Royal Orthopaedic Hospital

! Ball and socket joint.

! Stability vs Mobility.

PASSIVE ACTIVE

! Musculo-tendinous ! GLENOID & LABRUM ! ROTATOR CUFF cuff. ! -VE INTRA-ARTICULAR MUSCLES ! 4 Muscles:- PRESSURE – Supraspinatus. ! CAPSULE & GLENO – Infraspinatous. HUMERAL LIGAMENTS – Subscapularis. – Teres minor. ! Centres head in glenoid. ! Axillary nerve – shoulder dislocation – Regimental badge ! Age – Deltoid

! Radial Nerve ! Occupation – Humeral shaft fractures – Wrist drop – 1st wed space sensory loss ! Handedness

! Pain or Stiffness ! Instability ! Site and precipitating features ! Functional Problems ! Night pain ! Weakness ! History of trauma ! Radiation ! Sporting history / aspirations

! Localisation to ACJ

! Direction of instability ! Neck

! Frequency ! Pancoast Tumour

! Precipitating factor ! Subdiaphragmatic

! Lax joints anywhere else ! Cardiac ! Look ! Pain with overhead activities

! Feel ! Painful arc

! Move ! Chronic pain and night pain ! Special Tests ! May develop rotator cuff tear

! Haemorrhage and oedema around rotator cuff ! Elderly settles with injection and conservative treatment (young) ! Pain & Stiifness ! Fibrosis and tendinitis (physio, injection and ? operative) ! X rays – Reduced joint space ! In older persons 40+ cuff tear and AC spur – Osteophytes progressive disability – Subchondral calcification ! Requires operative decompression and repair of – cysts the cuff.

TREATMENT ! Insidious pain

! Non Operative ! Loss of ext rotation – Anti inflammatories ! – Activity modification Normal xray – Physiotherapy – Steroid Injections ! Associated with: ! Operative – DM – -MI – Arthroplasty – -Post trauma ! Natural history ! Stability vs Mobility – Self limiting ! ! 6 months worsens Sporting injury ! 6 months plateau – Anterior 85% ! 6 months improves ! Electrocution / Epilepsy ! Probably not true – Posterior 2%

! Treatment: – injection + physiotherapy + analgesia – MUA + injection

! Sensory deficit 12.6% ! Torn Loose ! Born Loose

! Fracture 33% ! Traumatic ! Atraumatic Perron 2003 j emerg med

! Unilateral ! Multidirectional ! Recurrence 60% < 20y 6% > 40y ! Bankart ! Bilateral Te slaa 2004 jbjs

! Surgery ! Rehabilitatation ! Rotator cuff tear 63% >50y ! Inferior Capsular Shift

! Atraumatic: minor trauma ! Multidirectional instability may be present ! Traumatic aetiology ! Unidirectional instability ! Bilateral: asymptomatic shoulder is also loose ! Bankart lesion is the pathology ! Rehabilitation is the treatment of choice ! Surgery is required – Operative intervention is designed to address the Bankart lesion. ! Inferior capsular shift: surgery required if – May tighten capsule by capsular shift. conservative measures fail ! Bony anatomy leads to inherent stability

! Complex bony & liamentous anatomy

! Complex of 3 joints:- ! Ulna nerve

! Humero-ulna – Complex hinge ! Radial nerve

! Radio capitella ! Median nerve – pronation/supination

! Proximal radio ulna – pronation / supination

! Pain & stiffness ! Tennis Elbow: lateral epicondylitis (extensor) ! Golfers Elbow: medial epicondylitis (flexor) ! Locking- loose bodies

! Olecranon bursitis ! Pins & needles , hand weakness ! Osteoarthritis ! Cubital Tunnel Syndrome (ulnar nerve compression) ! Tennis elbow: ! Often middle aged (35 - 50) – Pain reproduction on resisted wrist extension (Mills' Test) ! May be recent history of excessive activity involving that elbow (rarely tennis ! dusting sweeping etc) ! Golferʼs elbow:

! Golferʼs elbow similar history but medial pain less – Pain reproduction on resisted wrist flexion. common than tennis

! Non operative ! Operative ! = “Ulnar neuritis” ! MANAGEMENT – Cubital tunnel – Activity modification – decompression decompression – NSAIDS ! Pain/paraesthesia in – Clasp ulnar nerve distribution – Physiotherapy ! Forced elbow flexion – Transposition – Ultrasound ! – Streroid injections Hypothenar wasting ! Guttering ! Fromentʼs sign

! Inflammation of bursa

! Often pain free

! May be infected by inoculation by foreign bodies ! Nerve compression Syndromes ! Flexor and extensor – Carpal Tunnel Syndrome retinaculum. – Cubital Tunnel Syndrome – Median nerve passes deep to FR with flexor tendons. ! Arthritis Except for palmar – rheumatoid cutaneous branch which is – osteoarthritis superficial!

