Transcript Treatment

Review Anatomy
Of
The Shoulder
The shoulder
consists of four
joints:




Glenohumeral.
Acromioclavicular
Sternoclavicular
Scapulothoracic
Cup and saucer joint

Labrum around edge of
saucer
Capsule and capsular
ligaments

Dynamic “cuff” of muscles

Subscapularis anterior
Supraspinatus superior
Infraspinatus posteriorsuperior
Teres minor posterior
Long head of biceps intra-articular




 The
patient should always be
examined from the front and from
the behind.
 Both upper limbs and the chest
must be visible.
 Examination of the shoulder
must include a full examination of
the neck and vice versa.
Basic Examination; Inspection
 General:
Swelling
Erythema
Joint Deformity
Muscle wasting
Front:



Sternoclavicular Joint
prominence
Clavicle deformity
Acromioclavicular
joint prominence
Side:
Swelling
Behind:
Scapula shape and
situation
Webbing of the skin
Winging
 Above:
Clavicle
Supraclavicular fossa
Swelling
Basic Examination; Palpation




temperature
Crepitations
Bony tenderness
Humeral head and shaft
Basic Examination; Movement
Active before
passive
Shoulder
Girdle
Movements
Elevation
50°
0 - 170°
Abduction
Adduction
FLEXION
0 - 165°
Depression
EXTENSION
0 - 60°


Internal rotation in abduction - 70°
External rotation in extension - 70°
Supraspinatus Weakness
Drop
Arm Test.
Bicep Tendon Irritation
Speed’s
Test.
Apprehension tests
Investigations










X-ray
WBC
ESR
Blood Culture
Aspiration of the Joint
CAT
MRI
Arthroscopy
Arthography
Examination under anesthetic
Shoulder
Disorder of the rotator
cuff

A acute tendinitis.

Chronic tendinitis (Impingement

Rotator Cuff Tears.

Frozen Shoulder.
Syndrome).
Supraspinatus Tendinitis
acute calcific tendinitis
 Pain
is caused by inflammation of
the tendon and subacromial bursa.
 Age
43
of onset is
 Men
being more
affected.
commonly
Clinical features
Rapid
onset
without
Warning. Disturbance of sleep.
Severe pain.
Apprehension to move the
arm.
Acute localised
tenderness.
Shoulder Impingement Tests
 Hawkins-Kennedy
Test.
Neer’s
Test
X-ray :
calcium deposit close to insertion of the
Supraspinatus tendon.
Treatment
 mild
cases :
Rest with sling.
Anti-inflammatories
Severe
cases :
1.long acting steroid injections
(methylprednisolone 40-80 mg).
with local anaesthetic (lignocaine 1%).
2.If symptom not relieved surgery for
removal calcific material.
Impingement
Syndrome

The pain is due to
irritation
of
the
Supraspinatus tendon.

Commonly caused by
repeated
overhead
movements
which
cause pinching of the
tendon.
The clinical features
 Patient
age 40-60 years.
Onset usually insidious .
 But can be sudden after overuse.
 Painful lateral aspect of upper arm(
over the deltoid muscle).
 Worse at night.

can not lie on
affected arm.
 The shoulder looks
normal.
 pain on overhead and
behind the back
movements.

 Repeating
the movement with the arm in
full external rotation may be easier and
painless
(pathognomonic
of
Supraspinatus
tendinitis)
 Crepitus
or
clicking
during
movement.
 In long standing cases wasting of
the muscles
 Loss of power
 Movement specially abduction and
external rotation are restricted.
Treatment
 Rest
in
the
younger patient,
modification of
activity (i.e. not
playing
golf/
racket sports).
In chronic cases

Physiotherapy.

analgesics and sometimes steroid
and local anaesthetic injections
become necessary.
If symptoms keep recurring,
operation is advisable by
decompressing
the
coracoacromial ligament (now

a
day
done
arthroscopy)
by
Operative



Acromioplasty
Coracoacromial ligament
release
Rotator Cuff Tear
Minor
 In
minor tears the
Supraspinatus
muscle is still able
to function.
Major
 In
a major tear
there is no activity
of
the
Supraspinatus
muscle.
Clinical features
 The
patient is usually aged 45-75.
 While lifting a weight or protecting
himself from falling, he 'sprains' his
shoulder.
 Pain is felt immediately.
 Unable to lift his arm sideways.
The
appearance is usually
normal.
 but in longstanding cases there
is Supraspinatus wasting.
 Tenderness may be diffuse or
may be localized to just below
the tip of the acromion process.

