Painful shoulder,elbow ,wrist ,hand.pdf

Painful shoulder ,Elbow ,Wrist and Hand Dr.Sarkawt S.Kakai KHCMS (orth. & Trauma) 11/1/2023 1 Objectives • Painful shoulder • Elbow deformities • Hand & Wrist deformities 11/1/2023 2 Disorders of the rotator cuff Anatomy • 11/1/2023 Abduction and • Elevation (a–c), glenohumeral joint. •...

Painful shoulder ,Elbow ,Wrist and Hand Dr.Sarkawt S.Kakai KHCMS (orth. & Trauma) 11/1/2023 1 Objectives • Painful shoulder • Elbow deformities • Hand & Wrist deformities 11/1/2023 2 Disorders of the rotator cuff Anatomy • 11/1/2023 Abduction and • Elevation (a–c), glenohumeral joint. • (c)GH joint and scapulothoracic . • (d) entirely scapulothoracic. 3 Disorders of the rotator cuff The commonest causes of pain around the shoulder • Rotator cuff syndrome • Adhesive capsulitis. 11/1/2023 4 The rotator cuff syndrome 11/1/2023 • Comprises several conditions with distinct clinical features and natural history: • Subacute tendinitis (painful arc syndrome); • Chronic tendinitis (impingement syndrome); • Rotator cuff tears. 5 1)The rotator cuff syndrome…… Pathology • Degeneration: • Trauma and impingement: • Vascular reaction…. End with repair or tear 11/1/2023 6 The rotator cuff syndrome…… Symptoms and signs Pain • ‘Rotator cuff ’ pain typically appears over the front and lateral aspect • The painful arc: on active abduction scapulohumeral rhythm is disturbed and pain is aggravated as the arm traverses an arc between 60 and 120 degrees. 11/1/2023 7 The rotator cuff syndrome…… Symptoms and signs • Neer’s impingement sign • Raises the affected arm to the full extent in passive flexion, abduction and internal rotation • Neer’s test • After injecting 10 mL of 1% lidocaine into the subacromial space 11/1/2023 8 The rotator cuff syndrome…… Symptoms and signs Subacute tendinitis ….(painful arc syndrome) • Pain after activity • Point tenderness is most easily elicited by palpating this spot with the arm held in extension, with the arm held in flexion the tenderness disappears 11/1/2023 9 The rotator cuff syndrome…… Symptoms and signs Chronic tendinitis • Age between 40 and 50 years, • history of recurrent attacks of subacute tendinitis,. • pain is worse at night; • cannot lie on the affected side. • slight stiffness of the shoulder may restrict hair grooming or dressing. • A coarse crepitation or palpable snapping(fibrous or partial tear) when the shoulder is passively rotated 11/1/2023 10 The rotator cuff syndrome…… Symptoms and signs Rotator cuff tears • The most advanced stage Partial tears • are not easily detected, • permits active abduction with a painful arc, • Neer’s test (to distinguish partial tear from complete). Full thickness tear Examiner abducts the patient's shoulder to 90° and then asks them to slowly lower arm to the side positive = pain or if arm drop • may follow a long period of chronic tendinitis, • sudden pain and the patient is unable to abduct the arm(actively). • shoulder shrug • (the ‘abduction paradox’); (the ‘drop arm sign’) positive. • In long-standing cases ….secondary osteoarthritis of the shoulder 11/1/2023 11 The rotator cuff syndrome…… Imaging • X-rays :are usually normal in the early stages • MRI :can effectively show cuff pathology ,always need to be correlated with the clinical examination. • Ultrasonography:(can not show repairable or not) 11/1/2023 12 The rotator cuff syndrome…… Treatment Conservative treatment(6months) Tendinitis is often self-limiting Avoiding the ‘impingement position’. Physiotherapy A short course of non-steroidal antiinflammatory medication • One or two injections of depot corticosteroids into the subacromial space(If all the above methods failed). • • • • 11/1/2023 13 The rotator cuff syndrome…… Surgical treatment Impingement(tendinitis): • Open surgery or arthroscopically(sub acromial debridement and acromioplasty) Cuff tears: • Open or arthroscopically repair with acromioplasty and sub acromial debridement. Osteoarthritis: • Arthrodesis or arthroplasty 11/1/2023 14 Adhesive capsulitis (‘frozen shoulder’) Disorder characterized by progressive pain and stiffness 11/1/2023 Usually resolves spontaneously after about 18 months. The process starts as a chronic tendinitis but it then spreads to involve the entire cuff and joint capsule. 15 Adhesive capsulitis (‘frozen shoulder’) Clinical features Diagnosis with MRI and clinically correlated The patient, aged 40–60 years, May give a history of trauma, often trivial, X-rays are normal 11/1/2023 Start with painful shoulder and end with pain free stiff shoulder. 16 Adhesive capsulitis (‘frozen shoulder’) Treatment Conservative treatment • Analgesics, antiinflammatory drugs, • Local heat and exercise (preventing further stiffening) • The role of physiotherapy and steroid injections is unproven. 11/1/2023 Once the acute pain has subsided, • Manipulation under anesthesia • Arthroscopic division of capsule 17 Elbow deformities Carrying angle Stiff elbow ..can’t fully extend 11/1/2023 18 congenital stiff in flexion or extension Elbow • Tennis elbow(lateral epicondylitis) • Golfer elbow(medial epicondylitis) 11/1/2023 19 11/1/2023 20 11/1/2023 21 11/1/2023 22 11/1/2023 23 Test for golfer Reverse cozen Pain 11/1/2023 24 Wrist deformities Radial club hand …dysplasia in radius…hand deviated to radial side Ulnar club hand …dysplasia in ulna….hand deviated to ulnar side Madelung’s deformity the lower radius curves ventrally , the distal end of the ulna projecting on the back of the wrist Spastic … in cerebral palsy or stroke 11/1/2023 25 Kienböck’s disease A patchy avascular necrosis of the lunate bone After injury or stress MRI in early stage Dense ,or collapsed 11/1/2023 26 De Quervain’s disease 11/1/2023 27 De Quervain’s disease signs and symptoms Thick 11/1/2023 28 11/1/2023 29 Ganglion Cyst It arises from cystic degeneration in the joint capsule or tendon sheath. The distended cyst contains a jellylike fluid. Treatment: The ganglion often disappears after some months, it can be aspirated; if it recurs…..excision, but there is a 30% risk of recurrence, even after careful surgery. 11/1/2023 30 Carpal Tunnel syndrome • Compression of the median nerve deep to the flexor retinaculum in volar wrist • Activities with repetitive gripping, throwing, wrist flexion and extension 11/1/2023 31 • Night pain • Thenar muscle wasting(base of thumb) 11/1/2023 32 Phalen & Reverse Phalen Test Phalen test For 60 seconds 11/1/2023 33 Treatment of carpal tunnel Conservative(6months) • Rest • NSAID • Physiotherapy • Shock wave • Steroid injection splint Surgery (division of flexor retinaculum) Open or endoscopic surgery 11/1/2023 34 Congenital hand deformities Congenital amputation Camptodactyly of fifth finger Cleft hand Giant finger 11/1/2023 Syndactyly Spider hand 35 11/1/2023 36 11/1/2023 37