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)! !" Golfer#s elbow:! !" Golfer#s 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! !" Froment#s 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. Colles# 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 don#t !" ! arthrodesis! correlate with x-rays! !" ! replacement! !" Systemic autoimmume disorder ! !" Other changes DIP joint arthritis (Heberden#s 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 (Peyronie#s)! " Epilepsy / Antiepileptics ! –" sole of feet (Ledderhosen#s)! !" Family history (Dupuytren#s diathesis)! !" Thick knuckle pads (Garrod#s)! !" Consider surgery if !" Congenital or acquired ! effecting function! –" Washing face - poking eye! –" Hand shake! !" Thickening of the flexor –" Can#t 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.! • !" Finkelsteins#s test.! •" Rheumatoid ! !" Treatment! •" Acromegaly, amyloid ! –" Rest and NSAID#s.! •" Myxoedeoma, mass, (diabetes) mellitus ! –" Corticosteroid injection " Pregnancy ! (beware of rupture).! • –" Decompression.! •" Sarcoidosis, SLE ! !" Signs:! !" Paronychia infection of –" Tinel#s sign! nailfold! –" Phalen#s 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!.