead to possible iatrogenic complications
Surgery
—> arthroscopic capsular release
Nerve blocks
—> Suprascapular nerve
Distention arthography
NSAIDs
nerve block?
the production of insensibility in a part of the body by injecting an anesthetic close to the nerves that supply it.
arthroscopic capsular release (?)
Arthroscopic capsular release is a minimally-invasive surgery used to help relieve pain and loss of mobility in the shoulder from adhesive capsulitis (frozen shoulder).
“Capsular release is an arthroscopic (keyhole) procedure to cut the tight capsular tissues surrounding the shoulder joint”
“A radiofrequency (RF) probe is inserted into the shoulder. The probe uses RF waves to cut the tissue capsule that surrounds the shoulder joint, allowing the shoulder to move more freely.”
distention arthography (?)
“Arthrographic distension is a procedure where fluid is injected into the shoulder joint to break up the adhesions that might be restricting the shoulder’s movement and causing disability.”
adhesive capsulitis Treatment (CONSERVATIVE MANAGEMENT)
Patient education
Massage
Modalities
—> US, electric stim, laser
Manipulation/mobilization
Pain free ROM/stretching
Rehab
is there a definitive treatment for adhesive capsulitis ??
Thedefinitive treatment for adhesive capsulitis remains uncleareven though multiple interventions have been studied
“Previously published prospective studies of effective treatment have demonstrated conflicting results for improving shoulder range of motion in patients with this condition”
“There is little evidence to support or refute the use of any of the common interventions listed for adhesive capsulitis”
“There are also no studies with objective data supporting the timing of when to switch to invasive treatments”
impingement syndrome
Inflammation, pain and edema in the tissues of the subacromion space
Within the coracoacromial arch and between the acromioclavicular and glenohumeral joints
NOTE CORACOACROMIAL ARCH (vs coracoacromial lig)
“The coracoacromial ligament (CAL), which restrains superior displacement of humeral head, is a component of coracoacromial arch”
impingement syndrome and rotator cuff tendons (esp supraspin)
Painful compression of the rotator cuff tendons may occur when the humerus is abducted against the acromion
—> Most commonly supraspinatus tendon
—> May also affect subacromial bursa
—> and long head tendon of biceps brachii
impingement syndrome can be classified as
structural vs functional
structural impingement syndrome
Reduction of the subacromial area
Can be caused by:
—> thickening of coracoacromial ligament,
—> osteophytes from degeneration of AC joint
—> or hooked acromion process
functional impingement syndrome
Caused by shoulder instability or muscle imbalances
Impingement syndrome – clinical presentation
..
impingement syndrome – age
Typically seen in 40-60 year old age group
Can also be seen in younger individuals: usually athletic population
impingement syndrome — SSx
Aching sensation in the shoulder
—> May go down arm along biceps
Pain when abducting arm
—> @ Anterior and lateral shoulder
Catching sensation when lowering arm (like catching @ medial meniscus injury)
Worse with overhead activities
Pain at night when lying/rolling on shoulder
shoulder impingement test
painful arc test (70-120 degrees)
three stages of shoulder impingement
Stage 1 – edema and hemorrhage of subacromial bursa
Stage 2 – tendinitis and fibrosis
Stage 3 – complete or incomplete tendinous rupture (surgery)
which stages reversible?
Stage 1 and 2 are reversible with conservative care
ELBOW
…
elbow dislocation
Posterior dislocation of the elbow
how elbow disl?
