Orthopaedic Diseases of the Neck and Upper Extremities
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University of Debrecen
Department of
Orthopaedic Surgery
Orthopaedic Diseases of the
Neck and Upper Extremities
Zsolt Hunya MD
DE OEC
Ortopédiai Klinika
Introduction
Neck
− Physical examination and imaging
− Congenital anomalies and developmental diseases (Torticollis,
Klippel Feil)
− Degenerative problems (cervical spondylosis-cervicobrachial sy.)
Shoulder
− Physical examination and imaging
− Congenital anomalies and developmental diseases (Sprengel,
Winged scapula, Neonatal Brachial Plexus Palsies, Thoracic Outlet)
− Glenohumeral instability
− Disorders of rotator cuff (biceps tendinitis, calcifying tendinitis,
impingemente, cuff tears)
− Adhesive capsulitis or frozen shoulder
− Degenerative diseases (GH,AC arthrosis)
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Introduction
Elbow
− Physical examination and imaging
− Congenital and developmental problems (varus- ,valgus
deformity, Radioulnar Synostosis)
− Elbow instability
− Overuse syndromes and degenerative problems (Golfer’s and
Tennis elbow, olecranon bursitis, arthrosis)
Wrist and Hand
− Physical examination and imaging
− Congenital and developmental problems (Madelung deformity,
radial club-hand, syndactyly, polydactyly, congenital amputations
and missing rays, infantile trigger thumb)
− Kienböck-disease
− Inflammatory tendon lesions (Tendovaginitis, Trigger finger, De
Quervain’s disease)
− Ganglia
− Osteoarthritis of the wrist and hand joints
− Dupuytren’s contracture
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Introduction
Elbow
− Physical examination and imaging
− Congenital and developmental problems (varus- ,valgus
deformity, Radioulnar Synostosis)
− Elbow instability
− Overuse syndromes and degenerative problems (Golfer’s and
Tennis elbow, olecranon bursitis, arthrosis)
Wrist and Hand
− Physical examination and imaging
− Congenital and developmental problems (Madelung deformity,
radial club-hand, syndactyly, polydactyly, congenital amputations
and missing rays, infantile trigger thumb)
− Kienböck-disease
− Inflammatory tendon lesions (Tendovaginitis, Trigger finger, De
Quervain’s disease)
− Ganglia
− Osteoarthritis of the wrist and hand joints
− Dupuytren’s contracture
DE OEC
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Exam titles
Torticollis
Thoracic outlet syndrome (cervical rib)
Cervical spondylosis
Cervicalbrachial syndrome
Rotator cuff syndrome (impingement syndrome), rotator cuff tear
Chronic instability of the shoulder
Dislocation, subluxation of the shoulder
Tennis elbow (lateral epicondylitis), Golfer’s elbow (medial
epicondylitis), Olecranon bursitis
Osteoarthritis of the wrist and hand
Tendovaginitis
Trigger finger
De Quervain’s disease (stenosing tenovaginitis)
Dupuytren’s contracture
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Neck
Look – Feel – Move
Neurological examination (sensation, muscle power, reflexes)
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Xray
Foramen view
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CT-MRI
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Torticollis (wry neck)
Primary
−congential, multifactorial
−risk factors (iu rupture, ischemia, malpresentations)
Secondary
−cervical scoliosis
−ocular torticollis
−inflamatory disease (pharingitis, tubercolosis)
−trauma
−muscle spasm (disc problem, encephalitis, vertabral infection)
−rheumatic or degenerative (RA, spondylosis)
−scar related (after burns and infectons)
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Torticollis
unilateral or bilateral contracture of m. sternocleidomastoideus
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Torticollis
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Torticollis
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Klippel-Feil syndrome (short neck)
DE OEC
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Klippel-Feil syndrome (short neck)
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Degenerative diseases of the neck
DE OEC
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Degenerative diseases of the neck
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Cervicobrachialgia
− Proper relaxation - pilow
− NSAID, muscle relaxants
− PHYSIOTHERAPY!!! manual th.,
massage, extension, subaqual th.
− SURGERY: stabilization,discectomy, etc.
Cervicobrachialgia
TREATMENT
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Shoulder
Subacromial joint
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Shoulder examination
ROM – active, passive
129 test - www.shoulderdoc.co.uk
Dislocation, instability (anterior, posterior, inferior,
SLAP) and laxity
Long Head of Biceps Tendon
Rotator cuff (supraspinatus, infraspinatus,
subscapularis, teres minor, massive cuff tear)
Impingemente signs
AC joint
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Shoulder Xray
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Shoulder US
Rotator cuff – tendinitis, tear
LHBT – position, tendinitis
Labrum – SLAP
Soft tissue tumors
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Shoulder MRI
Rotator cuff – muscle atrophy, degeneration
LHBT – position, tendinitis
Labrum – Bankart, ReverseBankart, SLAP
Bone and Cartilage – AVN, Hill-Sachs, tumors
Soft tissue tumors
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Sprengel’s deformity
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Winged scapula
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Thoracic Outlet Syndrome
− complex neurovascular disturbance in upper limb
− middle aged women
− cervical rib, abnormal scalenus position
− mainly lower trunk and vascular disturbances
− posture related symptoms – Adson test
− physiotherapy
− surgical removal of cervical rib
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Thoracic Outlet Syndrome
Cervical rib
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Glenohumeral Instability
Definitions
−Laxity – Sulcus sign-Beighton scale-general
−Instability - unidirectional, multidirectional
−Dislocation - antero inferior, posterior, antero-superior,
luxatio erecta
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Glenohumeral Instability
Classification
Extent subluxation
luxation
Direction anteroinferior 95%
posterior 3%
anterosuperior1%
caudal1%
multidirectional
Onset acute
inveterate
recurrent
Etiology traumatic
habitual
voluntary
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Glenohumeral Instability
Classification-Matsen
TUBS or “Torn Loose”
Traumatic aetiology
Unidirectional instability
Bankart lesion is the pathology
Surgery is required
AMBRI or “Born Loose”
Atraumatic: minor trauma
Multidirectional instability may be present
Bilateral: asymptomatic shoulder is also loose
Rehabilitation is the treatment of choice
Inferior capsular shift: surgery required if conservative
measures fail
www.shoulderdoc.co.uk
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Glenohumeral Instability
Bankart lesion – Hill Sachs lesion
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Glenohumeral Instability
Treatment
Reposition maneuvers
– Hippokratesz, Artl, Kocher, Matsen, scapula
manipulations
– just for professionals
– circulation, innervation (plexus, n. axillaris!)
