7 – Shoulder disorders + upper extremity

Basics

• From an orthopaedic point of view the upper extremity starts from the neck and the heart
  • This is because upper extremity symptoms may come from the neck (nerves) or heart (vessels)
  • Nerve roots of the brachial plexus innervates the dermatomes of the upper extremity
• Upper extremity consists of three joints – shoulder, elbow, and hand
  • Only full function of all three joints allow normal movement of upper extremity
• Pain can radiate up or down the upper extremity
  • The area which is painful can be far away from the diseased area
• DD of shoulder problems or pain
  • Adhesive capsulitis (frozen shoulder)
    • Negative x-ray
    • Severely restricted movement
  • Osteoarthritis of the shoulder
    • X-ray findings like in any OA
  • Rotator cuff tear
  • Problems in the neck, heart (AMI), A/C joint, tumours in the region
• We use only 15% of the ROM of the shoulder during daily activity
  • -> try using the whole ROM to prevent problems

14. Rheumatoid arthritis, surgical aspects of

• In cases of severe joint destruction causing severe pain or unacceptable dysfunction
• Mainly joint replacement
  • Mainly shoulder, hip, knee, PIP, MCP
• In some cases: joint fusion
  • Mainly wrist, ankle

21. Tennis elbow (humerus epicondylitis)

• Tennis elbow = lateral humerus epicondylitis
  • Overuse of extensor muscles causes chronic periostitis
    • The extensors originate from the lateral epicondyle
  • Very common cause of elbow pain
  • Etiology
    • Many small repeating movements without rest
    • Excessive computer use
    • Racquet sports
  • Clinical features
    • Pain over lateral epicondyle and the extensors
  • Treatment
    • Conservative
      • The primary treatment is conservative
      • Rest
      • Lifestyle changes
      • NSAIDs
      • Physiotherapy
    • Surgical
      • Injection of local anaesthetics and steroids
        • Less and less used because of local steroid side effects (like skin atrophy)
      • Surgery
        • Detachment of muscles and excision of periosteum
        • Only in recurring cases

• Golf elbow = medial humerus epicondylitis
  • Overuse of flexor muscles causes chronic periostitis
    • The flexors originate from the medial epicondyle
  • Very common cause of elbow pain
  • Etiology
    • Many small repeating movements without rest
    • Golfing
    • Excessive computer use
  • Clinical features
    • Pain over medial epicondyle and the flexors
  • Treatment
    • Same as for tennis elbow

28. Recurrent dislocation of the shoulder

• Chronic/recurrent dislocation of the shoulder, also called chronic shoulder instability
• Etiology
  • Untreated or poorly treated previous trauma
    • Most common cause
    • After one traumatic dislocation the joint capsule is torn, which predisposes to recurrent dislocation
    • After a dislocated shoulder has been reduced, further dislocations must be prevented by immobilizing the shoulder
    • Immobilizing allows the joint capsule to heal back to its normal and tight position
    • No immobilization causes the joint capsule to heal into a looser position
  • Dysplasia (underdevelopment of the glenoid fossa)
  • Voluntary dislocation
    • Due to psychiatric problems
• Types according to direction
  • Antero-inferior dislocation (most common)
  • Posterior dislocation
    • Mostly only occurs in epilepsy or electric shock, especially if bilateral
• Treatment of recurrent dislocation
  • Surgical stabilization

34. Periarthritis of the shoulder, frozen shoulder

• Frozen shoulder = adhesive capsulitis of the shoulder (= periarthritis of the shoulder)
  • = inflammation of the joint capsule which shrinks it and makes movement painful
  • Can be idiopathic (primary) or secondary to diabetes, thyroid disease, etc.
  • Pathomechanism
    • Inflammation of the joint capsule makes movement of the shoulder painful
    • Pain causes the shoulder to be less frequently used
    • Lack of use and inflammation causes the shoulder capsule to thicken and adhere to itself and the humerus -> the symptoms become progressively worse
    • In the “end-stage” adhesive capsulitis the shoulder cannot be moved at all -> frozen shoulder
  • Stages
    • Freezing stage – pain and limited motion
    • Frozen stage (frozen shoulder) – less pain, no motion
    • Thawing stage – symptoms improve
  • Clinical features
    • Restricted and painful movements of shoulder
      • Especially internal and external rotation
  • Diagnosis
    • Adhesive capsulitis is a clinical diagnosis based on decreased movement without underlying disease
    • Negative X-ray
    • MRI may show soft tissue inflammation
  • Treatment
    • It’s usually self-limiting
    • Conservative
      • NSAIDs
      • Physiotherapy
    • Surgical
      • Manipulation under anaesthesia (MUA)
        • (Not so much used anymore)

