4 – 5:45 pm
Orthopedic Update: Hand and Shoulder SPEAKERS Charles S. Day, MD, MBA Arun J. Ramappa, MD
Goal: Simplify Evaluation of the Painful Shoulder • Can be challenging • Overlapping diagnoses • Multiple complaints - Neck - Shoulder - Back - Arm
Shoulder Disorders: Overview • Anatomy - Surface - Deep
• History • Common Shoulder Disorders - Evaluation - Management
• Injections
Presenter Disclosure Information The following relationships exist related to this presentation: ► Charles S. Day, MD, MBA: Consultant for Cartiva Inc. and Integra LifeSciences. Researcher for Boston Brace. ► Arun J. Ramappa, MD: No financial relationships to disclose. Off-Label/Investigational Discussion ► In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.
Shoulder vs Neck Pathology • Very common to have neck pain with shoulder problems • Cervical spine disease: often associated with pain and/or weakness • PE of shoulder can exclude cervical disease
Shoulder: Bony Anatomy • Three major bones - Humerus - Clavicle - Scapula
• Four major joints: - Acromio‐clavicular - Gleno‐humeral - Scapulo‐thoracic - Sterno‐clavicular
Shoulder: Muscular Anatomy • Nine major muscles • Synchronous action results in shoulder motion • Imbalance results in pain
Shoulder: Muscular Anatomy • Supraspinatus coursing under acromion • Infraspinatus • Subscapularis • Teres Minor • Biceps tendon directly under supraspinatus
Shoulder: Rotator Cuff Anatomy • Subscapularis • SUPRASPINATUS
Shoulder: History • Age • Hand dominance, occupation • Chief complaint: pain, weakness, stiffness, or instability
• Infraspinatus
• Location
• Teres Minor
• Onset • Precipitants • Prior treatment: meds, PT, injections • Disability/Progression • Neurologic complaints
Common Shoulder Disorders • Rotator cuff impingement • Rotator cuff tears • Adhesive capsulitis • Osteoarthritis • AC Joint Disorders • Calcific Tendonitis
Case 1 • 35 yo physician with shoulder pain • No trauma • Prompted ER visit • Radiates down arm • No complaints of weakness
Case 1 • Exam: + Spurling’s maneuver
Case 2 • 45 yo male injured his shoulder while throwing football
• Exam: ‐ impingement signs
• Feels a click
• Exam: Normal strength
• Pain with sleeping
• Diagnosis: Neck related NOT Shoulder
• Pain with reaching overhead • Can’t play with kids
Case 2 • ROM is symmetric but FE above 120 degrees is painful • Impingement signs are present • Strength is normal
Common Shoulder Disorders • Rotator cuff impingement • Rotator cuff tears • Adhesive capsulitis • Osteoarthritis • AC Joint Disorders • Calcific Tendonitis
Shoulder: Rotator Cuff Disease • Subscapularis
Rotator Cuff Disease: Impingement Syndrome
• SUPRASPINATUS
• Tendinosis/Bursitis at the Supraspinatus
• Infraspinatus
• Under the Acromion
• Teres Minor
• History: Pain overhead, behind back, sleep • Physical Findings: - Impingement Signs - No Weakness
Shoulder: Exam ‐ Impingement • Neer sign:
• Hawkins sign:
- Sensitivity: 85% - Specificity: 50%
• Painful arc of motion: forward elevation • Compression of rotator cuff between underlying humerus and overlying acromion
•
Shoulder: Exam ‐Impingement
Rotator Cuff Disease: Impingement Syndrome Rehabilitation
- Sensitivity: 75% - Specificity: 45%
• Painful arc of motion: - forward elevation 90 + internal rotation
Rotator Cuff Disease: Impingement Syndrome
- Strengthen Rotator Cuff and Scapular Stabilizers
• Surgical Treatment – arthroscopic
- Stretch Posterior Capsule
• Surgery: RARE
• Activity Modification
• Bursectomy
• NSAIDs
• Acromioplasty
• Injections - Lidocaine + Cortisone
- Cures 80%
Case 2: Treatment • NSAIDs • PT with emphasis on scapular strength • Steroid injection? • Rotator cuff tear VERY UNLIKELY
Case 3 • 42 yo male falls onto his shoulder while snowboarding • Difficulty raising arm • XRays: No fracture • Plan?
