Shoulder lesionsShoulder lesions

H.Makhmalbaf MDH.Makhmalbaf MDConsultant Orthopedic & Consultant Orthopedic &

Knee surgeonKnee surgeonGhaem Hospital Medical Ghaem Hospital Medical

SchoolSchool

Painful arc syndrome Painful arc syndrome

Pain in mid ROM of abduction Pain in mid ROM of abduction Partial supraspinatus tendon tear Partial supraspinatus tendon tear Tendinitis of Supraspinatus Tendinitis of Supraspinatus Calcium deposite in supraspin. Calcium deposite in supraspin.

TendonTendon Sub-acromial bursitisSub-acromial bursitis Greater tuberosity fractureGreater tuberosity fracture

Painful arc syndromePainful arc syndrome

Pain in 45Pain in 45°° abduction – 160 abduction – 160 X-ray calcium deposit or #X-ray calcium deposit or # H/o trauma? Or inflamationH/o trauma? Or inflamation Conservative treatment mainlyConservative treatment mainly Or acromioplastyOr acromioplasty

Frozen shoulderFrozen shoulder

Painful restriction of ROMPainful restriction of ROM Unknown etiologyUnknown etiology Gradually progressiveGradually progressive ChronicityChronicity Slow spontaneous restoration of Slow spontaneous restoration of

ROMROM

Etiology Etiology

Tendinitis of rotator cuffTendinitis of rotator cuff Bicipital tenosynovitisBicipital tenosynovitis Muscle imbalance, inactivityMuscle imbalance, inactivity RSDRSD Association with cardiovascular dis.Association with cardiovascular dis. Trauma; degeneration; granulation Trauma; degeneration; granulation

tissue; adhesionstissue; adhesions

Frozen shoulderFrozen shoulder

Clinical pictureClinical picture

55thth & 6 & 6thth decades particularly women decades particularly women Insidious onset ;injury ? InactivityInsidious onset ;injury ? Inactivity Pain over anterolateral of shoulderPain over anterolateral of shoulder Worse at nightWorse at night Limitation of active & passive ROMLimitation of active & passive ROM Muscle spasm; internal rotationMuscle spasm; internal rotation Tenderness over bicipital groveTenderness over bicipital grove

Treatment: Treatment:

Bed rest , heat , sedationBed rest , heat , sedation If RA :injection of steroids & oralIf RA :injection of steroids & oral Pendulum exercisesPendulum exercises No forcible movementNo forcible movement Only MUA if necessaryOnly MUA if necessary Rarely need surgical releaseRarely need surgical release

Lesions of the rotator cuffLesions of the rotator cuff

Aging, degenerative changeAging, degenerative change Rupture of cuff, deltoid takes overRupture of cuff, deltoid takes over Recurring pain & stiffness, Recurring pain & stiffness,

aggravated by activity in the aggravated by activity in the shoulder & armshoulder & arm

Tenderness over tuberosity & Tenderness over tuberosity & bicipital grovebicipital grove

H/o fall or lifting, acute pain & snap H/o fall or lifting, acute pain & snap

Rotator cuff ruptureRotator cuff rupture

Unable to abduct armUnable to abduct arm 45’ abd. by deltoid, 45- 90 is 45’ abd. by deltoid, 45- 90 is

painfulpainful Size of tear is importantSize of tear is important Repair acute tear Repair acute tear Conservative neglected & oldConservative neglected & old

Calcified deposits in the Calcified deposits in the rotator rotator cuffcuff Ca phosphate & Ca carbonateCa phosphate & Ca carbonate In the tendon, lig. & capsuleIn the tendon, lig. & capsule Mainly in the white collar middle age Mainly in the white collar middle age Freq. Bilateral, men 3Freq. Bilateral, men 3rdrd& 4& 4thth decades decades Gradual or acute, pain, lim. AbductionGradual or acute, pain, lim. Abduction X-ray Ca deposits X-ray Ca deposits

Treatment :Treatment :

Conservative :Conservative :– Ice bag, rest , needle aspiration Ice bag, rest , needle aspiration

irrigationirrigation– Diathermy, steroids, exercisesDiathermy, steroids, exercises

Surgical :Surgical :– Relieves pain completelyRelieves pain completely– Large deposits, recurrence, Large deposits, recurrence, – Resistant to conservative, impingementResistant to conservative, impingement

Tennis elbowTennis elbow

Chronic disabling painChronic disabling pain At radiohumeral articulationAt radiohumeral articulation EpicondylitisEpicondylitis Degeneration of origin of Degeneration of origin of

ext.c.r.brevisext.c.r.brevis Frequent rotary motion of forearmFrequent rotary motion of forearm Incomplete healing response to stress Incomplete healing response to stress

of overload & overuse of overload & overuse

Treatment :Treatment :

Non-operative in 90%Non-operative in 90% Avoid overuse, brace, steroid Avoid overuse, brace, steroid

injectioninjection Forceful manipulation under LA.Forceful manipulation under LA. Operative if needed, MUAOperative if needed, MUA Release of tendon, excision of bursaRelease of tendon, excision of bursa RehabilitationRehabilitation

Osteochondritis DissecanOsteochondritis Dissecan

Localized disorder of convex joint Localized disorder of convex joint surf.surf.

