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Orthopaedic Series: Upper Limb Conditions Amin SohaniLearningObjectives •Wrist & Hand Injuries/Conditions •Shoulder & Clavicle Injuries •Shoulder & clavicle fracture •Distal radius fracture •Shoulder dislocation (anterior and posterior) •Scaphoid fracture •Adhesive capsulitis / frozen shoulder •Carpal tunnel syndrome •Subacromial impingement syndrome •Dupuytren's contracture •Rotator cuff tear •De Quervain's tenosynovitis •Elbow Injuries & Conditions •Trigger finger •Lateral and medial epicondylitis •Radial head fracture •Supracondylar and olecranon fractureShoulderdislocation • A 32-year-old male with a history of epilepsy presents to A&E after experiencing a generalized tonic-clonic seizure.He complains of severe right shoulder pain and is holding his armin slight adduction and internal rotation.Examination reveals a loss of the normal shoulder contour with prominent acromion.There is reduced range of motion and no obvious neurovascular compromise. • Question: What is the most likely type of shoulder dislocation in this patient? • A) Anterior B) Posterior C) Inferior Anterior Dislocation Posterior Dislocation www.emrms.com Radiopaedia.org. From the case rID: 35746Shoulderdislocation:presentation • Anterior (90%) • Arm is held in internally rotated and abducted position • Shoulder silhouette flattened with a prominent acromion • Posterior (10%) • Arm is fixed, internally rotated, and adducted • Posterior shoulder prominence • Inferior • Fixed, abducted position • Arm held above the headShoulderdislocation:management • Painkillers (e.g. morphine) • History: Ask about the mechanism of injury. First-time dislocation often results from a high-energy mechanism (e.g., sports injury or fall). Previous episodes of instability increase the likelihood and ease of dislocation. Ask about a fit or any other injuries (e.g. to the tongue). • Examination: Perform neurovascular examination. An axillary nerve palsy results in numbness in the ‘regimental badge’area. The patient will not be able to demonstrate any external rotation in posterior dislocation. • X-ray before reduction (two views minimum!). • Closed reduction (if no associated fracture or injuries). • X-ray after reduction to ensure successful reduction.Shoulderdislocation:reductiontechniques • Kocher’s technique • Milch’s technique • Hippocratic method • Stimpson’s technique • Many moreKocher’stechniqueforclosedreductionof ananteriorshoulderdislocation Handposition: Lifting andadduction The cliniciantakes the acrosschest: patient’s elbow inthe right Maintaining the external hand and the wrist inthe left. rotation, the humerus is thenlifted forwards tothe front ofthe chest. External rotation: Internal rotation: Without applying traction, Finally, the shoulder the humerus is externally is rotated internally rotated slowly and gently tobring the hand to untilresistance is reached. the opposite The arm canusually be shoulder. rotated to70–90°. Relocationcanoccur during any point ofthe described manoeuvre. From:McRae'sorthopaedic traumaandemergency fracture management.Stiffshoulder • A 44-year-old female patient was walking the dog when she slept on a frozen path and landed on her left shoulder. She developed a persistent aching in her shoulder and later attended urgent care. A few days later she is still having difficulty washing and dressing despite having no pain. Past medical history of diabetes and is on insulin. On examination there is no signs of obvious swelling or deformity on palpation she has no tenderness however on movement she has a markedly reduced range of movement particularly with external rotation. No concerns re neurovascular injury.Stiffshoulder • Question: What is the most likely diagnosis in this patient? • A) Rotator cuff tear C) Proximal humerus fractureen shoulder) D) Acromioclavicular joint dislocation E) Glenohumeral osteoarthritisAdhesivecapsulitis • Inflammatory condition of the shoulder capsule resulting in pain, contraction and shoulder stiffness. • It can present as an emergency with the rapid onset of severe shoulder pain and restricted movement. There may be an identifiable traumatic precipitant. • Frozen shoulder following a significant injury (such as a proximal humeral fracture) is termed adhesive capsulitis • Typically, has three stages: Freezing phase (3 months), Frozen phase (6 months), Thawing phase (12 months). Eventually resolves spontaneously after many months or years. • Management: Oral analgesia (NSAIDs) and physiotherapy. Patients may be referred back to their GP or to an