39. Cervical rib, thoracic outlet syndrome (TOS)

• Symptoms occurring due to compression of structures like
  • Brachial plexus (95% of cases)
  • Subclavian vein (4% of cases)
  • Subclavian artery (1% of cases)
• Caused by narrowing of the anatomical opening called “thoracic inlet”, “thoracic outlet” or “superior thoracic aperture”, which is a hole surrounded by
  • Clavicula
  • The first rib
  • Scalenus anterior
  • Scalenus medius
• If the thoracic outlet becomes narrower some or all of the neurovascular structures may be compressed
• Etiology
  • Trauma
    • Collarbone fracture
  • Hypertrophy of scalenus muscles
  • Pancoast tumor
  • Congenital cervical (extra) rib
• Clinical features
  • Neurogenic thoracic outlet syndrome
    • Due to compression of brachial plexus
    • Pain, anaesthesia, paraesthesia in neck and arm
    • Often in areas innervated by ulnar nerve
  • Venous thoracic outlet syndrome
    • Due to compression of subclavian vein
    • Swelling
    • Venous distension
    • Venous thrombosis
  • Arterial thoracic outlet syndrome
    • Due to compression of subclavian artery
    • 4 Ps
      • Pulselessness (in the hand)
      • Pain
      • Pallor
      • Paraesthesia
• Treatment
  • Physical therapy
    • In mild cases, can be enough
  • Thoracic outlet decompression surgery
    • Transaxillary resection of extra rib or first rib
    • Angioplasty, if vessels are affected
• Cervical rib
  • Some people have a congenital extra rib before the first rib called the cervical rib
    • The first rib starts at Th1
    • The cervical rib starts at C7
  • This cervical rib compresses the thoracic outlet, causing TOS
  • The treatment is surgical resection of the cervical rib

Rotator cuff tear

• = tear in the tendon of one or more muscles of the rotator cuff
  • Most commonly affects supraspinatus tendon
• Rotator cuff
  • = supraspinatus, infraspinatus, teres minor, and subscapularis
  • These muscles attach to the greater tubercle of the humerus
  • Function is to stabilize the shoulder and allow for normal shoulder motion
• Clinical features
  • Painful/weak/impossible elevation of shoulder
• Imaging
  • US or MRI
• Differential diagnosis
  • OA
  • Frozen shoulder
  • Cervical problems
• Treatment
  • Surgical reinsertion of tendon with arthroscopy (not open surgery)

Wrist osteoarthritis

• Epidemiology
  • Usually affects people in working age, unlike other OA
• Etiology
  • Vibration work
    • Miners, roadworkers, etc.
  • Fracture of distal radius
  • Scaphoid fracture
    • In that case: fix the scaphoid fracture with a screw
• Clinical symptoms
  • Pain
  • Restricted ROM
• Treatment
  • Wrist arthrodesis with plate and screws
    • Unlike arthrodesis for knee and hip joint (which is never performed anymore), wrist arthrodesis is still performed
    • This is because wrist prosthetic replacement is not as good as hip or knee replacement
  • Wrist prosthetic replacement
    • Good only for mild movements and light lifting
    • For these reasons, wrist replacement is not good for non-elderly

Dupuytren contracture

• Idiopathic
• Pathology
  • Hypertrophy/metaplasia of palmar aponeurosis -> shrinkage of palmar aponeurosis -> the affected finger gets pulled -> flexion contracture
• Clinical features
  • Painless
    • The patient does not complain of pain but rather of the deformity
  • Most commonly affects the 4th finger, but can affect any finger
  • Flexion contracture of MCP and PIP joint
• Treatment
  • Surgical removal of the aponeurosis

Osteoarthritis of the fingers

• May occur in physical workers
• Treatment:
  • Conservative
  • Surgical: joint replacement