Segment of subchondral bone Segment of subchondral bone becomes avascular & separatesbecomes avascular & separates

Knee & Elbow commonestKnee & Elbow commonest Rarely hip & ankleRarely hip & ankle

OCD : cause ;OCD : cause ;

Unknown ;impairment of blood supplyUnknown ;impairment of blood supply Thrombosis of an end artery?Thrombosis of an end artery? The significance of an injury uncertainThe significance of an injury uncertain An inborn susceptibility to the diseaseAn inborn susceptibility to the disease Several joints of a patientsSeveral joints of a patients Several members of the familySeveral members of the family

OCD : pathologyOCD : pathology

Segment of articular surface avascularSegment of articular surface avascular A line of demarcation formsA line of demarcation forms Various sizes:1-3 cm in the kneeVarious sizes:1-3 cm in the knee Always in the convex surfaceAlways in the convex surface Small segments reattach spontaneousSmall segments reattach spontaneous Or separates and form lose bodyOr separates and form lose body Cavity; irregularity; OACavity; irregularity; OA

OCD : clinical featuresOCD : clinical features

Adolescent or young adultAdolescent or young adult Aching ; mechanical irritationAching ; mechanical irritation Recurrent effusionRecurrent effusion After separation:locking, pain, After separation:locking, pain,

effusioneffusion O/E : effusion, wasted quads, O/E : effusion, wasted quads,

ROM okROM ok

OCD : radiographic OCD : radiographic features features A clear cut defect of the boneA clear cut defect of the bone Of the articular surfaceOf the articular surface Med. Femoral condyle of the kneeMed. Femoral condyle of the knee Cavity with or without fragmentCavity with or without fragment Lose body in place or elsewhereLose body in place or elsewhere Tunnel view: P/A knee semiflexedTunnel view: P/A knee semiflexed

Osteochondritis DissecanOsteochondritis Dissecan

OCD : knee arthroscopyOCD : knee arthroscopy

Clearly evident, for stagingClearly evident, for staging Articular surface sometimes Articular surface sometimes

normalnormal Softening, partial separationSoftening, partial separation Or total separation in place or outOr total separation in place or out Lose bodyLose body

OCD : treatmentOCD : treatment

In developing stage; knee supportIn developing stage; knee support Avoid strenuous activityAvoid strenuous activity Heals spontaneously orHeals spontaneously or Removal of lose body or fixation Removal of lose body or fixation

ofof A large fragment A large fragment

Congenital dislocation of Congenital dislocation of patellapatella Familial & bilateralFamilial & bilateral Occasionally with Arthrogryposis M.C Occasionally with Arthrogryposis M.C And Dawn syn.And Dawn syn. Persistent & irreducible, +or- Persistent & irreducible, +or-

genovalgum & ext. rot. Of tibiagenovalgum & ext. rot. Of tibia Quads contractureQuads contracture

Cong. Dislocation of Cong. Dislocation of patellapatella Late diagnosis, patella ossifies at Late diagnosis, patella ossifies at

3-4y3-4y Early operationEarly operation Lateral releaseLateral release Medial plication of capsuleMedial plication of capsule Tibial tubercle transferTibial tubercle transfer

Osgood-Schelatter’s dis.Osgood-Schelatter’s dis.

Apophysitis of tibial tubercle in Apophysitis of tibial tubercle in childhoodchildhood

T.T. becomes enlarged and T.T. becomes enlarged and painfulpainful

Is strain of developing tibial Is strain of developing tibial tubercletubercle

From the pull of patella tendon From the pull of patella tendon

O.S: clinical pictureO.S: clinical picture

Child of 10-14y, usually a boyChild of 10-14y, usually a boy Pain in front of the kneePain in front of the knee Worse on strenuous activityWorse on strenuous activity T.T. prominent & painfulT.T. prominent & painful Tender on palpationTender on palpation Knee extension against resistant Knee extension against resistant

O.S.O.S.