elective shoulder clinic.Subacromialimpingement • most common cause of shoulder pain (insidious onset, exacerbated by overhead activities) • as a result of compression of the rotator cuff muscles by superior structures, leading to inflammation and formation of bursitis • Diagnosis can be made on physical examination with a positive Neer and Hawkins tests • Treatment is a trial of nonoperative measures including NSAIDs, physical therapy and corticosteroid injections. Arthroscopic subacromial decompression if conservative measures fail.GlenohumeraljointOA • More common in female patients, incidence increases with increasing age. • Predominant symptoms are pain and stiffness, leading to loss of motion (active and passive).pation of joint line, restricted range of • Important to exclude other causes of stiffness such as a frozen shoulder or locked posterior dislocation. • X-rays to distinguish from other traumatic or nontraumatic causes of stiffness: look for signs of loss of joint space, and an inferomedial osteophyte (commonly seen on the humeral head). Normal Shoulder OA OA Joint space narrowingInferior osteophytes Images from Radiopaedia.org. GlenohumeraljointOA:management Primary care options Secondary care options • Regular paracetamol (NSAIDs if • Corticosteroid injection paracetamol ineffective) -> pain control • Arthroscopic debridement: short- to • Refer to physiotherapy for strength medium-term relief of symptoms in training -> function improvement younger patients. • Advise on activity modification • Arthroplasty: When patients have • Refer to shoulder specialist if: significant pain and functional •Pain is severe and not controlled by the limitation, arthroplasty may be offered. If the rotator cuff is intact, anatomical above methods total shoulder replacement may be •The patient is significantly affected by the stiffness undertaken. •The diagnosis is not clearRotatorcufftendinopathy • Recognised as part of the normal ageing processes. • Predominant symptoms are lateral shoulder and upper arm pain, pain aggravated by overhead activities and weakness. Signs: Painful arc, Neer signs impingement elicited. • Can progress over time. Symptomatic tears are likely to increase in size. Over time, a torn rotator cuff may retract and become scarred. The muscle bellies can be replaced by fat, which is thought to be irreversible. • Imaging findings often do not correlate with clinical findings. (In many cases evidence of rotator cuff tendinopathy can be seen in patients without symptoms.) • Arthritis resulting from rotator cuff disease and tears is termed rotator cuff arthropathy (RCA) and has a different pattern of radiological changes. Muscle Origin Insertion Action Innervation Rotatorcuff tendinopathy: Supraspinatus Supraspinous Greater Abductionof Abductionof anatomy fossa of tubercle of arm arm scapula humerus Infraspinatus Infraspinous Greater External Suprascapular fossa of tubercle of rotationofarm nerve scapula humerus Teres Minor Lateralborder Greater External Axillary nerve ofscapula tubercle of rotationofarm humerus Subscapularis Subscapular Lesser tubercle Internal Subscapular ofhumerus rotationofarm nerveRotatorcufftendinopathy:investigation& management • Investigation Management • Plain radiographs (x-ray): • Physiotherapy: to exclude other differentials, re-establish rotator cuff strength and balance. e.g. glenohumeral joint • Corticosteroid injection: osteoarthritis. may be a useful adjunct to treatment and aims • Ultrasound scan: to assess the rotator cuff and to reduce inflammation . It is important not to long head of the biceps give repeated corticosteroid injections where there is only a short-term response. There is a • Magnetic resonance imaging risk of long-term tendon damage with multiple (MRI): injections to to assess the rotator cuff, • Surgery (rotator cuff +/− arthroscopic including determining if there subacromial decompression): are any tears , retraction or if inadequate response to nonoperative fatty infiltration of the cuff management programme (up to 1 year of muscles. used as a predictor of outcome in cases of repair therapy and two steroid injections), consider of rotator cuff tears surgery.Rotatorcuffarthropathy • A 78-year-old retired school teacher presents with progressive shoulder painand limited range of motion over the past few years. She has a history of hypertensionand diabetesbut is otherwise independent in daily activities.Imaging reveals cuff tear arthropathy,with superior migrationof the humeral head and an incompetent coracoacromial arch.Despite the degeneration,her