Shoulder, elbow and hand Flashcards by Jamie Craig

intrinsic muscles of shoulder?

supraspinatus
infraspinatus
subscapularis
teres minor

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extrinsic muscles of shoulder

deltoid
trapezium
pectoralis major
latissimus dorsi

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range of movement of shoulder

abduction/adduction
flexion/extension
internal/external rotation

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what type of shoulder problem is most likely in young people?

instability

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what type of shoulder problem is most common in middle age

rotator cuff tear/frozen shoulder

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what type of shoulder problem is more likely in older patients

rotator cuff tear/glenohumeral OA

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what is impingement syndrome of the shoulder and causes?

compression of tendons of rotator cuff in subacromial space
tendonitis
subacromial bursitis
acromioclavicular OA with inferior osteophyte
hooked acromion
rotator cuff tear

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clinical features of impingement syndrome?

painful arc of 60-120 degrees abduction
+ve hawkins kennedy test
pain to deltoid, upper arm, lateral edge of acromion

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conservative management of impingement syndrome

NSAIDs
analgesia
physiotherapy
subacromial steroid injection

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surgical management of impingement syndrome

decompression but you need to have had ineffective non operative management for 6 months

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classical history of rotator cuff tear?

sudden jerk in patient >40 with subsequent pain/weakness

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what rotator cuff muscle is most commonly affected

supraspinatus

if large infraspinatus and subscapularis may be affected

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what may be seen on examination with rotator cuff tear

weaker initiation of abduction, internal rotation or external rotation
wasting of supraspinatus

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non operative management of rotator cuff tears?

phyiotherapy to strengthen remaining muscles to compensate for loss of supraspinatus
subacromial injection

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operative management of rotator cuff tears?

repair with subacromial decompression

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what is acute calcific tendonitis and how is it managed

actue onset severe shoulder pain characterised by calcium hydroxapatite in supraspinatus tendon seen on x ray just prox to greater tuberosity
subacromial steroid injection and local anaesthetic
condition is self limiting

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what is adhesive capsulitis and who is it more common in

capsule/glenohumeral ligaments become inflamed and contract causing progressive pain/stiffness
women x2
middle aged 
diabetics 
hyperlipidaemia 
dupuytren's disease

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presentation of adhesive capsulitis

pain 2-9 months progressing to sohulder stiffness 4-12 months
anterior pain at rest/night
stiffness
lost external rotation followed by globally reduced ROM

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management of adhesive capsulitis?

physiotherapy, analgesia, steroid injection for pain

MUA or surgical release to divide capsule

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what may cause referred shoulder pain?

angina
hepatic abscess
biliary colic

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true/false - posterior shoulder dislocation is most common

false - anterior is

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immediate shoulder dislocation management?

reduction by manipulation

analgesia

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true/false - after dislocation the chance of a recurring dislocation increases with age

false

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associated injuries with shoulder dislocation/instability

bankart labral lesion
fracture humeral head
fracture glenoid
rotator cuff tear

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surgical option for recurrent dislocation

bankart surgery to reattach labrum to anterior glenoid

typical hx of shouler OA

gradual onset pain at night and rest stiffness intermittent exacerbation

typical examination findings shoulder OA

``` asymmetry wasting limited external rotation globally reduced movement pain through ROM ```

non operative shoulder OA management

analgesia physiotherapy GH steroid injection

operative shoulder OA management

shoulder resurfacing total arthroplasty shoulder replacement reverse polarity shoulder arthroplasty

movement of humero-ulnar joint?

flexion/extension

movement of radio-capitallar joint?

pronation/supination with radioulnar joints

___ inserts into ____ for extension of the forearm

triceps brachii | olecranon process

what muscles supinate forerm

biceps brachii and supinator muscles

what muscles pronate forearm

pronator teres proximally and pronator quadratus distally

where does the common extensor origin come from

lateral epicondyle

where does the common flexor origin come from

medial epicondyle

in who is lateral epicondylitis more common

tennis players and those regularly performing resisted extension at the wrist

clinical features of lateral epicondylitis

painful and tender lateral epicondyle | pain on resisted middle finger/wrist extension

conservative management of lateral epicondylitis

