Transcript Shoulder and knee lesions

Shoulder lesions
H.Makhmalbaf MD
Consultant Orthopedic & Knee
surgeon
Ghaem Hospital Medical School
Painful arc syndrome
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Pain in mid ROM of abduction
Partial supraspinatus tendon tear
Tendinitis of Supraspinatus
Calcium deposite in supraspin. Tendon
Sub-acromial bursitis
Greater tuberosity fracture
Painful arc syndrome
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Pain in 45° abduction – 160
X-ray calcium deposit or #
H/o trauma? Or inflamation
Conservative treatment mainly
Or acromioplasty
Frozen shoulder
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Painful restriction of ROM
Unknown etiology
Gradually progressive
Chronicity
Slow spontaneous restoration of ROM
Etiology
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Tendinitis of rotator cuff
Bicipital tenosynovitis
Muscle imbalance, inactivity
RSD
Association with cardiovascular dis.
Trauma; degeneration; granulation
tissue; adhesions
Frozen shoulder
Clinical picture
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5th & 6th decades particularly women
Insidious onset ;injury ? Inactivity
Pain over anterolateral of shoulder
Worse at night
Limitation of active & passive ROM
Muscle spasm; internal rotation
Tenderness over bicipital grove
Treatment:
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Bed rest , heat , sedation
If RA :injection of steroids & oral
Pendulum exercises
No forcible movement
Only MUA if necessary
Rarely need surgical release
Lesions of the rotator cuff
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Aging, degenerative change
Rupture of cuff, deltoid takes over
Recurring pain & stiffness, aggravated
by activity in the shoulder & arm
Tenderness over tuberosity & bicipital
grove
H/o fall or lifting, acute pain & snap
Rotator cuff rupture
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Unable to abduct arm
45’ abd. by deltoid, 45- 90 is painful
Size of tear is important
Repair acute tear
Conservative neglected & old
Calcified deposits in the
rotator cuff
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Ca phosphate & Ca carbonate
In the tendon, lig. & capsule
Mainly in the white collar middle age
Freq. Bilateral, men 3rd& 4th decades
Gradual or acute, pain, lim. Abduction
X-ray Ca deposits
Treatment :
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Conservative :
– Ice bag, rest , needle aspiration irrigation
– Diathermy, steroids, exercises
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Surgical :
– Relieves pain completely
– Large deposits, recurrence,
– Resistant to conservative, impingement
Tennis elbow
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Chronic disabling pain
At radiohumeral articulation
Epicondylitis
Degeneration of origin of ext.c.r.brevis
Frequent rotary motion of forearm
Incomplete healing response to stress
of overload & overuse
Treatment :
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Non-operative in 90%
Avoid overuse, brace, steroid injection
Forceful manipulation under LA.
Operative if needed, MUA
Release of tendon, excision of bursa
Rehabilitation
Osteochondritis Dissecan
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Localized disorder of convex joint surf.
Segment of subchondral bone
becomes avascular & separates
Knee & Elbow commonest
Rarely hip & ankle
OCD : cause ;
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Unknown ;impairment of blood supply
Thrombosis of an end artery?
The significance of an injury uncertain
An inborn susceptibility to the disease
Several joints of a patients
Several members of the family
OCD : pathology
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Segment of articular surface avascular
A line of demarcation forms
Various sizes:1-3 cm in the knee
Always in the convex surface
Small segments reattach spontaneous
Or separates and form lose body
Cavity; irregularity; OA
OCD : clinical features
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Adolescent or young adult
Aching ; mechanical irritation
Recurrent effusion
After separation:locking, pain, effusion
O/E : effusion, wasted quads, ROM ok
OCD : radiographic
features
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A clear cut defect of the bone
Of the articular surface
Med. Femoral condyle of the knee
Cavity with or without fragment
Lose body in place or elsewhere
Tunnel view: P/A knee semiflexed
Osteochondritis Dissecan
OCD : knee arthroscopy
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Clearly evident, for staging
Articular surface sometimes normal
Softening, partial separation
Or total separation in place or out
Lose body
OCD : treatment
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In developing stage; knee support
Avoid strenuous activity
Heals spontaneously or
Removal of lose body or fixation of
A large fragment
Congenital dislocation of
patella
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Familial & bilateral
Occasionally with Arthrogryposis M.C
And Dawn syn.
Persistent & irreducible, +orgenovalgum & ext. rot. Of tibia
Quads contracture
Cong. Dislocation of patella
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Late diagnosis, patella ossifies at 3-4y
Early operation
Lateral release
Medial plication of capsule
Tibial tubercle transfer
Osgood-Schelatter’s dis.
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Apophysitis of tibial tubercle in
childhood
T.T. becomes enlarged and painful
Is strain of developing tibial tubercle
From the pull of patella tendon
O.S: clinical picture
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Child of 10-14y, usually a boy
Pain in front of the knee
Worse on strenuous activity
T.T. prominent & painful
Tender on palpation
Knee extension against resistant
O.S.
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Enlargement or fragmentation on X-R
Self-limiting, normal function when
tubercle fused
Rest in plaster for two month if
Osgood Schelatter
Osteoarthritis :OA
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Is a degenerative wear & tear in joints
That are impaired by congenital defect
vascular insufficiency, or previous
disease or injury
Is the commonest variety of arthritis
Caused by wear & tear
OA
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No stress no OA
Less OA in the joints of the upper limb
A predisposing factor accelerates w&t
Any abnormality may be responsible
Congenital ill-development
Previous fracture
OA : predisposing factors
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Internal derangement: lose body
Previous disease: RA, hemophilia
Mal-alignment of a joint, bow leg
Obesity & overweigth
Age alone is not a cause of OA
Impaired capacity for repair after
injury
Overview of the process
OA: pathology
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Any joint may be affected
Articular cartilage is worn away
Subchondral bone exposed
Osteophytes form at the margin
No primary change in capsule or synov
Often thickening & fibrosis later
Cartilage destruction
OA: clinical features
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Most patients are past middle age
If younger; a clear cause is
Gradual onset, pain
Restriction of ROM; deformity
O/E : bony thickening, osteophytes
Not warm, limitation of ROM, fixed def
OA: X-ray
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Diminution of cartilage space
Subchondral sclerosis
Spurring or lipping of the joint margins
Cyst formation
Severe OA
OA: diagnosis
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History
Clinical findings
X-ray features
OA is not confused with inflammatory
No synovial thickening, no local warm.
No muscle spasm no rarefaction on XESR is not increased
OA: treatment
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No treatment
Conservative
Operative treatment
Reassurance and advice
Conservative : physio, heat, exercises
Analgesics, support, stick
OA: surgical treatment
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Osteotomy for realignment
Arthroplasty and replacement
Arthrodesis
OA of the knee
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Knee is the commonest
Particularly in elderly & fat woman
Previous damage: torn menisci
OCD, torn ligaments
Malalignment of tibia on the femur
Usually both knees
OA of the knee: O/E
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Osteophytes
Effusion unusual
Limitation of ROM, crepitation
Wasted quadriceps
Varus deformity> valgus
Limitation of extension
Knee deformity & OA
OA of the knee; treatment
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Conservative : heat , phyisio
Steroid injection
surgery
In the worst cases
Sever persistent pain
Especially with deformity
Operative treatment:
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Arthroscopy & removal of lose bodies
UTO
Excision of patella (or elevation)
Arthroplasty
Arthrodesis
Thank you