With a recent injury,
active abduction is
grossly limited and
painful.
To distinguish between
partial and complete
tears, pain is abolished
by injecting a local
anesthetic.
 if active abduction is
now possible, the tear
must be only partial.

Weeks later




Two types are easily
differentiated.
With a complete tear.
Pain has by then
subsided.
Active abduction is
impossible .

Passive abduction is full and
once the arm has been lifted
above a right angle, the
patient can keep it up by
deltoid (the abduction
paradox).

When he lowers it sideways
it suddenly drops (the
drop-arm sign). 


With a partial tear.
abduction slowly recovers.
Investigations
 The
diagnosis may
be confirmed by
ultrasonography.
M
RI
 Arthroscopy
Frozen Shoulder
 The
term frozen shoulder should he
reserved for,
((((a well-defined disorder characterized
by progressive pain and stiffness
which usually resolves spontaneously
after about
18
months))).

The patient, aged 40-60.
May give a history of trauma, often trivial.
 Pain gradually increases in severity.
 Prevents sleeping on the affected side.
 After several months pain begins to
subside.


But
as
it
does
becomes more
so,
stiffness
and more.
 Untreated,
stiffness persists for another 612 months. Gradually movement is
regained, but may not return to normal.
 Usually there is nothing to see except slight
wasting.
 There may also be some tenderness.
 But movements are always limited and in
a severe case the shoulder is extremely stiff.
Stages:



Freezing
Moderate diffuse
pain, normal but
painful motion.
Frozen
Pain
subsides,
leaving stiffness and
severe decrease in
function.
Thawing
Return to normal
function gradually.
X-rays

Show decreased bone
density in the humerus.

Arthrography shows a
contracted joint.
Frozen Shoulder: Treatment

Freezing:
Try to abort in the inflammatory stage, local heat ,
NSAIDs, cortisone injection locally sometimes help ,
physiotherapy.

Frozen or Thawing:
Manipulation under GA if no progress with
physio
Arthroscopic release for resistant cases

Both upper limbs must be complete."
and it is essential to look for the
exposed
back
as well the
front.

neck
The
,shoulder and
also be examined.
hands
should




look
Looking at the patient from
the front,
with his or her arms in the
anatomic position.
the elbows are seen to be held
in 5-10
valgus;
this
is
degrees
the
of
normal
'carrying angle'.
 Anything
more, especially if unilateral,
is regarded as a valgus deformity.
 Varus
deformity is less obvious.

The most
swelling is
common
in the
olecranon bursa
at the back of the elbow.
Feel
Important bony landmarks are the medial
and lateral condyle ,and the tip of the
olecranon.
 These are palpated to determine whether
the joint is correctly positioned.
 Superficial structures are examined for
warmth and subcutaneous nodules.

The joint line (including
the radioulnar joint
 depression is located
and
palpated
for
synovial thickening.
 Tenderness can usually
be localized to a
particular structure.

 The
ulnar nerve
is fairly superficial
behind
the
medial
condyle and here it can
be tolled under
Movement

Flexion
and
extension
are
compared on the
two sides.
the radioulnar joints are :
pronation and supination
General examination


symptoms and signs do not point
clearly to a local disorder,
other parts are examined:
the neck
lesions),
for cervical disc
the shoulder (for cuff lesions)
the
hand (for nerve lesions)
Radiological examination
position of each bone is noted.
 then the joint line and space.
 Next, the individual bones are inspected
for evidence of old injury or bone
destruction.
 Finally, loose bodies .

ELBOW
DEFORMITIES
CUBITUS VARUS
(or 'gun-stock') deformity



is most obvious when the
elbows are extended and the
arms are elevated.
The most common cause is
malunion
of
a
supracondylar fracture.
The deformity can be
corrected
by
a
wedge
Osteotomy of the lower
humerus.
CUBITUS VALGUS



The most common cause
is non-union of a fractured lateral
condyle; this may give gross
deformity and a bony knob on the
inner side of the joint.
The importance of valgus deformity
is the liability for
ulnar palsy
delayed
to develop;
years after the causal injury,
the
patient
notices
weakness of the hand with
numbness and tingling of
the ulnar fingers.
 The deformity itself needs
no treatment.
 but for delayed ulnar palsy
the nerve should be
transposed to the front
of the elbow

'TENNIS ELBOW'
 The
cause of these common disorders is
unknown.
 Most cases follow minor trauma or
repetitive strain on the tendon
aponeuroses attached to the lateral .


Pain is probably due to a vascular repair
process similar to that of rotator cuff
tendinitis around the shoulder.
Often there is a history of occupational stress
or unaccustomed
1.
2.
3.
activity.
such as house painting,
carpentry or
other activities that involve strenuous wrist
movements and forearm muscle contraction
Clinical features
pain is felt over the outer side of the elbow.
 in severe cases it may radiate widely.
 It is initiated or aggravated by movements
such as pouring out tea.
turning a stiff door-handle.
shaking hands or.
lifting with the forearm.

