Royal Orthopaedic Hospital! !  Ball and socket joint.! !  Stability PASSIVE ACTIVE GLENOID & LABRUM !  -VE INTRA-ARTICULAR PRESSURE !  CAPSULE & GLENO HUMERAL LIGAMENTS !  !  ROTATOR CUFF MUSCLES vs Mobility.! Musculo-tendinous cuff.! !  4 Muscles:-! !  –  Supraspinatus.! –  Infraspinatous.! –  Subscapularis.! –  Teres minor.! !  Centres head in glenoid.! !  Axillary nerve! –  shoulder dislocation! –  Regimental badge! –  Deltoid! !  Radial Nerve! –  Humeral shaft fractures! –  Wrist drop! –  1st wed space sensory loss! !  Pain !  Age! !  Occupation! !  Handedness! or Stiffness! !  Instability! !  Functional Site and precipitating features! !  Night pain ! !  Radiation! !  Localisation to ACJ! Problems! !  Weakness! !  History !  of trauma ! history / aspirations! !  Sporting !  Direction of instability! !  Frequency! !  Precipitating !  Lax !  Neck! !  Pancoast factor! joints anywhere else! Tumour! !  Subdiaphragmatic! !  Cardiac! !  Pain with overhead activities! !  Painful arc! !  Chronic pain and night pain! !  May develop rotator cuff tear ! Haemorrhage and oedema around rotator cuff settles with injection and conservative treatment (young) ! !  Fibrosis and tendinitis (physio, injection and ? operative) ! !  In older persons 40+ cuff tear and AC spur progressive disability ! !  Requires operative decompression and repair of the cuff.! !  Elderly! !  Pain & Stiifness! !  X rays! TREATMENT! !  !  Look ! !  Feel! !  Move! !  Special Tests! !  !  Non Operative! –  –  –  –  Anti inflammatories! Activity modification! Physiotherapy! Steroid Injections ! –  –  –  –  Insidious pain! Loss of ext rotation! !  Normal xray! !  !  !  Operative! –  Arthroplasty! Reduced joint space! Osteophytes! Subchondral calcification! cysts! Associated with:! –  DM ! –  -MI! –  -Post trauma ! !! !  Natural history! !  Stability vs Mobility! !  Sporting injury! –  Anterior 85%! !  Electrocution / Epilepsy! –  Posterior 2%! –  Self limiting! 6 months worsens! 6 months plateau! !  6 months improves! !  !  !  !  Probably not true! Treatment:! –  injection + physiotherapy + analgesia! –  MUA + injection! !  Sensory deficit 12.6% !  Torn Loose !  Born Loose !  Fracture 33% !  Traumatic !  Atraumatic !  Unilateral !  Multidirectional !  Bankart !  Bilateral !  Surgery !  Rehabilitatation !  Inferior Capsular Shift Perron 2003 j emerg med !  Recurrence 60% < 20y 6% > 40y Te slaa 2004 jbjs !  Rotator cuff tear 63% >50y !  Atraumatic: !  Traumatic aetiology !  Unidirectional instability !  Bankart lesion is the pathology !  Surgery is required –  Operative intervention is designed to address the Bankart lesion. ! –  May tighten capsule by capsular shift.! minor trauma !  Multidirectional !  Bilateral: instability may be present asymptomatic shoulder is also loose !  Rehabilitation !  Inferior is the treatment of choice capsular shift: surgery required if conservative measures fail !  Complex of 3 joints:-! !  Humero-ulna! –  Complex hinge! !  Radio capitella! !  Bony anatomy leads to inherent stability! !  Complex bony & liamentous anatomy! !  Ulna nerve! !  Radial nerve! !  Median nerve! –  pronation/supination! !  Proximal radio ulna! –  pronation / supination! !  Pain & stiffness ! !  !  Locking- loose bodies ! !  Olecranon bursitis! Osteoarthritis! !  Cubital Tunnel Syndrome (ulnar nerve compression)! !  !  Pins & needles , hand weakness! Tennis Elbow: lateral epicondylitis (extensor) ! Golfers Elbow: medial epicondylitis (flexor)! !  !  Often middle aged (35 - 50)! !  May be recent history of excessive activity involving that elbow (rarely tennis ! dusting sweeping etc)! !  Golferʼs elbow similar history but medial pain less common than tennis! !  Non operative! –  –  –  –  –  –  Activity modification! NSAIDS! Clasp! Physiotherapy! Ultrasound! Streroid injections! !  Inflammation of bursa! !  Often pain free! !  May be infected by inoculation by foreign bodies! !  Operative! –  decompression! !  Tennis elbow:! –  Pain reproduction on resisted wrist extension (Mills' Test)! !  Golferʼs elbow:! –  Pain reproduction on resisted wrist flexion.! !  = “Ulnar neuritis”! Pain/paraesthesia in ulnar nerve distribution! !  Forced elbow flexion! !  Hypothenar wasting! !  Guttering! !  Fromentʼs sign! !  !  MANAGEMENT! –  Cubital tunnel decompression! –  Transposition! !  Flexor and extensor retinaculum.! –  Median nerve passes deep to FR with flexor tendons. Except for palmar cutaneous branch which is superficial!! !  Sensory supply to hand from ulna,median and radial nerves.! !  Wrist pain ! –  specific wrist pathology or generalised condition! –  onset! !  rapid: trauma or infection! !  slow: degenerative! –  association with other joint problems! –  other obvious conditions e.g. RA! !  night pain ! !  pattern of symptoms! –  aggravating and relieving factors! –  worse after activity / use! !  swelling of the wrist/surrounding tissues! !  Nerve compression Syndromes! –  Carpal Tunnel Syndrome! –  Cubital Tunnel Syndrome! !  