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Clin Med - MSK > Lecture 9 - UE Disorders > Flashcards

Lecture 9 - UE Disorders Flashcards

1
Q

What is impingement syndrome?

A

aka:
rotator cuff syndrome
rotator cuff disease
shoulder impingement

reduction in the space below the coracoaromial arch

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2
Q

What causes impingement syndrome?

A

decreased cuff strength or outlet stenosis
supraspinatus and infrapsinatus tendons become compressed under acromion –> tendinopathy
subacromial bursa becomes compressed –> brusitis

this then causes progressive rotator cuff tendonitis
partial tear of the rotator cuff
or full tear of rotator cuff

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3
Q

How do pts with impingement syndrome present?

A

shoulder pain
worse with overhead activity
located superior and lateral aspect of shoulder, over deltoid
may be acute and burning (brusitis) or intermittent and dull (tendinopathy)

decreased active ROM
weakness of arm abduction

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4
Q

What general PE tests are done for impingement?

A

Neer
Hawkins

also on PE you will note that ROM is normal
+/- tenderness to palpation of anterior shoulder
+/- weakness with abduction but must distinguish between true weakness and resistance of motion secondary to pain

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5
Q

How do you dx impingement syndrome?

A

Shoulder xray after suggestive hx and PE

if xray is normal consider MIR of shoulder
alternatively may use US which is very good at ruling out tears

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6
Q

What is the treatment for impingement syndrome?

A

NSAIDs
rest, ice, activity modification
PT: cuff strengthening, stretching, coordinated motion
subacromial injections: lidociane + methylprednisolone
f/u in 6 weeks to tests ROM and strength

surgery:
rare - may need for isolated bursitis (bursectomy)
acromioplasty for spur
cuff debridement

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7
Q

What is the prognosis for impingement syndrome?

A

1 in 3 will get impingement syndrome at some point in their life
only 1 in 5 will actually be symptomatic

IF LEFT UNTREATED WILL PROGRESS TO ROTATOR CUFF TEAR
60- 90% will become sxs free with conservative measures

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8
Q

What is a rotator cuff tear?

A

tear, either full thickness or partial thickness, in tendons of rotator cuff
most commonly affected: supraspinatus

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9
Q

Why do rotator cuff tears happen?

A

chronic repetitive injury of overhead movement
chronic dislocations
acute trauma (less common)

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10
Q

How do pts with rotator cuff tears present?

A

similar to impingement syndrome
pain in anterior lateral shoulder with radiation distally
weakness of the shoulder, especially with overhead movemenet
“night pain”
>40yo

PE:
active ROM may show weakness, esp with overhead reaching (above 90 degrees)
passive ROM is usually fine
impingement signs may be positive

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11
Q

What physical exam tests are done for possible rotator cuff tear?

A

drop arm test (nonspecific_
empty can test (supraspinatus)
lift off test (subscapularis)
external rotation (intraspinatus/teres minor)
External rotation lag sing (infraspinatus)

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12
Q

How do you dx rotator cuff tears?

A

shoulder x-ray (AP, axillary, and outlet view)
superior migration of humoral head supports chronic tear

then order should MRI
more sensitive and specific for cuff disease
can distinguish partial from full thickness tears

US
cheap
technician specific

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13
Q

How do you classify/describe a rotator cuff tear?

A

there is no one classification system adopted so we use a descriptive way to classify the tear based on:
number of tendons involved
size of tear
amount of tendon retraction
degree of fatty atrophy of rotator muscles

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14
Q

What are the treatment options for rotator cuff tears?

A

partial rotator cuff tears:
<50% tendon area affected:
NSAIDs, subacromial steroid injections, and PT
>50% tendon area affected:
will likely require surgical repair
failed conservative therapy after 6-8 weeks –> surgery

complete rotator cuff tear:
surgery, the sooner the better

surgery: 
open or arthroscopic rotator cuff repair 
acromioplasty 
debridement 
suture together torn segments 
 suture tendon to bone or bone anchors
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15
Q

What happens if conservative treatment for partial rotator cuff tear has not shown improvement after 6-8 weeks?

A

surgery

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16
Q

What does the surgery for complete rotator cuff tear or ailed conservative treatment look like?

A 
open or arthroscopic rotator cuff repair 
acromioplasty 
debridement 
suture together torn segments 
 suture tendon to bone or bone anchors
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17
Q

What is the prognosis for rotator cuff tears?

