Shoulder, elbow and hand Flashcards
intrinsic muscles of shoulder?
supraspinatus
infraspinatus
subscapularis
teres minor
extrinsic muscles of shoulder
deltoid
trapezium
pectoralis major
latissimus dorsi
range of movement of shoulder
abduction/adduction
flexion/extension
internal/external rotation
what type of shoulder problem is most likely in young people?
instability
what type of shoulder problem is most common in middle age
rotator cuff tear/frozen shoulder
what type of shoulder problem is more likely in older patients
rotator cuff tear/glenohumeral OA
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
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
conservative management of impingement syndrome
NSAIDs
analgesia
physiotherapy
subacromial steroid injection
surgical management of impingement syndrome
decompression but you need to have had ineffective non operative management for 6 months
classical history of rotator cuff tear?
sudden jerk in patient >40 with subsequent pain/weakness
what rotator cuff muscle is most commonly affected
supraspinatus
if large infraspinatus and subscapularis may be affected
what may be seen on examination with rotator cuff tear
weaker initiation of abduction, internal rotation or external rotation
wasting of supraspinatus
non operative management of rotator cuff tears?
phyiotherapy to strengthen remaining muscles to compensate for loss of supraspinatus
subacromial injection
operative management of rotator cuff tears?
repair with subacromial decompression
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
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
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
management of adhesive capsulitis?
physiotherapy, analgesia, steroid injection for pain
MUA or surgical release to divide capsule
what may cause referred shoulder pain?
angina
hepatic abscess
biliary colic
true/false - posterior shoulder dislocation is most common
false - anterior is
immediate shoulder dislocation management?
reduction by manipulation
analgesia
true/false - after dislocation the chance of a recurring dislocation increases with age
false
associated injuries with shoulder dislocation/instability
bankart labral lesion
fracture humeral head
fracture glenoid
rotator cuff tear
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
30
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