– additional injuries
Bracing
– duration 3/52-6/52 (younger – longer)
– internal or external rotation*
www.shoulderdoc.co.uk
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Glenohumeral Instability
Surgery
– minimal invasive vs. open , soft tissue vs.
bony procedure
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Glenohumeral Instability
Surgery
– Bankart (ASC-open)
– Capsuloplasty (Neer)
– Bone block (J-span, Eden Hybinette, Bristow
Latarjet)
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Subacromial impingement
Primary - Intrinsic
anatomic variation (acromial
shape, os acromiale)
AC arthrosis
greater tubercle fracture
Secundary - Extrinsic
cuff tear
muscle dysbalance
posture
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Subacromial impingement
(Bigliani et al 1986)
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Subacromial impingement (Neer 1982)
Stage 1 patients younger than 25 years
acute inflammation, edema, and hemorrhage in the rotator cuff
Stage 2 patients aged 25-40 years
fibrosis, tendonitis, partial cuff tear
.
Stage 3 patients older than 40 years
full thickness tear, osteophytes, and tendon rupture
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Impingement syndrome
Symptoms
painful arch
night pain
decreased ROM
Treatment
Stage 1 nonoperative treatment
(fizioth., injections)
Stage 2 as above or bursectomy, CA
resection
Stage 3 acromioplasty and rotator cuff
repair
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Impingement syndrome
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Rotator Cuff Tear Definitions-Classification
− Traumatic (20-40) – degenerative (above 40)
− Impingemente – tendinitis – rupture
− RC tendons (SSP,ISP,SSC,TM)
− Partial – full thickness
− Partial: articular or bursal surface
− Full: shape and retraction
− Symptoms: see impingemente
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Rotator Cuff Tear
UH vs. MRI
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Rotator Cuff Tear treatment
− physio, NSAID, injection (steroid, hyaluronic acid)
− surgery
open or minimal invasive
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Rotator Cuff Tear
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Biceps tendintis
− specific anatomical situation – intraarticular, bony groove
− young athletes, heavy laborers
− accompanied by full thickness tear
− chronic pain
− biceps load test, US
− NSAID, physioth, steroid inj (just geriatric patient)
− arthroscopic debridemente, tenodesis (young,active)
− tenotomy (geriatric)
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Calcifying tendintis
− middle aged women (around 40)
− acute pain - days
− diagnostic criteria: radiodense CA-hydroxyapatite deposites
in RC tendons
− Xray: AP ext, int rotation, axial
− spontaneous recovery, weeks relax
− NSAID, physioth, steroid inj
− asc removal of deposits and bursa
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Adhesive capsulitis
Frozen shoulder
− fibrotic adhesions inside the GH joint
− middle aged women
− pain and stiffness
− no significant X-ray, US changes
− association with diabetes and other metabolic diseases
− primary – unknown etiology
− secondary – after injury, surgery, injection or infection
− spontaneous recovery in 1-3 year
− NSAID, physiotherapy – exercises
− manipulation under anaestesia – hazardous
− arthroscopic release –up-to-date
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GH arthrosis
− painful limitation of ROM in GH joint degenerative changes
− primary – above 60
− secondary: trauma, avascular necrosis, rotator cuff
arthropathy – any age
− treatment – physio, NSAID or surgery (ASC or arthroplasty)
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Arthroplasty
Hemi vs. Total Anatomic vs. Total Reverse
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Reverse (inverse) total shoulder
arthroplasty
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Elbow
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Elbow
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Elbow
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Elbow
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Overuse syndromes
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Overuse syndromes
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Overuse syndromes
− elbow strap, NSAID, ice, rest
− physicotherapy
− local steroid+lidocaine
− surgical release
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Olecranon bursitis
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Olecranon bursitis
− common condition
− chronic irritation or blow on the tip of elbow
− metabolic disorders
− hematogenous bacterial infection!
− if sterile-NSAID, ice, rest
− suspected infection – aspiration and antibiotics
− surgical removal
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Osteoarthritis of the elbow
− primary or secondary (trauma, inflammation, infection,
metabolic disorders)
− painful restriction of movements
− secondary nerve entrapment
− physicotherapy, NSAID – long time
− joint preserving method – elbow arthroscopy (arthrolysis)
− joint replacement
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References
Required book:
ORTHOPEDICS (Edited by Miklós Szendrői)
Semmelweis, Budapest, 2008, first edition
Recommended books:
Mark D. Miller: Review of Orthopaedics
Saunders, 2004, fourth edition
A. Graham Apley, Louis Solomon: Apley's System of Orthopaedics
and Fractures
Butterworth-Heinemann, 1993, seventh edition
www.shoulderdoc.co.uk
DE OEC
Ortopédiai Klinika
Thank You for attention!
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