Shoulder + Elbow Problems Flashcards
Shoulder epidemiology i.e. what conditions are most common in what ages
- TEENS/20s = FRACTURES & INSTABILITY/DISLOCATIONS
- 30s & 40s = ROTATOR CUFF & CAPSULITIS
- 50s & 60s = IMPINGEMENT & AC JOINT
- 70s+ = DEGENERATIVE ROTATOR CUFF & JOINT
Upper limb #
- SIMILAR EPIDEMIOLOGY to HIP FRACTURES
- YOUNG = HIGH ENERGY INJURIES
- ELDERLY = OSTEOPOROTIC INJURIES
MANAGEMENT: DEPENDS on FRACTURE CONFIGURATION & PT. BIOLOGY
○ DISPLACED PROXIMAL HUMERAL FRACTURES INVOLVING SURGICAL NECK = NO SIG. DIFFERENCE bwtn SURGICAL & NON-SURGICAL TREATMENT in pt.-reported clinical outcomes
Traumatic shoulder dislocation: presentation + management
- SHOULDER JOINT = MOST MOBILE JOINT in body
- STABILITY SACRIFICED for MOBILITY
90% - anterior; 9% - posterior, 1% - inferior
PRESENTATION:
* SPORTING Hx usually * IF FRACTURE/DISLOCATE when YOUNG = MORE LIKELY to have RECURRENT DISLOCATION as SOFT LABRUM DAMAGED (labrum is soft when young & can become damaged; labrum should be tightly adhered to glenoid)
MANAGEMENT:
* MANIPULATION * IMMOBILISATION * PHYSIOTHERAPY * SURGERY - individual discussion, depending on pt. & injury characteristics; can also be used to reattach labrum to glenoid • DISCUSSION = esp. for young pt. about engaging in high risk activities e.g. rugby
Rotator cuff tear: aetiology
- TRAUMATIC = INJURY
* DEGENERATIVE = AGEING (INSIDIOUS presentation)
Rotator cuff tear: presentation
• SHOULDER WEAKNESS + PAIN
○ NIGHT PAIN - may affect sleep as pt. unable to keep arm in comfortable position
○ PSEUDOPARALYSIS = not actually paralysed - passively have full ROM, actively don’t - as w/o supraspinatus tendon, the humerus migrates upwards & the deltoid cannot work effectively due to this
• FALLEN OVER + SHOULDER PAIN + NORMAL X-RAY = could be ROTATOR CUFF INJURY
TYPICAL AGE: > 40yrs
Rotator cuff tear: pathophysiology
• TEARS in SUPRASPINATUS TENDON/SUBSCAPULARIS & INFRASPINATUS
Rotator cuff tear: investigations
• X-RAY
• USS
MRI - can also give info about + QUANTIFY MUSCLE WASTING (can be useful prognostic indicator)
Rotator cuff tear: management
- ACUTE ROTATOR CUFF TEARS = EARLY SURGERY (if they had a normal shoulder beforehand)
- CHRONIC DEGENERATIVE TEARS = SURGERY if SYMPTOMATIC○ Depends on SIZE, TIME, AGE
- INCOMPLETE = SURGERY if SYMPTOMS PERSIST
- COMPLETE = PROMPT REFERRAL for OPEN/ARTHROSCOPIC REPAIR
Frozen shoulder (capsulitis): aetiology
- PRIMARY = IDIOPATHIC
- SECONDARY
Frozen shoulder (capsulitis): presentation
- SEVERE PAIN = may present to A&E, occurs at NIGHT + WORSE at NIGHT (may wonder if joint is infection, calcific tendonitis as they also present to A&E w/ painful shoulder)
- Will EVENTUALLY RESOLVE - may take years
- PAINFUL PHASE = up to 1yr, ACTIVE & PASSIVE MOVEMENT RANGE REDUCED e.g. ABDUCTION < 90° ± EXTERNAL ROTATION < 30°
- FROZEN PHASE = 6 - 12 months, PAIN usually SETTLES, SHOULDER REMAINS STIFF