A

conservative measures:
poor success in those with significant weakness lasting > 1 year
success ranges from 33-85%

post-operative recovery
12 weeks to return to “normal” function, back to work (for non athletes)
6-12 months to regain total function (esp for athletes)

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18
Q

A famous pitcher comes to you for a complete rotator cuff tear and wants to know how long after surgery he can return to play baseball, what do you tell him?

A

6-12 months after surgery you can expect to regain total function

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19
Q

What is biceps tendonitis?

A

primary (less common):
inflammation of the proximal biceps tendon in the intertubercular groove

secondary (more common): inflammation of the proximal biceps tendon in the intertubercular groove as result of pathologic changes to surrounding structures (rotator cuff impingement or tear)

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20
Q

How do pts with biceps tendonitis present?

A

anterior shoulder pain
radiation down toward biceps
tenderness over the bicipital groove
impingement sings (neer and Hawkins) are often positive

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21
Q

Which specialty tests are used to test for biceps tendonitis?

A

speed’s test

yergason’s test

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22
Q

How do you dx biceps tendonitis?

A 
shoulder xray (unless already done for impingement) 
MRI evidence of edema around thickened tendon
23
Q

What is the treatment for biceps tendonitis?

A

treat the underlying condition (impingement, cuff tear)
conservative measures: rest, NSAIDs, ROM exercises
US guided steroid injection to the bicipital sheath

surgery for failed conservative approach –> tendon debridement, release of synovial sheath, tenotomy, tenodesis

24
Q

What is adhesive capsulitis?

A

aka frozen shoulder
“a condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder”

primary - believed to be autoimmune disorder, more common in females and pts with DM

secondary - postsurgical or posttraumatic

soft tissues contracture –> local inflammatory response of the shoulder capsule –> gradual loss of active and passive ROM

25
Q

How do pts with adhesive capsulitis present?

A 
pain with active and passive ROM 
pain worse at end of motion 
progressive loss of ROM 
shoulder "stiffness" 
rest pain 
night pain

PE:
ROM should be assessed while stabilizing the scapula
reduced active and passive ROM

26
Q

How do you dx adhesive capsulitis?

A

clinical dx

shoulder xray to r/o other causes (like arthritis)

27
Q

What is the treatment for adhesive capsulitis?

A

conservative therapy: ice, NSAIDs, steroid injections
PT: VERY HELPFUL

surgery for failed conservative therapy: lysis of adhesions and selective release of middle glenohumeral ligament

28
Q

What is the prognosis for adhesive capsulitis?

A

PT works very well but..
pt must be active participant in their own care
recovery will take a very long time

29
Q

What is glenohumeral osteoarthritis?

A

same concept as OA of other joint
progressive degenerative condition of the articular surface of the joint
may ne posttraumatic (ex. h/o shoulder instability due to multiple dislocations, subluxations)

30
Q

How do pts with gelnohuumeral osteoarthritis present?

A

slowly progressive vague and diffuse shoulder pain
pain is present at rest and exacerbated with activity
progressive limitations on movement of shoulder, mostly due to pain

PE:
crepitus
reduced ROM
pain on ROM testing

31
Q

What imaging do you order for glenohumeral osteoarthritis and what does it show?

A

Xray of the shoulder

joint space narrowing
osteophyte and cyst formation
subchondral sclerosis

32
Q

What is the treatment for glenohumeral osteoarthritis?

A

gentle ROM exercises
NSAIDs
modification of activity
steroid injections is NOT done –may delay labral healing

surgery:
joint arthroplasty (mainstay of surgical approach)
-total shoulder replacement
-hemiarthrolplasty

other options available (ex. debridement) but must be done early in the disease process

33
Q

What is the prognosis of glenohumeral osteoarthritis?

A

long term NSAIDs can be risky - pts and providers must balance risk-benefit profile of medical vs surgical therapy
surgical outcomes are highly dependent on the skill of the surgeon; higher volume portends better outcome

34
Q

What is Lateral epicondylitis?

A

tennis elbow
repetitive strain injury to extensor muscle tendon(s) of the forearm
associated with forceful wrist extension against resistance (ex. backhand stroke in tennis)
common in non-competitive tennis players; uncommon in professional athletes –> technique makes a difference

35
Q

How do pts with tennis elbow present?