deltoid muscle remains intact.Considering her condition and functional status,what is the most appropriate treatment? • A.Reverse total shoulder arthroplasty B.Hemiarthroplasty C. Arthroscopic debridement D.Deltoid incorporation exercise E.ArthrodesisExplanation • Correct answer: A • Cuff tear arthropathy is the final stage of severe rotator cuff damage. It happens when the supraspinatus or other rotator cuff tendons tear, causing the humeral head to move upwards (proximal migration) and press against the acromion. Over time, this leads to joint degeneration. • Reverse total shoulder arthroplasty (RTSA) is the best treatment because it changes the mechanics of the shoulder, allowing the deltoid muscle to take over the function of the damaged rotator cuff. This improves movement, especially arm elevation (abduction). • Key Point: RTSA only works if the deltoid muscle is intact since it becomes the main mover of the shoulder. • For frail elderly patients who cannot undergo major surgery, arthroscopic debridement (cleaning up damaged tissue) may be an option, but it does not restore function. Seebauer classification ofcufftear arthropathy FromVisotskyJL,BasamaniaC,SeebauerL,Rock-woodCAJr.,JensenKL.Cuffteararthropathy:pathogenesis,classification,andalgorithmfortreatment.JBoneJoint SurgAm2004;86:38. Reversetotal shoulder arthroplasty (RTSA) proximal humerus: 6 to 42 months of follow up". BMC Musculoskeletal Disorders14 (1).ractures of the DOI:10.1186/1471-2474-14-231. ISSN 1471-2474 Elbowpain • A 30-year-old male mechanic, who has been working in the industry for several years, presents to his GP complaining of right elbow pain that has been gradually worsening over the past few weeks. He mentions that the pain is particularly aggravated when performing tasks that require wrist flexion, such as gripping tools or lifting objects at work. He localizes the discomfort primarily to the inner, medial side of the elbow joint. On examination, there is no visible swelling, bruising, or deformity of the elbow. Palpation reveals tenderness that is localized over the medial epicondyle. There is no evidence of muscle wasting, and his range of motion remains largely preserved, though certain movements exacerbate his symptoms. A neurovascular assessment is performed and found to be normal, with intact sensation and good distal circulation.Elbowpain • What is the most likely diagnosis? • A) Lateral epicondylitis B) Medial epicondylitis C) Cubital tunnel syndrome D) Olecranon bursitisEpicondylitis Features Medial Epicondylitis Lateral Epicondylitis (Tennis (Golfer’s Elbow) Elbow) Location of Pain Medial epicondyle (inner Lateral epicondyle (outer elbow) elbow) Aggravating Movements Wrist flexion & forearm Wrist extension & forearm pronation supination Common Causes Repetitive wrist flexion (e.g., Repetitive wrist extension golf, throwing, manual work) (e.g., tennis, painting, typing) Clinical Findings Pain/tenderness over medial Pain/tenderness over lateral epicondyle, worsened by epicondyle, worsened by resisted wrist flexion resisted wrist extension Management Rest, activity modification, physiotherapy, NSAIDs, corticosteroid injections if severe Tunnelsyndromes Feature Cubital Tunnel Syndrome Carpal Tunnel Syndrome Compressionofthe ulnar nerve at the Compressionofthe mediannerve in Cause cubitaltunnel(elbow) the carpaltunnel Clinical Features Tingling/numbness in 4th & 5th fingers, Pain, pins & needles in thumb, index, and progressing from intermittent to constant; middle finger; symptoms may ascend weakness & musclewasting; pain worsens proximally; shaking hand relieves with elbow pressure; associated with OAor symptoms (classically at night), Weak trauma thumb abduction (abductor pollicis brevis), thenar eminence wasting, positive Tinel’s sign (tapping causes paraesthesia), positive Phalen’s sign (wrist flexion induces symptoms) Investigations Clinicaldiagnosis;nerve conduction Clinicaldiagnosis;nerve conduction studies inselected cases studies Management Avoid aggravating activity, physiotherapy, s6-week trial of conservative treatment: injections, surgery for resistant cases corticosteroid injection, wrist splints at night (especially useful in transient cases like pregnancy), Surgical decompression (flexor retinaculum division)Handstiffness • A 65-year-old male carpenter presents to his GP with progressive stiffness in his right hand over the past year. He reports difficulty fully extending his ring and little fingers. He denies pain but has noticed that his fingers appear permanently bent. He has a history of type 2 diabetes