- THAWING PHASE = 1 - 3yrs, shoulder SLOWLY REGAINS RANGE of MOVEMENT
Frozen shoulder (capsulitis): pathophysiology
• JOINT CAPSULE bwtn BALL & SOCKET = INFLAMED, TIGHT, THICK, CONSTRICTED = GLOBAL RESTRICTION of MOVEMENT
Frozen shoulder (capsulitis): risk factors
- 40S, 50S
- IDDM, THYROID DISEASE
- CERVICAL SPONDYLOSIS (MORE GLOBAL RESTRICTION of MOVEMENT)
Frozen shoulder (capsulitis): investigations/diagnosis
• CLINICAL DIAGNOSIS + NORMAL RADIOGRAPH (NORMAL X-RAY)
○ X-RAY = as only other DDx is ACUTE INFLAMMATORY ARTHRITIS/DISLOCATION of SHOULDER ○ TEST = STAND UP w/ LEGS APART = ARMS should ABDUCT & IF it DOESN'T ABDUCT to ~ 50% of NORMAL ARM then it's frozen shoulder • ARTHROGRAM = will show GREATLY REDUCED SPACE
Frozen shoulder (capsulitis): management
• EARLY PRESENTATION = HYDRODILATION (CONTRAST MEDIUM + ANAESTHETIC + CORTISONE - trying to reduce inflammation, which can reduce pain + increase space inside capsule)
○ ARTHROSCOPIC ARTHROLYSIS = PHYSICALLY INCREASE SPACE = CONTRAST MEDIUM + LOTS of SALINE (keep pushing in saline, looking for SUDDEN GIVE = CAPSULAR RUPTURE; may INJECT STEROID) * LATER = SURGERY * EARLY PHYSIOTHERAPY + NSAIDs may help if tolerated, as may CORTICOSTEROID JOINT INJECTIONS early on to reduce pain
Subacromial impingement: aetiology
SUPRASPINATUS TENDINOPATHY/PARTIAL RUPTURE of SUPRASPINATUS TENDON = PAIN REPRODUCED by ADDUCTING PRESSURE on PARTIALLY ABDUCTED ARM:
TYPICAL AGE: 35 - 60yrs
MANAGEMENT:
• PHYSIOTHERAPY (ACTIVE SHOULDER MOVEMENT) + PAIN RELIEF • SUBACROMIAL BURSA INJECTION of CORTICOSTEROID W/ LOCAL ANAESTHETIC might help ≥ 6 MONTHS REFRACTORY SYMPTOMS = REFER for consideration of ARTHROSCOPIC SUBACROMIAL DECOMPRESSION
CALCIFYING TENDINOPATHY = one of the ACUTE CALCIFIC TENDINOPATHIES; ACUTE INFLAMMATION of SUPRASPINATUS; PAIN MAXIMAL DURING PHASE of RESORPTION:
TYPICAL AGE: ~ 40yrs
MANAGEMENT:
* PHYSIOTHERAPY * NSAIDs * STEROID INJECTION * RARELY - CALCIUM EXCISION
ACROMIOCLAVIULAR JOINT OSTEOARTHRITIS:
COMMON among YOUNG WEIGHTLIFTERS
MANAGEMENT:
* REST * NSAIDs * STEROID INJECTIONS * EXCISION of AC JOINT = only if RESISTANT to NON-OPERATIVE measures
Subacromial impingement: presentation
- PAINFUL ARC when pt. ABDUCTING = 50° - 120° (or bwtn 45° - 160°) is PAINFUL + CANNOT MOVE BEYOND 180° = due to NARROW SPACE in SUBACROMIAL SPACE
- Only some have painful arc - OTHERS have INCREASING PAIN UP TO FULL ABDUCTION
BIGLIANI DEFINITION (1991)
* PAIN + DYSFUNCTION * RESULTING from ANY PATHOLOGY, which DECREASES the VOLUME of the SUBACROMIAL SPACE/INCREASES the SIZE of ITS CONTENTS ○ DECREASING VOL. of the SPACE = EXTRA BONE ○ INCREASING CONTENTS = SWOLLEN TENDON, SWOLLEN BURSA
The NARROWED SUBACROMIAL SPACE results in the SUPRASPINATUS TENDON CATCHING UNDER the ACROMION during ABDUCTION
Subacromial impingement: management
• STEROID INJECTION + PHYSIOTHERAPY = EQUAL to SURGERY
