Common upper limb pathologies 2

Question 1

what is adhesive capsulitis

Answer 1

formation of excessive scar tissue or adhesions across the GHJ, leading to stiffness, pain, dysfunction, and ligaments affected
Primary (idiopathic)_ spontaneously, secondary- often after trauma

Question 2

adhesive capsulitis - statistics

Answer 2

3-5% in general population, 20% with diabetes, 40-50% bilateral involvement, resolve in 1-3 years

Question 3

adhesive capsulitis risk factors

Answer 3

female>male- females respond better to female, age over 40, trauma, HLA-B27- positive blood test- shows higher change of autoimmune disease, diabetes- worse symptoms, cerebrovascular disease, coronary artery disease

Question 4

adhesive capsulitis- stage 1 and 2

Answer 4

1- primary complaint of shoulder pain- especially at night, arthroscopically- evidence of synovitis without adhesions, inflammatory cells infiltrate synovium
2- patient begins to experience stiffness, arthroscopically- synovitis, some loss of axillary fold- early adhesions, synovial proliferation- more dense fibrous tissue

Question 5

adhesive capsulitis- stage 3 and 4

Answer 5

3- profound global loss of ROM, pain at ER, Arthrosocpically- synovitis is resolved, significant adhesions- axillary fold obliterated, dense collagenous tissue within capsule
4- chronic stage- persistent stiffness, minimal pain, synovitis resolved, advanced adhesions

Question 6

adhesive capsulitis- clinical presentation

Answer 6

usually present first with pain, followed by gradual loss of A/PROM- LR- most affected, PROM with firm, painful end feel, imaging not necessary for diagnosis but can rule out other conditions- pancrose tumor

Question 7

adhesive capsulitis- pancose tumor

Answer 7

type of lung cancer at apex of lung- 25% have delayed diagnosis, 1% of patient with frozen shoulder have this

Question 8

adhesive capsulitis- management

Answer 8

physio- early mobilisation, education
NSAIDs. corticosteroid injection, hydrodilation- large volume of fluid injected into shoulder capsule to tear adhesions and stretch out shoulder,
surgery- MUA, capsular release- involves CH lig and rotator interval, contractor capsule, safer and more effector

Question 9

fractures- clavicle fracture

Answer 9

most result from fall, neuro/vascular structures near by, mid-shaft>lateral>medial
management- conservative- sling use, physiotherapy- early mobilisation of shoulder girdle, then loading, surgery

Question 10

fractures- proximal humerus

Answer 10

3 most common fracture in elderly, more common in women (2:1), classified depending on how many fragments are displaced (0- 1 part, 1- 2 part), usually occur due to a fall
management- collar and cuff- 2-3/52, followed by progressive active management physio, surgery older they are progress slowly- left with reduce ROM

Question 11

fractures- distal radius fracture

Answer 11

colles facture- most common- extra articular, dorsally displaced distal radius fracture, smiths fracture- anterior displacement of distal radius, bartons fracture- intra articular fracture with associated dislocation of the rcj, occur due to FOOH

Question 12

fractures-distal radius fracture- management

Answer 12

splints, casts, K-wires, MUA, physio following period of immobilisation- 6 weeks- increase mobillity/ strength/ function

Question 13

fractures- scaphoid fracture

Answer 13

most common fractured carpal bone (70%), often occurs from a FOOH, waist> prox pole- if waist fractured, blood cant get to it AN> distal pole, risk of non- union (5%), pain over anatomical snuff box
management- cast, surgery, physio, after immobilisation perioid

Question 14

osteoarthritis

Answer 14

most common form of arthritis, can develop in synovial joint, most common in knees, hips and small joints of hand

Question 15

osteoarthritis- management

Answer 15

management- physio- exercises for strength and mobility/ hands on technique/ hydrotherapy/ education, corticosteroid injection
surgery- joint replacement (concave prosthesis replaced socket convex head of humerus replaced ball, debridement)

Question 16

rheumatoid arthritis

Answer 16

systemic autoimmune disease characterised by inflammatory arthritis with extra articular involvement, synovium infiltrated by immune cells, systemic inflammation and autoimmunity in RA begin long before onset of inflammation

Question 17

rheumatoid arthritis- epidemiology and risk factors

Answer 17

most prevalent in northern America and Europe, female>male 1-3:1, increases with age, paediatric population- juvenile idiopathic arthritis
risk factors- genetic factors, smoking, air pollution, obesity, low vit D

Question 18

rheumatoid arthritis- management

Answer 18

goal of treatment is symptom management, pharmacological management- disease managing anti-rheumatic drugs (DMARDs), nutrition, physio

Question 19

shoulder dislocation-

Answer 19

shoulder stability provided by ligament, labrum- static stablisers, and RC and scapular musculature- dynamic stablisers, can be anterior or posterior (<5%)

Question 20

shoulder dislocation- anterior

Answer 20

often caused by the arm being position in abduction and LR (apprehension position), humeral head displaced anterior inferior, concurrent RC injuries can occur- slap lesion, haggle, alpsa, vascular/neural structure at risk- axilla and brachial plexus

Question 21

shoulder dislocation- lesion

Answer 21

hills sachs lesion- cortical depression on posterolateral head of humerus, caused by impaction of humeral head on roof of glenoid
bankrupt lesion- damage to attachment point of anterior labrum to the glenoid

Question 22

shoulder dislocation- posterior

Answer 22

usually caused by a blow to the front of the shoulder, can only occur during seizures, can easily be overlooked in AP X-ray, concurrent injuries to RC (subscap) and posterior labrum