Can be due to a fall on hand with the elbow slightly flexed or severe hyperextension of the elbow(foosh, sports, mva)
Usually requires significant amount of force (elbow is quite stable)
Radius and ulna dislocate posteriorly and always with severe soft tissue injuries
Frequently associated with fractures
olecranon bursitis
Aka “Student’s elbow”
Can be due to a hard impact on the elbow or constantly leaning on the elbow
—> over-use vs trauma
Constant pain at olecranon
Painful swelling
Limited mobility
what is other mechanism of olecranon bursitis – other than trauma and over-use (elbow on table)
May also be d/t infection or inflammatory conditions (RA, PA, Gout)
lateral epicondylitis
Aka tennis elbow
Thought to be a premature degeneration in the flat tendinous origin of the forearm extensor muscles from the lateral epicondyle of the humerus
Cause:
—> Local injury
—> Repetitive overuse of extensors
lateral epicondylitis features
Pain over or near the lateral aspect of the elbow
Radiation of pain down forearm
Aggravated by use or stretch of extensor muscles origin
Discrete point of local tenderness is present just distal to the lateral epicondyle
medial epicondylitis
Aka golfer’s elbow
Involves the common flexor tendon near the medial epicondyle
Cause:
Repetitive flexion movements of the wrist
—> Golfing, pitching a ball, grasping, lifting heavy objects
medial epicondylitis is associated with…
Often associated with ulnar nerve problems (due to proximity)
WRIST AND HAND
…
lunate dislocation
Anterior dislocation is common
Result of falling on a dorsiflexed wrist (FOOSH)
lunate dislocation – what happens? Sx
Lunate is squeezed out of place towards the palmar surface into the floor of the carpal tunnel
Wrist is swollen, experience pain when trying to extend fingers,
can compress median nerve
lunate dislocation – Tx
Traction with strong force on lunate (reduction?)
Surgery
lunate dislocation – COMPLICATIONS
Avascular necrosis
Median nerve compression
DJD
Dequervain’s tenosynovitis
Inflammation of the abductor pollicis longus and extensor pollicis brevis tendon sheaths.
Usually caused by repetitive use microtrauma from repeated thumb use, repetitive radial/ulnar deviation and forceful gripping.
More common in women.
Usually 30 – 50 years of age
Dequervain’s tenosynovitis – management (Conservative)
Bracing (6 weeks)
Avoid aggravating activities
NSAIDS, Ice
Massage, stretching, strengthening
Corticosteroid injection
Dequervain’s tenosynovitis – management (Surgical)
Endoscopic release of 1st dorsal compartment
Trigger Finger
Excessive thickening of common fibrous sheath that surrounds deep and superficial flexor tendons
flexor digitorum profundus/superficialis
Idiopathic and spontaneous
Most common in middle-aged women
Thickening produces a constriction in the tunnel (stenosis)
trigger finger – what happens
Tendons become secondarily enlarged
Unable to actively extend
Passive finger extension “snaps”
Active flexion “snaps”
trigger finger – Tx
Treatment includes immobilization in extension, steroid injections, surgery
trigger finger – “finger snaps”
“Overview. Trigger finger makes a finger get stuck in a bent position. It may straighten suddenly with a snap. The fingers most often affected are the ring finger and the thumb, but the condition can affect any finger.”
“Trigger finger occurs when the pulleys that help bend your fingers become too thick, leading to a popping or catching feeling as well as pain.”
trigger finger – pathologies linked to progression/development
RA, PA, gout
Mallet finger
Injury to the distal IP joint
Commonly occurs during sporting injury
mallet finger – MOI
Active finger extension and forced distal phalange flexion
(when extending, tendon contracting and tight, so when distal phalanx hyperflexion, more likely to avulse bone)
mallet finger – i.e.
Ext. Digitorum
Avulsion fracture
mallet finger – features / SSx
Failure of active extension
Can extend entire fingers except affect DIP
Painful, swollen around DIP joint
mallet finger – Tx
Splinting 6 weeks
—> Removal before healed = finger perm. Bent
Tendon will self heal
Gamekeeper’s thumb
A tear or complete rupture of the ulnar collateral ligament at the 1st MCP joint
Due to abduction and extension of the thumb
Treatment – immobilization or surgery
Jersey Finger
Aka rugby finger
Rupture of the flexor digitorum profundus tendon
Occurs when DIP is actively flexed and is then forced into extension
Volkmann’s Ischemic Contracture
Permanent flexion contracture of the hand and fingers
Typically caused by fractures of the arm/forearm, leading to ischemia and necrosis of the distal tissues
Dupuytren’s Contracture
Contracture of the palmar fascia
Leads to permanent flexion of one or more digits
—> Most commonly the 4th digit
Idiopathic:
“It may be linked to cigarette smoking, alcoholism, diabetes, nutritional deficiencies, or medicines used to treat seizures”