``` rest from activities exacerbating physiotherapy NSAIDs steroid injection analgesia use of a brace ```

true/false - division of fibres of the common extensor origin is a curative surgery for lateral epicondylitis

false - it is a variable result surgery

what is medial epicondylitis and how is it managed conservatively

``` NSAIDs analgesia physiotherapy rest steroid injection ```

what must you beware of when injecting for medial epicondylitis

damage to ulnar nerve

true/false - OA is common in the elbow

false - primary OA isnt but secondary OA to trauma is

true/false - RA In elbow is common

true

OA in radio-capitellar joint with failed conservative management may be managed how?

surgical removal of the radial head with minimal functional impairment

OA In humero-ulnar joint with failed conservative management may be managed how?

total elbow replacement, can only lift 2.5kg following the procedure

what is cubital tunnel syndrome and what may cause it

compression of ulnar nerve behind medial epicondyle tight band fascia forming roof tightness at IM septum or between heads of flexor carpi ulnaris as nerve passes through

what is froments test

adductor pollicis eakness cannot maintain thumb grip so flexor pollicis longus tries to maintain grip strength

what is trigger finger

tendonitis of flexor tendon causing nodular enlargement that catches on the A1 pulley

management options for trigger finger?

steroid injection | surgery to divide the A1 pulley

where are ganglion cysts common

dorsal/volar wirst, foot, ankle, knee, DIPJ

clinical signs and symptoms of a ganglion cyst?

firm, rubbery, transilluminate, lump | localised pain or irritation

true/false - needle aspiration of a ganglion cyst is curative

false - it often recurs and so surgery is definitive, but can lead to scarring

what is dupytrens contracture, describe the pathology

proliferative connective issue disorder involving myofibroblast and type 3 collagen proliferation and hyperplasia (instead of type 1) leads to palpable nodules, skin puckering and contractures common to ring and little fingers

in who is dupytrens contracture more common

``` 10x males north europe/scandanavia phenytoin diabetics alcoholic cirrhosis ```

dupytrens contracture in penis is called?

peyronies disease

dupytrens contracture in the feet is called

ledderhose disease

up to ___ degrees contracture is tolerated in the MCPJ in dupytrens

surgery for dupytrens involves what?

removing diseased tissue or division of cords | amputation in severe cases

heberdens nodes are seen in PIPJ/DIPJ

DIPJ

bouchards nodes are seen in PIPJ/DIPJ

PIPJ

surgical intervention for DIPJ OA?

removal of ganglion cysts/osteophytes | Arthrodesis if severe

surgical intervention for PIPJ OA?

Arthrodesis for index finger | arthrodesis may be done for other fingers but results vary

how common is MCPJ OA and what causes it

quite rare | Gout, trauma, occupational stress, infection

complications of MCPJ replacement

ulnar drift | extensor tendon subluxation

management of 1st CMCJ OA

steroid injection for acute flare up | arthrodesis/arthroplasty for chronic pain

causes of radiocarpal OA and management?

truama - scaphoid non-union/carpal dislocation | wrist arthroplasty/arthrodesis

natural history of RA in the hands?

synovitis/tenosynovitis, inflammation in joints and tendon sheath joint erosion due to inflammatory pannus joint instability and tendon rupture extending to extensor tendon rupture/subluxation

visible RA deformities in the hand on examination

``` volar MCPJ subluxation ulnar deviation swan necking boutonniere Z shaped thumb ```

what is a swan neck deformity

hyperextended PIPJ and flexed DIPJ

what is a boutonniere

flexed PIPJ with hyperextended DIPJ

soft tissue management of hand RA

tenosynovectomy to prevent rupture tendon transfer/fusion for extensor tendon rupture soft tissue release for contractions

bony joint surgical management for hand RA

MCP replacement PIPJ replacement/fusion wrist replacement/fusion

what passes through carpal tunnel

FDS to 4 digits FDP to 4 digits FPL median nerve

causes of carpal tunnel

``` idiopathic RA Diabetes, hypothyroidism, chronic renal failure, pregnancy colles fracture or any women 8x ```

clinical features carpal tunnel

``` paraesthesiae in thumb and radial 2 1/2 fingers worse night lost sensation weak thumb clumsy muscle wasting thenar eminence +ve tinels/phalens ```

conservative/surgical management of carpal tunnel

wrist split at night + steroid injection | surgical division of transverse carpal ligament under local anaesthetic

complication of division of transverse carpal ligament

median nerve damage or damage to one of its branches