A

pain to lateral aspect of elbow
pain worse after work or activities involving repeated wrist extension and supination against resistance (think turning a screwdriver, painting a house, playing tennis)

radiation of pain down posterior (dorsal) forearm
pain reproduced with shaking hands, opening/turning doorknob
weakened grip, difficulty picking up heavy objects
ROM fully intact

Mills test and Cozens test will be positive

36
Q

Which specialty tests are done when you suspect tennis elbow?

A

Mills Test

Cozens Test

37
Q

How do you dx tennis elbow?

A

clinical dx

imaging not necessary

38
Q

What is the treatment for tennis elbow?

A

rest and NSAIDs are very successful
PT: US, icing, friction massage
Steroid injections provide immediate relief but no long-term benefits
arthroscopic debridement is an option but outcomes are no better than conservative

39
Q

What is medial epicondylitis?

A

aka golfers elbow
similar concept to lateral epicondylitis
repetitive motions: wrist flexion and pronation

40
Q

How do pts with medial epicondylitis present?

A

pain over medial epicondyle that radiates down anteromedial forearm
pain reproduced with wrist flexion against resistance

41
Q

What is the treatment for medial epicondylitis?

A

rest, NSAIDs, friction massage, US, icing
splinting
steroid injection
activity modification x 1 month
surgery: debridement, bone spur shaving, release of flexor muscle

42
Q

What is olecranon bursitis?

A

inflammation of the olecranon bursa
usually inciting traumatic event (fall onto elbow, overuse injury, repetitive pressure)
pain after initial trauma but then dissipates unless infected
progressive formation of boggy swelling over elbow
if infected: erythema, warmth, and pain

43
Q

How do you dx olecranon bursitis?

A

Xray recommended to identify any olecranon fracture

aspiration may help identify infectious cause (if suspected) or other complicating factors (crystalline deposition disease) but is not always required

44
Q

What is the treatment for olecranon bursitis?

A

conservative: compression, splinting, +/- aspiration, +/- steroid injection

surgery:
resreved for failure of conservative approach or in the pt with infective bursitis; debridement, bursal excision

45
Q

What is de quervian disease?

A

aka “mommy thumb” or de quervian tenosynovitis

repetitive overuse injury involving abductor pollicis longus and extensor pollicis brevis along the dorsal radial aspect of the wrist

seen often in those who have to lift babies or toddlers while using outstretched hands
pain along later (radial) wrist and distal forearm

46
Q

What specialty test is done to test for de quervian disease?

A

Finkelstein’s test

imaging not necessary

47
Q

What is the treatment for de quervian disease?

A 
activity modification 
ice
NSAIDs 
thumb spica splint
injections along tendon sheath
surgical decompression of tendon
48
Q

What is Dupuytren’s Contracture?

A

slowly progressive fibroproliferative disease of the palmar fasica
cause unknown

several important risk factors:
genetics - genetic predisposition but its not mendelian 
age- MC >50yp
M > F
ethnicity - northern european ancestry 
environmental exposures:
repetitive handling tasks or vibration 
higher prevalence in pts with DM
hx of smoking
ETOH
49
Q

What are the risk factors for dupuytren’s contracture?

A 
genetic predisposition but its not mendelian  MC >50yp
M > F
northern european ancestry 
environmental exposures:
repetitive handling tasks or vibration 
higher prevalence in pts with DM
hx of smoking
ETOH
50
Q

How do pts with dupuytren’s contracture present?

A

starts with painless nodule over the MCP joint in one or multiple fingers
nodule expands proximally to form “cord” along tendon
cord and nodule begin to limit finger extension resulting in persistent flexion of finger toward palm

51
Q

How do you dx dupuytren’s contracture?

A

clinical dx

just be sure to eliminate other acute, inflammatory conditions

52
Q

What is the treatment for dupuytrens contracture?

A

early in the disease:
adjust work environment (wear appropriate gloves, cushion tape, built-up handles)

persistent sxs:
intralesional steroid injections
surgical repair: open fasciotomy

53
Q

What is the prognosis of dupuytrens contracture?

A

varialbe course - difficult to predict long term outcome
may stabilize disease if environmental risk factors are controlled
without intervention, 50% will progress from initial presentation to varying degrees of incapacity in 5-6 years
treatments are palliative - none are curative

Clin Med - MSK (10 decks)

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