Enlargement or fragmentation on Enlargement or fragmentation on X-RX-R

Self-limiting, normal function Self-limiting, normal function when tubercle fusedwhen tubercle fused

Rest in plaster for two month if Rest in plaster for two month if

Osgood SchelatterOsgood Schelatter

Osteoarthritis :OAOsteoarthritis :OA

Is a degenerative wear & tear in Is a degenerative wear & tear in jointsjoints

That are impaired by congenital That are impaired by congenital defect vascular insufficiency, or defect vascular insufficiency, or previous disease or injuryprevious disease or injury

Is the commonest variety of Is the commonest variety of arthritisarthritis

Caused by wear & tearCaused by wear & tear

OAOA

No stress no OANo stress no OA Less OA in the joints of the upper limbLess OA in the joints of the upper limb A predisposing factor accelerates w&tA predisposing factor accelerates w&t Any abnormality may be responsibleAny abnormality may be responsible Congenital ill-developmentCongenital ill-development Previous fracturePrevious fracture

OA : predisposing factorsOA : predisposing factors

Internal derangement: lose bodyInternal derangement: lose body Previous disease: RA, hemophiliaPrevious disease: RA, hemophilia Mal-alignment of a joint, bow legMal-alignment of a joint, bow leg Obesity & overweigthObesity & overweigth Age alone is not a cause of OAAge alone is not a cause of OA Impaired capacity for repair after Impaired capacity for repair after

injury injury

Overview of the processOverview of the process

OA: pathologyOA: pathology

Any joint may be affectedAny joint may be affected Articular cartilage is worn awayArticular cartilage is worn away Subchondral bone exposedSubchondral bone exposed Osteophytes form at the marginOsteophytes form at the margin No primary change in capsule or No primary change in capsule or

synovsynov Often thickening & fibrosis laterOften thickening & fibrosis later

Cartilage destructionCartilage destruction

OA: clinical featuresOA: clinical features

Most patients are past middle ageMost patients are past middle age If younger; a clear cause isIf younger; a clear cause is Gradual onset, painGradual onset, pain Restriction of ROM; deformityRestriction of ROM; deformity O/E : bony thickening, osteophytesO/E : bony thickening, osteophytes Not warm, limitation of ROM, fixed Not warm, limitation of ROM, fixed

defdef

OA: X-rayOA: X-ray

Diminution of cartilage spaceDiminution of cartilage space Subchondral sclerosisSubchondral sclerosis Spurring or lipping of the joint Spurring or lipping of the joint

marginsmargins Cyst formation Cyst formation

Severe OASevere OA

OA: diagnosisOA: diagnosis

History History Clinical findingsClinical findings X-ray featuresX-ray features OA is not confused with inflammatoryOA is not confused with inflammatory No synovial thickening, no local warm.No synovial thickening, no local warm. No muscle spasm no rarefaction on X-No muscle spasm no rarefaction on X- ESR is not increasedESR is not increased

OA: treatmentOA: treatment

No treatmentNo treatment Conservative Conservative Operative treatmentOperative treatment Reassurance and adviceReassurance and advice Conservative : physio, heat, Conservative : physio, heat,

exercisesexercises Analgesics, support, stickAnalgesics, support, stick

OA: surgical treatmentOA: surgical treatment

Osteotomy for realignmentOsteotomy for realignment Arthroplasty and replacementArthroplasty and replacement ArthrodesisArthrodesis

OA of the kneeOA of the knee

Knee is the commonestKnee is the commonest Particularly in elderly & fat womanParticularly in elderly & fat woman Previous damage: torn menisciPrevious damage: torn menisci OCD, torn ligamentsOCD, torn ligaments Malalignment of tibia on the femurMalalignment of tibia on the femur Usually both kneesUsually both knees

OA of the knee: O/EOA of the knee: O/E

Osteophytes Osteophytes Effusion unusual Effusion unusual Limitation of ROM, crepitationLimitation of ROM, crepitation Wasted quadricepsWasted quadriceps Varus deformity> valgusVarus deformity> valgus Limitation of extensionLimitation of extension

Knee deformity & OAKnee deformity & OA

OA of the knee; OA of the knee; treatmenttreatment Conservative : heat , phyisioConservative : heat , phyisio Steroid injectionSteroid injection surgerysurgery In the worst casesIn the worst cases Sever persistent painSever persistent pain Especially with deformityEspecially with deformity

Operative treatment:Operative treatment:

Arthroscopy & removal of lose Arthroscopy & removal of lose bodiesbodies

UTOUTO Excision of patella (or elevation)Excision of patella (or elevation) Arthroplasty Arthroplasty Arthrodesis Arthrodesis

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