7 – Shoulder disorders + upper extremity

From greek.doctor

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