Shoulder and Elbow Problems Flashcards
what is the epidemiology of shoulder and elbow problems?
- Teens/20’s: Fractures and instability
- 30’s & 40’s: Rotator cuff & capsulitis (inflammation of the capsule of the shoulder joint)
- 50’s & 60’s: Impingement and AC joint
- 70’s + : Degenerative rotator cuff and joint
whoa dn how do upper limb fractures occur?
- Similar epidemiology to Hip Fractures
- Young high energy injuries
- Elderly Osteoporotic injuries
In comparison to lower limb, young people you get high velocity injuries to the humeral neck but in elderly you see similar fracture but in osteopenia bone with little force
what does the management of an uppe rlimb fracture depend upon?
•Management depends on fracture configuration and patient biology (patient health and qualities of bone your trying to fix)
what is shown here?
Bilateral shoulder problem
Humeral head dislocated form the glenoid on the right
Humeral head completely dislocated from the shoulder on the left and also the humeral neck is fractured off and also a fracture of the greater tuberosity
Traumatic Shoulder Dislocation - why does it happen?
- Shoulder joint is the most mobile joint in the body
- Stability sacrificed for mobility
Stability not as good in something that is mobile
Traumatic Shoulder Dislocation occur sin what areas?
• Anterior 90%, posterior 9%, inferior 1%
Posteriorly – due to electric shock, people who have epileptic fits
Rare inferior dislocation – when people fall long distance
what is the treatment of shoulder dislocation?
- Manipulation - Manipulation under sedation is usually required
- Immobilisation
- Physiotherapy
- Surgery - Surgery better in younger who are activate as would lead to recurrent dislocation where as in old people recurrent dislocation doesn’t happen as much
what is shown here?
Anterior inferior dislocation
what is Subacromial Impingement?
Symptoms of people in middle years of life when they abduct their arm and painful arc
Okay to start but as arm gets higher its gets more sore then often okay once you get past around 120 degrees
Degeneration in acromion clavicular joint
Bursae separating the 2 becomes inflamed
Subacromial impingement syndrome (SAIS) refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion within the shoulder
Bigliani Definition (1991) of subacromial impingement
Pain and dysfunction resulting from any pathology which decreases the volume of the subacromial space or increases the size of the contents
what is the treatment and management of Subacromial Impingement?
- Subacromial Steroid injection (calms down inflammation and improves space for rotator cuff)
- Physiotherapy
- Arthroscopic subacromial decompression
what is shown here?
Osteophytes are bony lumps (bone spurs) that grow on the bones of the spine or around the joints. They often form next to joints affected by osteoarthritis, a condition that causes joints to become painful and stiff
Grow on the inferior surface of the acromioclavicular joint narrowing space, in surgery these are resected away to give more space
what is Frozen Shoulder?
- Adhesive Capsulitis? (another name for it)
- Primary (Idiopathic) or Secondary (may of had injury to shoulder, dislocstion and then secondary to that develop a very stiff joint)
Frozen shoulder is where your shoulder is painful and stiff for months, sometimes years
Initially pain and as pain gets better stiffness gets worse
Doesn’t always return to normal
In subacromial impingement, only abduction is painful but in frozen shoulder – all movements of the shoulder are restricted
how do you invesitage and manage froen shoulder?
- Clinical diagnosis
- Normal Radiograph
- Early presentation – inject steroid, hydrodilation (large amount of fluid put in joint to stretch capsule)
- Later - surgery
Anterior part of the shoulder, inferior glenohumeral ligament, increased thickening. Red is post surgical picture and the ligament has been resected
hwat makes up the rotator cuff?
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
Rotator cuff tear occur sin what 2 ways?
Traumatic and degenerative
Can tell what part of rotator cuff is damaged, US or MRI. US you see if complete or partial tear
what is shown here?
Arthroscopic view of rotator cuff tear
Repair can be on arthroscopic or open
what is the treatment of rotator cuff tears?
- Acute rotator cuff tears = early surgery
- Chronic degenerative tears (often eldery) = surgery if symptomatic
- Size (of defect), Time (intervil between injury and surgery) and Age
what is Superior Capsular Reconstruction?
- An operation for massive, irreparable rotator cuff tear (if humeral head migrating superiorly and rubbing on the clavicle)
- Cadaveric skin graft to reconstruct capsule, not tendon
what arthritis can occur in the shoulder?
- Osteoarthritis (less common in shoulder than the knee)
- Inflammatory arthritis (particularly rheumatoid)
- Post-traumatic arthritis
- Rotator cuff integrity is paramount (for surgery success)
(Left arhtritic and is showing Narrowing of subacromial space, Right is axillary view)
what surgery would be done for shoulder arthritis if the rotator cuff is okay?
Total shoulder arthroplasty if rotator cuff is okay (the surgical reconstruction or replacement of a joint)
how is a complex reconstruction carried out? (Severely arthritic shoulders, glenoid is absent or severely destroyed)
- Custom made implants (may be lack of bone so need custom impant to fit what remains of the bone)
- Based on 3D reconstruction from CT
- Patient specific implants rather than “off the shelft”
what problems occur at the elbow?
- Fractures & dislocations in young
- Tendinopathies in middle age (inflammation of the tendons attaching around the elbow)
- Degenerative disease in elderly (rarer to be symptomatic comapred ot the hip or knee)
- Cubital Tunnel syndrome at any age (tight space behind the medial epicondyle can trap the median nerve and this can happen at any age)
(Open fracture dislocation of the elbow)
what is tennis and golfers elbow and what is the treatment?
Lateral aspect is worse on using the limb (common extensors), tendon may be torn at insertion tob one and tried ot repiar itself with inflammatory tissue and stressing on the inflammatory tissue causes more pain
More common on lateral side than the medial side
Actually unusual for these sports people to get it, normally people doing repetitive tasks
Treatment - Rest, physio, analgesics and steroid infections
what is shown here?
Injecting platelet rich plasma
Inject it around the tendon that is inflamed and this seems to help healing occur
where is the ulnar nerev and what does it supply
Ulnar nerve
Posteriorly to the medial epicondyle and moves down to the flexor carpi ulnaris
In tight space
Feeling in the ulnar 1.5 digits
May present with pain and tingling in these digits and may see wasting of the small muscles of the hands (abductor of the thumb and interossei)