Case 3 • Inspection
Common Shoulder Disorders • Rotator cuff impingement
- No atrophy
• Rotator cuff tears
- No ecchymosis
• Adhesive capsulitis
- No deformity
• Osteoarthritis
• RC strength: Weak supraspinatus
• AC Joint Disorders • Calcific Tendonitis
• ROM: Passive > active
Rotator Cuff Tears
Rotator Cuff Tears
• Follow Impingement
• Follow Impingement
• Begin Small
• Begin Small
• Progress
• Progress - 174 Tears: • 61% of full thickness tears and 44% of partial thickness tears progress at median of 5 years
Keener, et al, JBJS 2015
Rotator Cuff Tears • Follow Impingement • Begin Small • Progress • Physical Findings: Weakness
Rotator Cuff Tears • Not all tears require surgery (Esp Partial Tears)! - MRI study: 54% of asymptomatic cohort > 65 with cuff tear! - Assessment of functional goals/comorbid conditions ESSENTIAL - Ability to comply / participate in rehabilitation ESSENTIAL
Sher, et al, JBJS 1995
Rotator Cuff Repair Improves Strength
Case 3
• Functional outcomes are equivalent whether tear heals or not
• Weakness after trauma
• Strength significantly greater with healing (75% heal)
• Suggests rotator cuff tear
• Scapular elevation strength intact vs torn = 5.0 vs 2.6 kg
• MRI!! • Surgery
Keener, et al, JBJS 2010 Russell, et al, JBJS 2014
Rotator Cuff Repair • Open Surgical Repair - Repair to Bone - Full Recovery‐Months!
Rotator Cuff Repair • Arthroscopic Repairs - Technology is Evolving - Lower morbidity
• Results - 90% Success at Pain Relief - 80% Success at Function
Zumstein, et al, JBJS 2008
Clinical Messaging • Surgery - Very effective - Can be painful - 4‐6 months for recovery
• Should normalize pain and function
Moosmayer, et al, J Bone Joint Surg 2014
- Success rates similar to open
Aleem and Brophy, Clin Sports Med 2012
Rotator Cuff Tear: Muscle Atrophy with Delay • Muscle infiltrated with fat over time • Surgery unsuccessful once significant atrophy occurs • Do not delay evaluation
Common Shoulder Disorders • Rotator cuff impingement
Adhesive Capsulitis – Frozen Shoulder • Painful shoulder
• Rotator cuff tears
• Restricted ROM (Active=Passive)
• Adhesive capsulitis
• Normal Xrays
• Osteoarthritis
• Thickening of shoulder capsule
• AC Joint Disorders
• Classification
• Calcific Tendonitis
- Idiopathic – especially Diabetes Mellitus - Posttrauma - Postsurgical
Adhesive Capsulitis – Frozen Shoulder • Treatment
Common Shoulder Disorders • Rotator cuff impingement
- Usually self limited
• Rotator cuff tears
- NSAIDS
• Adhesive capsulitis
- Physical Therapy – Stretching Capsule
• Osteoarthritis
- Intraarticular Injections
• AC Joint Disorders • Calcific Tendonitis
- Arthroscopic Surgery if unresponsive
Shoulder: Osteoarthritis
Common Shoulder Disorders
• Progressive pain
• Rotator cuff impingement
• Limitation of ROM (Active=Passive)
• Rotator cuff tears
• Treatment - NSAIDs - PT - Surgery: Joint Replacement
• Adhesive capsulitis • Osteoarthritis • AC Joint Disorders • Calcific Tendonitis
AC Joint Disorders
Common Shoulder Disorders
• AC joint arthritis: common but not often painful
• Rotator cuff impingement
• Distal clavicle osteolysis: weightlifters
• Rotator cuff tears
• Pain: overhead, crossarm activities • Point Tender at AC joint • Treatment: activity modification, NSAIDs, injections, surgery
• Adhesive capsulitis • Osteoarthritis • AC Joint Disorders • Calcific Tendonitis
Buttaci, et al, Am J Phys Med Rehabil 2004
Calcific Tendonitis • Calcification of supraspinatus tendon
Shoulder Injection • Office
• Painful arc of motion
- Rotator Cuff Impingement
• Acute onset: VERY PAINFUL
- Calcific Tendinitis • Ultrasound/Fluoroscopic Guided
• Treatment - NSAIDs
- Adhesive Capsulitis
- PT
- Osteoarthritis
- Injections - Surgery
Shoulder Injections • SUBACROMIAL - Accuracy: 80‐90%