Arthritis! –  rheumatoid! –  osteoarthritis! !  Trauma! –  Tendon injuries! –  Chronic injuries! !  Swellings! !  Dupuytrens! !  hand dominance! of previous injury! !  history –  e.g. Collesʼ fracture, scaphoid fracture! !  job / occupation! –  ability to continue with this! –  what does job involve?! !  hobbies! –  musical instruments! !  Hand pain! –  Many similar features to wrist pain! –  Specific location e.g. base of thumb! –  Neurological origins! !  pain distribution! –  carpal tunnel syndrome! –  ulnar neuritis! !  precipitating events! –  holding paper up! –  night time symptoms ! –  other medical conditions Thyroid, RA, DM! !  Functional !  lack !  swellings! –  rapidity of onset! –  soft or hard discrete! –  diffuse single or multiple! !  other swellings on bony areas in the body! problems:! –  lack of grip strength! –  dropping items and “clumsiness”! –  triggering of fingers! of ability to straighten fingers! Look ! Feel! Move ! Special tests! !  very common! !  females often! !  may not be symptomatic! !  symptoms donʼt correlate with x-rays! Treatment:! !  ! splint + analgesia! !  ! injection! !  ! excision! !  ! arthrodesis! !  ! replacement! !  Other changes DIP joint arthritis (Heberdenʼs nodes)! !  mucous cysts.! !  Treat hand therapy! !  Systemic !  Predominantly !  Goals –  Hot wax and NSAIDs! !  Arthroplasty !  Fuse !  arthroplasty! Synovitis can lead to: ! Cartilage destruction by pannus! –  pannus is granulation tissue! Tendon compression and rupture! !  !  Hyperextended PIPJ! Flexion deformity DIPJ! !  Treatment:! !  –  early - splinting! –  late – soft tissue correction or fusion! –  sometimes treating more proximal problems may resolve the deformity! MCP ulnar drift ! –  cause soft tissue stretch and ulnar subluxation of the extensors ! !  !  Nerve compression! Erosion and dislocation of joints! synovial invovement! of treatment! –  !1) pain relief !! –  ! 2) improved function ! –  ! 3) prevent further damage ! –  ! 4) cosmesis! (MCP and PIP) ! DIP! !  Interposition autoimmume disorder ! !  Therapy and medical treatment ! Surgical rebalance of muscles and realignment of the extensor tendons ! New MCP joints! !  Dorsal capsular attrition and central slip rupture! !  Lateral bands migrate in a palmar direction and act as flexors of the PIPJ! !  Therapy and splintage! Soft tissue procedures! Fusion! !  !  !  Synovitis! –  synovectomy! !  Subluxation and collapse! fusion provides a stable base for hand function! !  Wrist !  !  Early synovitis ! !-medical management! !  Persistent synovitis !-synovectomy! !  Specific deformity !-corrective reconstruction! !  Severe crippling ! !-salvage.! !  Fibrosis of longitudinal structures in palmer fascia! !  !  Contractures of MCPJ & PIPJ! !  Also associated with! –  penile fibrosis (Peyronieʼs)! –  sole of feet (Ledderhosenʼs)! !  Thick knuckle pads (Garrodʼs)! !  Flexion of DIPJ which corrects passively.! Rupture/avulsion of ectensor tendon from distal phalanx.! Usually treated with mallet splint.! Risk factors! !  !  !  !  !  !  !  Northern European Races! Chronic alcoholism! Liver disease! Smoking! Diabetes! Epilepsy / Antiepileptics ! Family history (Dupuytrenʼs diathesis)! !  Consider surgery if effecting function! –  –  –  –  !  Washing face - poking eye! Hand shake! Canʼt put hand in pocket! Work place risks! !  Congenital or acquired ! !  Thickening of the flexor tendon such that it does not pass through the sheath.! !  Local injection or release! Complications! –  nerve and vessel damage! –  Joint stiffness ! –  Haematoma ! !  Congenital or acquired ! !  !  Thickening of the flexor tendon such that it does not pass through the sheath.! !  !  Local injection or release! !  !  !  !  !  !  !  Inflammation affecting EPB and APL.! Women. ! 30-50yrs.! Finkelsteinsʼs test.! Treatment! –  Rest and NSAIDʼs.! –  Corticosteroid injection (beware of rupture).! –  Decompression.! Thick fluid surrounded by synovium.! Develop around joints or tendon sheaths, but rarely communicate with the joint.! Most common around the wrist.! Treatment, beware of recurrence!! !  Causes (ICRAMPS)! •  Idiopathic ! •  Colles, Cushings ! •  Rheumatoid ! •  Acromegaly, amyloid ! •  Myxoedeoma, mass, (diabetes) mellitus ! •  Pregnancy ! •  Sarcoidosis, SLE ! !  Signs:! –  –  –  –  –  !  !  Tinelʼs sign! Phalenʼs sign! Direct compression sign! APB weakness! sensory disturbance! Consider nerve conduction tests! Non-surgical treatment:! –  splint/analgesia/injection! !  Decompression! !  signs:! –  pain (passive extension)! –  flexed position ! –  local tenderness along tendon sheath! –  swelling! !  !  Elevation, antibiotics, drainage and irrigation! Untreated tendon liquefies! !  !  Paronychia infection of nailfold! Fight bite! –  MCPJ inoculation with oral organisms! –  Human bites complicated group of organisms treat with considerable seriousness! !  Web space and palmar space infections!