○ SUBACROMIAL STEROID INJECTION = USS GUIDED, IF ROTATOR CUFF OK = then INJECTION occurs ○ PHYSIOTHERAPY = 1ST ASK PT. WHAT EXERCISES they have SPECIFICALLY DONE - want them to do exercises to STRENGTHEN ROTATOR CUFF MUSCLES specifically • ARTHROSCOPIC SUBACROMIAL DECOMPRESSION = ONLY if above 2 FAILED
Shoulder arthritis: types
- OSTEOARTHRITIS
- INFLAMMATORY ARTHRITIS
- POST-TRAUMATIC ARTHRITIS
Shoulder arthritis: investigations
• X-RAYS = AP + AXILLARY VIEW (axillary view imp. for assessing)
Shoulder arthritis: management
- MECHANICAL SHOULDER REPLACEMENT = rotator cuff has to be intact, otherwise the plastic head of the replacement will wear out due to instability; CERAMIC HEADS also exist
- REVERSE SHOULDER REPLACEMENT (ball is on the socket) = try to MAXIMISE RANGE of DELTOID MOVEMENT
- COMPLEX RECONSTRUCTION using CUSTOM MADE IMPLANTS = based on 3D reconstructions from CT, pt. specific implants rather than standard off the shelf implants
Elbow epidemiology i.e. what conditions are most common in what ages
- YOUNG = FRACTURES & DISLOCATIONS
- MIDDLE AGE = TENDINOPATHIES
- ELDERLY = DEGENERATIVE DISEASE
Elbow dislocation
- V. UNLIKELY in NORMAL PT.
* e.g. PT. ON STEROIDS = OSTEOPOROTIC + POOR SOFT TISSUES
Elbow tendinopathies: presentation
Lateral epicondylitis:
- INFLAMMATION where COMMON EXTENSOR TENDON arises from LATERAL EPICONDYLE of HUMERUS
- CLEAR Hx of REPETITIVE STRAIN
- PAIN = FRONT of LATERAL CONDYLE + WORSE when TENDON MOST STRETCHED (wrist + finger flexion w/ hand pronated
INVESTIGATIONS/DIAGNOSIS:
• CLINICAL TEST: EXTEND WRIST + RESIST EXTENSION of MIDDLE FINGER = IS PAIN ELICITED?
Medial epicondylitis:
- INFLAMMATION of FOREARM FLEXOR MUSCLES at their ORIGIN on MEDIAL EPICONDYLE
- MOST COMMON CAUSE of MEDIAL ELBOW PAIN
- PAIN = WORSE when doing PRONATION + FOREARM FLEXION
- Occasionally ass. w/ ULNAR NEUROPATHY as ulnar nn. runs behind epicondyle
Elbow tendinopathies: management
- PHYSIOTHERAPY - mainly
- PLATELET-RICH PLASMA INJECTION = IN & ~ TENDON - tries to use body’s own healing system + GROWTH FACTORS
1 INJECTION BLINDLY ~ MOST TENDER SPOT
Elbow tendinopathies: aetiology
- DEGENERATIVE CONDITIONS rather than inflammatory conditions
- CASES TYPICALLY LAST 6 - 24 months + 90% RECOVER w/I 1yr
Cubital tunnel syndrome: presentation
• PAIN + PARAESTHESIA in ULNAR DISTRIBUTION
○ 1ST = SENSORY SYMPTOMS then CLUMSINESS of HAND + WEAKNESS of 4 SMALL HAND MUSCLES INNERVATED by ulnar nn.
Cubital tunnel syndrome: pathophysiology
- ULNAR NN. LIKELY to be COMPRESSED in CUBITAL CANAL; could be ANYWHERE ALONG NN. COURSE
- OA/RA NARROWING of ULNAR GROOVE & CONSTRICTION of ulnar nn. as it passes BEHIND MEDIAL EPICONDYLE
- Or FRICTION of ULNAR NN. due to CUBITUS VALGUS (poss. Due to childhood supracondylar fractures) = can cause ULNAR NN. FIBROSIS & ULNAR NEUROPATHY
Cubital tunnel syndrome: investigations
• NERVE CONDUCTION STUDIES = confirm site of lesion
Cubital tunnel syndrome: management
• SURGICAL DECOMPRESSION