(c)
(a)
(a)Tenderness over the
anterior
aspect of the lateral
epicondyle; (b) pain provoked
by resisted wrist extension; (c)
tennis elbow surgery – the
abnormal extensor carpi
radialis brevis origin is excised
(b)
 The
elbow looks normal and flexion and
extension are full and painless.
is localized to a spot just
below the lateral epicondyle, and pain is
reproduced by getting the patient to
extend the wrist against resistance.
 Tenderness
 Or
simply
by
passively flexing the
wrist so as to
stretch
the
common extensors.
Treatment



Rest and analgesia.
If pain is severe. the area of
maximum tenderness is
injected with a mixture of
corticosteroid and local
anaesthetized .
Persistent pain
surgery with detachment
origin at the humeral
epicondyle
'GOLFER'S ELBOW'
In golfer's elbow


Similar
symptoms
occur
around the medial epicondyle
and, owing to involvement of
the common tendon of origin
of the wrist flexors.
pain
is
reproduced
by
passive extension of the
wrist.
Treatment



Rest, or avoiding the precipitating activity, allow the
lesion to heal.
If pain is severe, the area of maximum tenderness is
injected with a mixture corticosteroid and local
anaesthetic.
Persistent pain which fails to respond conservative
measures may call for operative treatment.
(((The affected common tendon on the medial side of
the elbow is detached from its origin at the humeral
epicondyle))).
PULLED ELBOW
“Nursemaids
Elbow”
Anatomy
A
pulled elbow
is due to the radial head
stretching the ligament and
slipping out from under its
cover.
occurs in children in the 2-6 age group,
 and is a common in young children
between 1 and 4 years of age.
 It
 It
is rare beyond the age of
 condition
6 years
that young children often get
from being swung around while
being held by the lower arms .

commonly occurs when
being grabbed suddenly
by the wrist, e.g. to
prevent a child running
into the road, or when a
child falls while his hand
is being held.

jerky pressure on the
elbow joint can pop the
radial head out from
under the ligament.
is not a considered a dislocation
of the elbow, which
 is extremely rare in young children.
 A child will begin to cry right after the
injury, and
 can not move the affected forearm
because of the pain.
 This

The arm is slightly bent at
the elbow, and the forearm
is usually held in front of
the stomach.

The patient’s history and
distinct posture of the
affected forearm make the
diagnosis.

An X-ray is
required.
not
usually
Investigation
X rays are unnecessary if there is a typical
history and no visible swelling or deformity.
 If the child has a pulled elbow the X ray is
normal.
 The child may have normal use of the arm on
return from radiology since positioning by the
radiographer may solve the problem.

Management

A pulled elbow is corrected by a
specific manipulation, which is
uncomfortable for a moment, a
click is often felt as the radial
head pops back under the
ligament.

The child will start
the
arm
afterwards.
using
soon
 If
the elbow is not corrected with
manipulation,
 the arm is rested in a sling as
spontaneous correction usually occurs
within 48 hours.
 You may wish to give your child pain
relief.
HOW TO PREVENT THIS FROM
HAPPENING
AGAIN



Avoid lifting or pulling a
child by the hands, wrist or
forearms.
Avoid swinging a child
around by their wrists or
forearms.
Use upper arms or arm-pits
to lift the child
OLECRANON BURSITIS

The
olecranon
bursa
sometimes
becomes
enlarged as a result of
pressure or friction. When it
is also painful, the
 Cause is more likely to
be infection.
gout or .
rheumatoid arthritis.
Treatment
 The
underlying disorder must be
treated.
 Septic bursitis may need local drainage.
 Occasionally a chronically enlarged
bursa has to be excised.
Wrist and hand
Anatomy
WRIST
DEFORMITIES
CONGENITAL
DEFORMITIES
Radial club-hand
 The
infant is born with
the wrist in marked
radial deviation.
 There
is absence of the
whole or part of the
radius, and usually
also the thumb.
Treatment
 In
the neonate consists of gentle
manipulation and splintage.
 If
function
deteriorates,
centralization of the carpus over
the
ulna
is
recommended,
preferably before the age of 3
years
Madelung's deformity


The
carpus
is
deviated
forwards, leaving the ulnar head
projecting on the back of the
wrist.
Deformity is seldom marked
before the age of 10 years.

function is usually excellent.

in the worst cases the deformity
may have to be corrected by
Osteotomy
RHEUMATOID ARTHRITIS
Wrist



After the metacarpophalangeal
joints.
the wrist is the most common site
of rheumatoid arthritis.
Pain.

swelling and tenderness may at
first be localized to the radioulnar
joint.

or to one of the tendon sheaths.

