Orthopaedic surgery

• Acromiclavicular joint arthritis: Can be posttraumatic, degenerative or rheumatoid
• Sx and signs of ACJ arthritis:

  • Tenderness over the joint
  • Pain on scarf test
  • Pain in arc 150-180 degrees of abduction
• X-ray findings of ACJ arthritis: Narrowing of the ACJ joint space and sclerosis of the lateral end of clavicle 
• Mx of ACJ arthritis

  • Conservative: NSAIDS or LASI (Local anaesthetic and steroid injection  for 6 months)
  • Surgery: Excision of the lateral end of clavicle.
• ACJ arthritis

  
• Calcific tendinitis: Deposition of calcium in the rotator cuff tendons
• • Precalcific: Tendinous tissue changes into fibrocartilage
  • Calcific: subdivided into formative, static and resorptive stage (most painful)
  • Post calcific: Reconstitution of tendon
• Mx of calcific tendinitis

  Conservative:

  • NSAIDS
  • LASI
  • Needling:
  • ECSWL: shock wave therapy

  Surgical

  • Excision of calcium open or arthroscopic
  • Acromioplasty
• Calcium over humeral head

  
• Rotator cuff syndrome: Rotator cuff tendon (supraspinatus) is  compressed under acromion and coracoacromial ligament
• Sx and signs of rotator cuff impingement syndrome

  • Pain on abduction and internal rotation
  • Pain over deltoid
  • Night pain (problems lying on the affected side)
  • Painful arc is 60-120 degrees
• X ray findings in rotator cuff impingement syndrome

  • X-rays-  Sclerosis over acromion and greater tuberosity
  • Os acromiale
  • Type 3 acromion
• Mx of rotator cuff impingement syndrome Conservative :

  • NSAIDS
  • Physiotherapy for strengthening cuff
  • LASI

  Surgery if above does not work"

  • Acromioplasty where you flatten the type 3 acromion
• Other investigations for rotator cuff impingement syndrome

  • MRI
  • Ultrasound
• Rotator cuff tears: can be traumatic or degenerative
• Symptoms of rotator cuff tears

  • Weakness of supraspinatus and infraspinatus
  • Pain on abduction and internal rotation
  • Pain over deltoid
  • Night pain
  • Painful arc is 60-120 degrees
• Investigations for rotator cuff tears

  • X-ray: elevated humeral head
  • U/S to determine size of tear
  • MRI
• Mx of rotator cuff tears

  Conservative:

  • NSAIDS
  • LASI
  • Physiotherapy

  Surgery (after 3-6 months of failed conservative):

  • Acromioplasty
  • Repair tendon
• Secondary causes of frozen shoulder :

  • Metabolic: Diabetes or thyroid disease
  • Intrathoracic or MI
  • Neurogenic or stroke
  • Reflex sympathetic dystrophy
  • Minor trauma can trigger it
• Frozen shoulder is also known as adhesive capsulitis
• 3 phases of frozen shoulder :

  • Freezing: pain and progressive stiffness
  • Frozen: stiff and painful
  • Unfreezing: Stiff and progressive increase in ROM
• Sx and signs of frozen shoulder

  • Diffuse pain with slow onset of symptoms
  • Poor sleep on affected side
  • Restricted movement (both active and passive) especially external rotation followed by abduction and then internal rotation.
• X-rays of frozen shouldr can be normal or generalised disuse osteopenia due to bone not being used
• Management of frozen shoulder

  Conservative

  • Hypnotics
  • Analgesics
  • Physio
  • NSAIDS
  • LASI

  Surgery (to restore ROM after 18months)

  • Manipulation under anaesthesia: Brisement
  • Surgical release of capsule (arthroscopically or open)
• Sx and signs of biceps tendinitis

  • Pain on palpation of biceps groove.
  • Pain in anterior aspects of shoulder
  • Yergason's and speed tests are positive
• Mx of biceps tendinitis

  Conservative :

  • NSAIDS
  • Physio for strengthening cuff
  • LASI
  • If this does not work, surgical repair
• Glenohumeral arthritis

  • Can be inflammatory due to infection or rheumatological
  • Can also be degenerative (wear and tear): often in older patients
• Glenohumeral arthritis signs and symptoms

  • Pain
  • Stiffness
  • Limited ROM
  • Swelling
  • Joint tenderness
• Xray findings of glenohumeral arthritis :

  • Joint space narrowing
  • Sclerosis
  • Osteophytes
  • Cysts
  • Osteopaenia 
• Mx of glenohumeral arthritis

  Infective

  • Drainage and antibiotics (urgent)

  Inflammatory

  • Rheumatology to treat medically and if it fails:
  • Synovectomy
  • Acromioplasty
  • Joint replacement

  Degenerative

  • Conservative
  • Surgery if above fails such as joint replacement
• Glenohumeral arthritis with osteophyte

  
• Special tests for shoulder instability:

  • Aprehension test
  • Relocation test
  • Sulcus test
• Instability of shoulder can be due to :

  Traumatic

  • Acute dislocation which is unidirectional
  • Bankart lesion formation
  • Atraumatic instability of shoulder is characterised by Increased laxity. It is often Multidirectional and often bilateral.
• A Bankart lesion refers to a tear or detachment of the labrum, which is a ring of cartilage that surrounds the socket (glenoid) of the shoulder joint

  
• Hill-sachs lesion which is indentation on humeral head that occurs when there is traumatic anterior dislocation

  
• Traumatic instability MX: Reduce and surgery if no improvement

  Atraumatic instability MX :

  • Rehabilitation and if it fails, then: inferior capsular shift surgery.
  • For recurrent instability:Bony procedures for anterior dislocations: Bristow and Latarjet
• In the Latarjet procedure, a piece of bone from the coracoid process is transferred to the front of the glenoid to increase stability. The Bristow procedure involves transferring a portion of the coracoid process along with the attached conjoint tendon to provide additional support to the shoulder joint
• Red flags in shoulder pain

  • Tumour (constitutional sx. History of cancer or unexplained deformity)
  • Infection (red skin, fever and systemically unwell)
  • Unreduced dislocation: Trauma, epileptic fit, electric shock: loss of rotation and normal shape
  • Acute rotator cuff tear: Trauma, acute disabling pain and significant weakness
  • Neurological lesion: unexplained significant sensory or motor deficit.