and consumes alcohol regularly. His father had a similar hand condition. • On examination: Palpable nodules along the palmar fascia Fixed flexion contracture of the ring and little fingers Inability to place his palm flat on the table (Hueston’s test positive)Handstiffness • Question: • What is the most appropriate next step in management? • A) Reassurance and observation B) Corticosteroid injection into the palmar fascia C) Physiotherapy and hand splinting D) Surgical intervention E) Phenytoin therapyDupuytren’sContracture–KeyPoints • Definition: A progressive thickening of thepalmar fascia, leading to fixed flexion contractures, mainly affecting thering and little fingers. • Epidemiology & Risk Factors: More common in older males, with 60-70% having a family history. Associated with manual labour, alcohol, diabetes, phenytoin use, and hand trauma. • Clinical Features: Patients develop painless nodules that progress to contractures, making it difficult to place the hand flat on a table (Hueston’s test positive). • Management: Surgical treatment is considered when contractures impair function. Needle aponeurotomy or collagenase injections are alternatives but have high recurrence rates.Triggerfinger • Trigger finger is a common condition associated with abnormal flexion of the digits • Aetiology: tendon becomes 'stuck' and cannot pass smoothly through the pulley • more common in the thumb, middle, or ring finger, initially stiffness and snapping ('trigger') when extending a flexed digit • steroid injection is successful in the majority of patients (surgery reserved for patients who have not responded to steroid injections)DeQuervain'sT enosynovitis • De Quervain's tenosynovitis: sheath containing the extensor pollicis brevis and abductor pollicis longus tendons get inflamed. • Typically affects females aged 30 - 50 years old. • Features • pain on the radial side of the wrist • tenderness over the radial styloid process • abduction of the thumb against resistance is painful • Finkelstein's test positive • Management: analgesia, adapating activities, steroid injection, immobilisation with a thumb splint (spica) to restrict movement. If steroids ineffective -> surgical release of sheath (AbPL&EPB)FracturesClaviclefracture • Clavicle fractures are common, usually from a direct blow or a fall on the shoulder. Deformity includes lateral fragment depression and shortening, with proximal displacement of the medial fragment. • The patient will be aware of pain, and often crepitus, at the fracture site, and will usually present supporting the elbow with the other hand, • Assess whether the skin overlying a spike of bone has been tented and is at risk of breaking down.Claviclefracture:investigation&management • X-ray: AP clavicle and 20° cephalad view • Attempts at closed reduction of the fracture are not recommended due to the risk of damage to the surrounding neurovascular structures. • Use a supportive sling for the elbow. The sling is only to provide comfort and the patient is encouraged to use the elbow, wrist and hand on the affected side. Indication for inpatient Indications for Indications for surgery include: referral: outpatient referral: •open fractures • Significant tenting • All clavicle •impending skin breakdown/tenting •severe shortening • Skin compromise fractures should •severe comminution • Neurovascular be referred to the •symptomatic non-union (late) compromise fracture clinic.Proximalhumerusfracture • 4-6% of all fractures, more common in females • low-energy falls (elderly with osteoporotic bone) or high-energy trauma (younger individuals) • Associate injuries: • nerve injury: axillary nerve injury most common • arterial injury: uncommon (5-6%), higher likelihood in older patients • Investigations: complete trauma series (AP view, scapular Y , axillary), CT scan (for pre-operative planning or if complex) • Management: sling immobilization followed by rehabilitation for most fractures, complex cases need operationHumeralshaftfracture • Radial nerve palsy is the most common neurological abnormality in mid-shaft humeral fractures is a, occurring in 10% of cases. Vascular complications are rare. • Classified according to the AO classification • Investigation: X-ray (AP and lateral humerus) • Has characteristics displacement: • If Proximal to deltoid insertion: proximal fragment is pulled into adduction by the action of pectoralis major and latissimus dorsi • If Distal to deltoid insertion: the proximal fragment is abducted by deltoidHumeralshaftfracture:management • Non-operative: Most fractures of