Sooner or later the whole
wrist becomes involved
and tenderness is much
more ill-defined.

In late cases the wrist is
deformed and unstable
ulnar deviation
Hand and
fingers
 To
start synovitis of the proximal
joints and tendon sheaths; later, joint
and tendon erosions.
 final
stage, joint instability and
tendon rupture cause progressive
deformity and loss of function.
 Pain
and stiffness of the fingers are
early symptoms.
 As
the
disease
progresses,
deformities begin to appear
 Ulnar
deviation of
the fingers and
subluxation of the
Mp joints, often
associated with
 boutonniere
deformities
swan-neck

Boutonniere.

Swan-neck deformity
 Extensor
tendons
may rupture where
they cross the dorsum
of the wrist. causing
one or more of the
fingers to drop into
flexion
 Dropped
 Ruptured
finger.
extensor
pollicis longus
X ray

The
characteristic
features are osteoporosis
and bony erosions.

Narrowing joint space.
small
periarticular
erosions appear
Treatment

Management in the early stage
consists of splintage.

local injection of corticosteroids.

Combined with systemic treatment.
Treatment
 At
late stage surgery different type.
KIENBOCK'S DISEASE
After injury or stress.
 The lunate bone may develop a patchy avascular
necrosis.


A predisposing factor:
may be relative shortening of the ulna .
which could result in excessive stress being
applied to the lunate where it is squeezed
between the distal surface of the (overlong)
radius and the second row of carpal bones.
 The
patient, usually a young adult.
 Complains of ache and stiffness.
 Tenderness is localized to the centre of
the wrist on the dorsum.
 wrist extension may be limited.
Imaging

The
earliest
signs
of
osteonecrosis can be detected
only by MRI.

Typical x-ray signs are
increased density in the lunate.
later osteoarthritis of the
wrist.

Treatment

During the early stage, while the shape of the lunate is
more or less normal, osteotomy of the distal end of
the radius may reduce pressure on the bone and
thereby protect it from collapsing.

In late cases, partial wrist arthrodesis may be the only
option.
DE QUERVAIN'S
DISEASE

Tenovaginitis of the first dorsal compartment is usually seen in
women between the ages of 30 and 50 years.

There
may
activity,
be
a
history
such as pruning roses,
cutting with scissors or
wringing out clothes.
of
unaccustomed
Clinical features




Pain.
and sometimes swelling, is
localized to the radial side of
the wrist.
The tendon sheath feels
thick and hard.
Tenderness is most acute at
the very tip of the radial
styloid.

The pathognomonic sign :

is elicited by
Finkelsteins
test..

Hold the patient's hand firmly,
keeping the thumb tucked in close to
the palm, then turn the wrist sharply
towards the ulnar side.

A stab of pain over the radial styloid
is a positive sign. Repeating the
movement with the thumb left free
is relatively painless.
Treatment

In early cases, symptoms can be relieved by
.
ultrasound therapy

Or a corticosteroid injection into the tendon
sheath.

Sometimes combined with splintage of the wrist.
Resistant cases need an

Operation, which consists
of slitting the thickened
tendon sheath.

Care should be taken to
prevent injury to the
dorsal sensory branches
of the radial nerve, which
may cause intractable
dysaesthia.
GANGLION
 The
ubiquitous ganglion:
 is seen most commonly on the back of
the wrist.
 It arises from cystic degeneration in the
joint capsule or tendon sheath.
 The distended cyst contains a glairy fluid






The patient, often a young
adult.
presents with a painless
lump.
usually on the back of the
wrist.
Occasionally there is a slight
ache.
The lump is well defined,
cystic and not tender.
It may be attached to one of
the tendons.
Treatment


The ganglion often disappears after some
months, so there should be no haste about treatment.
If the lesion continues to be troublesome, it can be
aspirated.

if it recurs, excision is justified, bur the patient should
be told that there is a 30 per cent risk of
recurrence, even after careful surgery .
CARPAL TUNNEL SYNDROME



This is the commonest and best
known of all the nerve entrapment
syndromes.
In the normal carpal tunnel there is
barely room for all the tendons
and the median nerve .
Any swelling is likely result in
compression and
of the nerve.

Common in
ischaemia
women at
the menopause, in rheumatoid
arthritis, in pregnancy and in
myxoedema.
Clinical features


The usual age group is 40-50 years
The history is most
diagnosis.
helpful in making the

Pain and paraesthesia occur in the distribution of
the median nerve in the hand.