! Sensory supply to hand ! Trauma from ulna,median and – Tendon injuries radial nerves. – Chronic injuries

! Swellings

! Dupuytrens

! Wrist pain ! hand dominance – specific wrist pathology or generalised ! history of previous injury condition – e.g. Collesʼ fracture, scaphoid fracture – onset ! job / occupation ! rapid: trauma or infection – ability to continue with this ! slow: degenerative – what does job involve? – association with other joint problems ! hobbies – other obvious conditions e.g. RA – musical instruments

! night pain ! Hand pain ! pattern of symptoms – Many similar features to wrist pain – aggravating and relieving factors – Specific location e.g. base of thumb – worse after activity / use – Neurological origins ! pain distribution ! swelling of the wrist/surrounding tissues – carpal tunnel syndrome – ulnar neuritis ! precipitating events ! Functional problems: – holding paper up – lack of grip strength – night time symptoms – dropping items and “clumsiness” – other medical conditions Thyroid, RA, DM – triggering of fingers ! lack of ability to straighten fingers

! swellings Look – rapidity of onset – soft or hard discrete Feel – diffuse single or multiple ! other swellings on bony areas in the body Move

Special tests

! very common Treatment: ! females often ! splint + analgesia ! may not be ! injection symptomatic ! excision ! symptoms donʼt ! arthrodesis correlate with x-rays ! replacement ! Systemic autoimmume disorder ! Other changes DIP joint arthritis (Heberdenʼs nodes) ! mucous cysts. ! Predominantly synovial invovement ! Treat hand therapy ! Goals of treatment – Hot wax and NSAIDs – 1) pain relief ! Arthroplasty (MCP and PIP) – 2) improved function ! Fuse DIP – 3) prevent further damage ! Interposition arthroplasty – 4) cosmesis

! Synovitis can lead to: ! MCP ulnar drift – cause soft tissue stretch and ulnar subluxation of the Cartilage destruction by pannus extensors – pannus is granulation tissue ! Therapy and medical treatment Tendon compression and rupture ! Surgical rebalance of Nerve compression muscles and realignment of the extensor tendons Erosion and dislocation of joints ! New MCP joints

! Hyperextended PIPJ ! Dorsal capsular attrition ! Flexion deformity DIPJ and central slip rupture

! Lateral bands migrate in a palmar direction and act ! Treatment: as flexors of the PIPJ – early - splinting

– late – soft tissue correction or fusion ! Therapy and splintage – sometimes treating more proximal problems may ! Soft tissue procedures resolve the deformity ! Fusion ! Synovitis – synovectomy ! Subluxation and collapse ! Wrist fusion provides a stable base for hand function

! Flexion of DIPJ which corrects passively. ! Early synovitis -medical management ! Rupture/avulsion of ectensor tendon from ! Persistent synovitis -synovectomy distal phalanx. ! Usually treated with mallet ! Specific deformity -corrective reconstruction splint.

! Severe crippling -salvage.

! Fibrosis of longitudinal Risk factors! structures in palmer fascia ! Northern European Races ! Chronic alcoholism ! Contractures of MCPJ & ! Liver disease PIPJ ! Smoking ! Diabetes ! Also associated with ! – penile fibrosis (Peyronieʼs) Epilepsy / Antiepileptics – sole of feet (Ledderhosenʼs) ! Family history (Dupuytrenʼs diathesis) ! Thick knuckle pads (Garrodʼs) ! Consider surgery if ! Congenital or acquired effecting function – Washing face - poking eye – Hand shake ! Thickening of the flexor – Canʼt put hand in pocket – Work place risks tendon such that it does not pass through the sheath.

! Complications – nerve and vessel damage ! Local injection or release – Joint stiffness – Haematoma

! Congenital or acquired ! Thick fluid surrounded by synovium.

! Thickening of the flexor ! Develop around joints or tendon such that it does tendon sheaths, but rarely not pass through the communicate with the sheath. joint. ! Most common around the wrist. ! Local injection or release ! Treatment, beware of recurrence!

! Inflammation affecting ! Causes (ICRAMPS)! EPB and APL. • Idiopathic ! ! Women. Colles, Cushings ! ! 30-50yrs. • ! Finkelsteinsʼs test. • Rheumatoid ! ! Treatment • Acromegaly, amyloid ! – Rest and NSAIDʼs. • Myxoedeoma, mass, (diabetes) mellitus ! – Corticosteroid injection Pregnancy ! (beware of rupture). • – Decompression. • Sarcoidosis, SLE ! Signs: ! Paronychia infection of – Tinelʼs sign nailfold – Phalenʼs sign ! Fight bite – Direct compression sign – MCPJ inoculation with oral – APB weakness organisms – sensory disturbance – Human bites complicated group of organisms treat ! Consider nerve with considerable conduction tests seriousness ! Non-surgical treatment: ! Web space and palmar – splint/analgesia/injection space infections ! Decompression

! signs: – pain (passive extension) – flexed position – local tenderness along tendon sheath – swelling ! Elevation, antibiotics, drainage and irrigation ! Untreated tendon liquefies