the humerus are treated without surgery by using a functional brace, and they generally heal within around 9 weeks. • Consider Operation when: Open fractures Neurovascular compromise Severe displacement Intra-articular fractures Segmental fractureDistalhumeralfracture • 1-2% of fractures • Presentation: elbow pain and swelling O/E: check for open wounds, neurvasacular compromise, ROM may not be assessed due to risk of neurovascular damage • Investigation: X-ray (AP & lateral) • Management: • Non-operative: • Minimally displaced fractures • Displaced fractures in the elderly • Operation: • Almost all displaced distal humerus fracturesRadialheadandneckfractures • Common presentation to ED (radial head fracutres) • Mostly isolated, minimally displaced and stable and require symptomatic management • Presentation: pain and tenderness along lateral aspect of elbow and limited supination/pronation • Check for unstable variants and exclude: • Monteggia fracture dislocation (combination of a radial head dislocation (with or without a radial head fracture) and ulnar fracture ) • ‘Terrible tr:combination of a radial head fracture with an elbow dislocation • Essex–Lopresti fracture • Investigation: AP and lateral x-ray • Always thoroughly examine a patient's wrist if they have sustained a radial head fracture. Pain at the distal radio-ulnar joint may indicate an Essex-Lopresti fracture dislocation, which is a more serious injury.Radialheadandneckfractures:management • Management depends on fracture classification • Mason type I and II fractures -> manage non-operatively • Mason II or III fractures with persistent loss of pronation/supination or radiocapitellar crepitus or pain -> operation Patients should be advised to move their arm freely within the limits of comfort to prevent stiffness. It’s important to remind them that while movement may be uncomfortable, it will not cause harm.Olecranonfractures • Common,resulting from a direct fall on to the elbow • The proximal fragment is often displaced proximally by the triceps muscle. • Presentation: pain well localized to posterior elbow O/E:palpable defect or inability to extend elbow may be seen • Investigation:x-ray (AP & lateral) • Management: • Non-operative if nondisplaced fractures with an intact extensor mechanism. • Operation in displaced fractures or fractures associated with loss of extensor mechanismWristpain • A 22-year-old male university student presents to A&E with right wrist pain following a fall onto his outstretched hand (FOOSH) while playing football. He reports immediate pain and swelling along the radial side of the wrist. He is otherwise well and has no previous wrist injuries. • On examination: • Tenderness over the anatomical snuffbox • Pain on longitudinal compression of the thumb • Mild wrist effusion • No deformity or open wounds • Initial plain X-rays show no obvious fracture, but clinical suspicion remains high.Wristpain • Question: • What is the most appropriate next step in the management of this patient? • A) Discharge with simple analgesia and reassurance B) Apply a below-elbow thumb spica cast and arrange orthopaedic follow-up in 7–10 days C) Immediate surgical referral for open reduction and internal fixation (ORIF) D) Perform an ultrasound to assess for soft tissue injury appearanceX-ray in 24 hours to check for interval fractureScaphoidfracture • Common wrist fracture due to fall onto outstretched hand (FOOSH), contact sports, or road traffic accidents. • 80% of blood supply from dorsal carpal branch (radial artery) in a retrograde manner. • Always suspect a scaphoid fracture in wrist pain post-FOOSH due to risk of avascular necrosis. Scaphoidfracture Clinical Presentation Investigation • X-ray (First-line) twoweeks after the event • Painat the base ofthe thumb, along the radial • Ifx-ray inconclusive, thenMRIis used wrist. Management • Lossofgrip/pinchstrength. Initial managent • Immobilisationwitha Futurosplint or standard below- ExaminationSigns elbow backslab • clinicalreview withfurther imaging should be arranged 1.Anatomical snuffboxtenderness(highsensitivity, low for7-10 days later Definitive management specificity). • Undisplaced fractures ofthe scaphoid waistcast for 6- 2.Wrist effusion(may be absent invery early or delayed 8 weeks cases). • Displaced scaphoid waist fractures & proximal scaphoid pole fractures -> surgicalfixation 3.Painonlongitudinal compressionof the thumb. Complication • Non-union→painand early osteoarthritis 4.Tendernessover scaphoidtubercle(volar wrist). • Avascular necrosis 5.Painonulnar deviationof the wrist.