Night after night the patient is woken with burning.
 Patients
tend to
seek relief by
hanging the arm
over the side of
the
bed
or
shaking the arm.

helpful test (Tinels
sign) :
sensory symptoms can
often be reproduced
by percussing over the
median nerve.
Phalens test:
 Holding
the wrist
fully flexed for a
minute or two .


late cases there is
In
wasting of
muscles.
the
thenar
weakness
of
thumb
abduction
and
sensory
dulling in the median nerve
territory.
 Electrodiagnostic
tests. which show
slowing of nerve
conduction across the
wrist.
Treatment


Light splints that prevent wrist flexion can help
those with night pain or with pregnancy-related
symptoms.
Steroid injection into the carpal canal, likewise,
provides temporary relief .

Endoscopic carpal tunnel
release offers an alternative
with
slightly
quicker
postoperative rehabilitation.

Open surgical division of
the
transverse
carpal
ligament usually provides a
quick and simple cure.
 Alternative
therapies.
Acupuncture . have
benefited
some
patients but their
effectiveness
remains unproved.
Hand
ACUTE INFECTIONS OF THE
HAND
Infection of The hand is frequently limited or
one of several well-defined compartments:
 Nail fold (paronychia).
 The pulp space (whitlow).
 Subcutaneous tissues elsewhere.
 A tendon sheath.
 One of the deep fascial spaces or a joint.

Almost invariably the cause
is a Staphylococcus which
has been implanted by trivial
or
unobserved
injury.
Pathology



Acute inflammation and suppuration in small closed
compartments (e.g. The pulp space or tendon sheath)
may cause an increase in pressure to levels at which
the local blood supply is threatened.
In neglected cases tissue necrosis is an immanent
risk.
Even if this does not occur, the patient may end up
with a stiff and useless hand unless the infection is
rapidly control.
Clinical features

Usually there is a history of trauma, but it may have
been so trivial as to pass unnoticed.

A thorn prick can be as dangerous as a cut Within
a
day or two, the finger (or hand) becomes painful
and swollen.
Clinical features





The patient may feel ill.
feverish and the pain becomes throbbing.
obvious redness and tension in the tissues.
exquisite tenderness over the site of infection.
Finger movements may be markedly restricted.
Principles of treatment
Antibiotics

As soon as the diagnosis is made and specimens
have been taken for microbiological investigation,
antibiotic treatment is started - usually with
 flucloxacillin
and, in severe cases, with
fusidic acid
 or a cephalosporin as well.
 This may later be changed when
bacterial sensitivity
is known.




Rest and elevation
In a mild case the hand
is rested in a sling.
In a severe case the arm
is elevated in a roller
towel.
while the patient is kept
in
hospital
under
observation.
Analgesics are given for
pain.


Drainage
If there are signs of an abscess
(throbbing pain, marked tenderness
and toxaemia). the pus should be
drained.
A tourniquet and either general or
regional block anaesthesia are
essential.

The incision should be made at the
site of maximal tenderness, but never
across a skin crease.

Necrotic tissue is excised and the
area thoroughly washed and cleansed.

The
wound
is either
left open
or lightly sutured and then covered with nonstick dressings.
 A pus specimen is sent for microbiological
investigation.
Splintage
always
with the joints in the position of
safe.
 splint
should be applied
Specific types of Infections
Paronychia
Pulp-space infection (felon)
Tendon-sheath infection
Deep fascial space infection
Human bites


M.O.
(including anaerobes) are encountered,
the commonest being Staphylococcus aureus,
Streptococcus group .
such wounds should be assumed to be
infected.
So
Treatment
Surgery to clean the infected tissue.
Antibiotic .
TRIGGER FINGER
 Intermittent
usually of the
finger.
'deformity'.
ring or middle

The
patient
complains
that,
when the hand is
clenched
and
then
opened, the finger (or
thumb) gets stuck in
flexion; with a little
more effort, it suddenly
snaps into fulI extension
Causes is:
thickening
of
the fibrous tendon
sheath
2.
similar
entrapment
may
occur due to a
bulky
Tenosynovitis.
1.
Treatment
 Either
healed spontaneously.
 Local injection steroid
 surgery
DUPUYTREN'S
CONTRACTURE
This is a nodular hypertrophy and contracture
of the palmar aponeurosis.
 The patient - usually a middle-aged man
complains of a nodular thickening in the palm.


If the subcutaneous cords extend into the
fingers, they may produce flexion deformities at
the MP and PIP joints.

Operation is indicated if the deformity is
progressive and interferes with function.