Shoulder, elbow Flashcards
Causes of adhesive capsulitis
pri: idiopathic (frozen shoulder)
- a/w T1DM, dupuytren contracture, HLD, hyperthyroid, cardiac dz
- global contracture
secondary
- intrinsic: chronic rotator cuff injuries, post traumatic
- extrinsic: painful disorders reuslting in decreased movement (cervical radiculopathy)
Stages of frozen shoulder
Stage1: 0-6m freezing: pain w movement, worse at night (sx release CI in this stage, will get recurrence from ongoing inflammation)
Stage2: 6-12m Frozen: pain less, stiffness ++, ROM dec
(sx release indicated) - no MUA - cause # or labral/ cuff tears
Stage3: 12-18m resolution
Mgx of frozen shoulder
IX: X ray TRO #, ultrasound, BMD for osteoporosis
Conservatives: relieve pain, prevent further stiffening
- analgesia (NSAIDS)
- corticosteroids injection
- heat therapy
- exercise
- physioT: repeated circular mvt, assisted abduction, assisted int rotation, wall crawling
Sx: (if no resolution >12m)
1. manipulation under anaesthesia (gold standard): passive stretching of capsule
> avoid in elderly, CI in DM or osteoporosis (cx: spiral # of humeral shaft)
2. arthroscopic capsular release (stage 2) - division of interval betw supraspinatus and infraspinatus
3. distending joint under pressure w normal saline
w aggressive physiological post op
Aggravating manoeuvres for
- tennis elbow
- golfer elbow
tennis (lateral epicondylitis): fully extend elbow, pronate forearm and actively extend wrist against resistance (or passive flexion of wrist)
golfer (medial): fully extend elbow, supinate forearm and actively flex wrist against resistance (passive extension of wrist)
age where secondary ossific centres appear in children (elbow x ray)
CRITOE Capitulum 2yr Radial head 4 Int epicondyle 6 Trochlea 8 Olecranon 10 Ext epicondyle 12
Mgx of tennis elbow/ golfer elbow
mild: rest, exercise, lifestyle modification
mod: corticosteroid, H&L
severe: sx to detach common tendon (ECRB), lengthen tendon, excision of fibrous mass, extra-corporeal shockwave
Cubitus varus
- aka
- cause
- cx
- mgx
Gunstalk deformity
malunion of supracondylar #
Cx: median n palsy. no serious cx… sx mainly for cosmesis
Sx: wedge osteotomy of lower humerus
Cubitus valgus
- cause
- cx
- mgx
non union of lateral condylar # (then medial condyle grows more)
- tardy ulnar palsy
Undisplaced: backslab
Moderate displacement: closed reduction + backslab
Unstable: K-wire and cast
Rotated: open reduction and K-wire
Xrays to detect slipping
TUNP: transposing ulnar nerve anterior to eblow
how to detect radial head dislocation on x ray
anterior humeral line: transect middle 3rd of capitulum
radiocapetellar line: dissect capitulum
how to relocate a pulled elbow
supinate then flex elbow
what is the terrible triad
- radial head #
- coronoid process #
- MCL injury
Classic description of colles # and thus M&R method?
displaced: dinner fork deformity
- dorsal translation»_space; exaggerate deformity
- shortened»_space; traction
- dorsal angulation»_space; volar tilt
- radial deviation»_space; ulnar tilt
what is the rule of 11s and its normal measurements
- radial height from scaphoid (head of ulnar to tip of radial styloid): 11cm (< in #)
- radial inclination: 22 deg (<20 in #)
- volar tilt of radius (lat view): 11 deg (<11deg in #)
what is a barton’s #
- mgx
intra-articular smith fracture
- results in anterior subluxation of distal fragment carrying carpus with it (#-dislocation/ subluxation)
Mgx: ORIF with anterior buttress plate
Mgx of greenstick #
- accept angulation of up to 30 deg in children <10yo
- up to 15deg in >10yo
if not accepted: M&R with thumb pressure
immobilise in full length cast
causes of tardy ulnar nerve palsy
medial and lateral condylar #
monteggia #
how can you clinical diagnose elbow dislocation
equilateral triangle by epicondyles and olecranon is disrupted
cx of gunstock deformity
cubitus varus
- ulnar tunnel syndrome
Mgx of lateral condylar #
SH 1/2: conservative - backslab and re-xray in 5 days, continue backslap for 3 w
SH3/4: closed reduction > internal fixation
what innervates supraspinatus and infraspinatus
how to test
supra scapular nerve
test:
- supra: abduction
- infra: ext rotation of arm
- sub: geber lift off test
- abduction paradox and drop arm sign
- jobe sign: inverting beer can (supra)
Types of shoulder instability
ANTERIOR (recurrent instability)
- TUBS: traumatic, unilateral, bankart lesion (tear in glenoid labrum), requiring surgery
- AMBRII: atrumatic, multidirectional, bilateral, requiring rehabilitation, with inferior capsular shift anf interval closure (check beighton score, sulcus sign) (sx rare: tightening of inferior capsule)
POSTERIOR dislocation
- seizure, electric shock
how to differentiate between impingement, tendinitis and tear
impingement: hawkin positive
tendinitis: painful arc+ drop arm sign
tear: abduction paradox and drop arm sign
for supraspinatus tendon: Neer impingement test, give H&L
- tear: no change
- tendinitis: pain relief w full ROM
Treatment of shoulder
- impingement
- tear
IMPINGEMENT
- conservative: activity mod, analgesia, support, PT, OT
- H&L injection
- surgical: open or arthroscopic subacromial decompression
TEAR
- conservative: same
- H&L
- Sx: open/ artho cuff repair/ debridement and subacromial decompression
what is the etiology of rotator cuff impingement
- repetitive rubbing of rotator cuff tendons under coracoacromial joint
- site: 1cm proximal to insertion into greater tuberosity (dec vascularity of supraspinatus tendon)
- contributed by: (bone OA swelling, osteophytes) (tendon swelling -RA) (bursa - subacromial bursitis)
Ddx for shoulder stiffness
- post traumatic stiffness
- diffuse stiffness
- adhesive capsulitis
- regional pain syndrome (reflex sympathetic dystrophy)
- infection
