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