Question 23

shoulder dislocation- recurrence rates

Answer 23

most likely to have shoulder stabilization surgery, 19.6% recurrence rate- mostly in first 2 years, higher rate in men, higher recurrence in young (10-19 aged 49.2%

Question 24

shoulder instability

Answer 24

characterised by disruption of the dynamic and static stabilizers of the GHJ leading to dislocation, subluxation or apprehension

Question 25

static shoulder stablisers

Answer 25

articular conformity, negative, intra articular pressure labrum, GH lig, damage to this can effect proprioception, cause delay in muscle respond

Question 26

shoulder instability- traumatic and atraumatic

Answer 26

traumatic- due to dislocation, results in damage to both static and dynamic stabilizers atraumatic- congenital- secondary to hypermobility, can be due to chronic recurrence use- cause change in mobility of shoulder- ant, post, inf, multidirectional- leads to laxity/instability

Question 27

shoulder instability- clinical presentation

Answer 27

clicking/ pain, possible sub-acromial signs (painful arc, pain on rotation), possible RC signs (resisted tests, pain on rotation), positive apprehension test/ relocation test (anterior), increase accessory motion at GHJ, positive sulcus sign

Question 28

shoulder instability- management

Answer 28

physio- education, motor control, strength training- deltoids, proprioception training- train dynamic stablisers surgery- depending on structural impairments- labreal tears- repair labral tears, physio starts after 4 weeks

Question 29

Dupuytren disease

Answer 29

Hypertrophy and contracture of the superficial palmer fascia, flexion contracture of MCP and PIP joints leading to loss of function, occurs slowly, typically progress over the course of several years, typically occurs bilaterally

Question 30

Dupuytren disease- progression

Answer 30

begins with thickening of the skin, then bands of fibrotic tissue form in palmer area, eventually leading to affected fingers being pulled into flexion

Question 31

Dupuytren disease- aetiology

Answer 31

most common in north europe, males>females, average onset age 60- incidence increases with increased age, strong genetic component, environmental factors- alcohol intake, smoking, manual labour, low body weight/ BMI, use of anticonvulsant drugs associated with diabetes, epilepsy, HIV, AC, cancer

Question 32

Dupuytren disease- surgical management

Answer 32

is the mainstay of treatment, simple fasciotomy- early stage, contracted cord is cut but not surgically removed- least invasive, fasciectomy- partial or total removal of the diseased palmer fascia including the cord/ nodule dermo fasciectomy- also removes overlying skin and fat, then required a full thickness skin graft to cover the surgical site- severe, recurrent dupuytren, amputation of the digits may be considered

Question 33

Dupuytren disease- physiotherapy

Answer 33

main role is post op splinting, exercises- passive stretching active exercise, function-restore mobilisation to digits, education and advice, oedema and scar management, recurrent of dupuytren disease.is common

Question 34

impingement

Answer 34

caused by the tendons of the RC becoming trapped as they pass through the shoulder joint internal- inner aspect of the tendon compressed external- outer aspect of the tendon compressed primary- mechanical impingement resulting from pathological narrowing/crowding of subacromial space secondary- mechanical impingement resulting in narrowing due to dynamic/functional instability of the shoulder and pectoral girdle

Question 35

impingement classification- stage 1

Answer 35

oedema and inflammation to sub-acromial tissues pt normally <25 overuse P along anterolateral shoulder, described as deep dull ache, sharp with elevation, full A/PROM P arc (60-120)

Question 36

impingement classification- stage 2

Answer 36

fibrosis of GH capsule, bursae and tendinotis of relevant tendons pt >20, <40, +ive capsular pattern, reduced A/PROM

Question 37

impingement classification- stage 3

Answer 37

disruption to involved tissues | typically >40, muscle weakness ER and ABD, visible atrophy of deltoid, RC, weakness/ drop arm

Question 38

AC joint injury

Answer 38

traumatic AC injury- occurs when the joint is disrupted. the ligaments that hold the two bones of joint together get stretched too far this is called a shoulder seperation overuse AC joint- this type of injury occurs over time due to repeated and too much stress on the joint. Cartilage at the end of the acromion and clavicle bones protect joint from daily wear and tear

Question 39

bicep tendinopathy

Answer 39

traumatic (FOOSH) or insidious Pain localised to LHB and muscle belly bony sputs, instability of tendon, poor scap, stability/posture, result from RC tear

Question 40

bicep rupture

Answer 40

rupture at one of 2 places- proximal or distally, M?F 35+ years localised px and swelling with bruising retracted muscle, distal common in deadlifts proximal forced GH ext, elbow ext, and pronation and dislocation

Question 41

shoulder bursitis- causes

Answer 41

trauma- due to an accident, the bursa could become irritated and inflamed, inflamed joint when the whole joint is inflamed, the bursa can become inflamed as well as other structures overload- the reps of a certain motion too often can lead to the inflammation of the bursa becasue of the friction between the bursa on the one hand and another structure on the other hand (e.g. tendon, bone lig) other causes- degeneration of tendon, calcium deposition, adjacent inflammation of the supraspinatus tendon

Question 42

clinical presentation shoulder bursitis

Answer 42

shoulder pain and decreased ROM for longer than 1 month but less than year (becomes chronic bursitis), the presence of pain in atleast 1 activity (sleep, dress, work) a loss of 10° or more in 1 or more ROM, patients with subacromial bursitis should have a GH abd greater than 45° from patients with frozen shoulders