Shoulder Injections: Subacromial • Rotator Cuff Disease/Impingement • Posterior approach
• Glenohumeral
• Betadine prep
• AC joint
• 5‐10 cc lidocaine w/o epi • 1‐2 cc of corticosteroid (40mg/ml) • Angle Needle Upward Parallel to Acromion
Marder, et al, JBJS 2012
• Diagnostic & Therapeutic
Shoulder Injections
Shoulder Injections
• Subacromial
• Subacromial
• GLENOHUMERAL
• Glenohumeral
- Low accuracy for blind injection - Anterior: 64% - Posterior: 45% - Supraclavicular: 45%
• AC joint Tobola, et al, JSES 2011
• AC JOINT - Low accuracy - 43% intra‐articular - 23% partially intra‐articular - 33% extra‐articular Wasserman, et al, Am J Sports Med 2013
Shoulder Injections: AC Joint • Acromioclavicular disease • Anterior approach • Betadine prep • 1 cc lidocaine w/o epi • 1 cc of corticosteroid (40 mg/ml) • Can be difficult
Clinical Messaging • If injection - Will be more sore for a couple of days - Typically starts working after 48‐72 hours
• Will improve over the next 6‐8 weeks • Self‐limited process • Reassess and consider an MRI
Wasserman, et al, Am J Sports Med 2013
Special Considerations before Injection • Pts with Diabetes - Injection may raise blood glucose levels
• Pts with HIV - Wary if on protease inhibitor • Ex. Ritonavir/Norvir • Can cause iatrogenic Cushing’s response
Shoulder Disorders: Summary • Refer to PT, but consider a delay in specialist referral - Frozen Shoulder - Shoulder pain with good ROM and strength
Shoulder Disorders: Summary • When to Refer?
Orthopedic Update
- ALL Fractures
(with a focus on the hand, shoulder, and knee)
- ALL Dislocations or Instability
Charles S. Day, M.D., M.B.A. Associate Professor in Orthopedic Surgery Director, Orthopedic Curriculum Harvard Medical School
- Traumatic event with NEW Weakness - Whenever in doubt
Chief, Hand & Upper Extremity Surgery Beth Israel Deaconess Medical Center Pri-Med East Annual Conference September 18-20, 2015
Outline • Terminology and Axes of Motion • Fundamental Surface Anatomical Landmarks • Physical Examination & Diagnoses for PCP’s
Terminology • Hand
–Dorsal surface –Volar or palmar surface –Radial and ulnar borders • Palm
–Thenar area –Mid‐palm area –Hypothenar area
Terminology • Fingers – Thumb, index, middle/ long, ring, & small (1st to 5th) • Each digit (except thumb) – 3 phalanges (prox, middle, distal) – metacarpal
Terminology • Each finger has three joints: – Metacarpophalangeal (MP) – Proximal interphalangeal (PIP) – Distal interphalangeal (DIP)
• Thumb – Two phalanges & two joints (MP, IP)
Hand Motion
Hand Motion • Standardized – Digits • Center of hand – Long finger ray
• Standardized – Forearm – Wrist
Thumb Motion
Thumb Motion
• Standardized – Opposition
• Standardized – Flexion – Extension (Planar abduction)
• Abduction • Flexion (Adduction) • Pronation
Essentials of Hand Surgery 2002
Surface Anatomy of Hand • Bones – Metacarpal – Phalanges • Joints – DIP, PIP, IP, MCP
Essentials of Hand Surgery 2002
Dorsal Surface Anatomy • Bones – Metacarpal – Phalanges • Joints – DIP, PIP, IP, MP
Anatomical Structures of the Wrist • # bones: • # joints: • # tendons:
15 17 24 (25)
Surface Anatomy of Wrist
Surface Anatomy of Wrist • First landmark: – Snuff box • CMC thumb • Thumb Extensors • Scaphoid
Surface Anatomy of Wrist • Third Landmark – Distal Ulna • Extensor Carpi Ulnaris (ECU) Tendonitis • Triangular Fibro‐ Cartilage Complex (TFCC) ligament
• Second Landmark – Lister’s tubercle • Distal Radius • Scapho‐Lunate Ligament
Surface Anatomy Summary • • • •
Volar MP joints PIP and DIP Joints Metacarpals Phalanges
• Snuffbox • Lister’s Tubercle • Distal Ulna
P.E. & Diagnoses of Hand & Wrist Pain
Case Study • 47 y.o. woman c/o 6 months h/o of numbness and tingling in right hand – Wakes her up at night
Clinical messages • Clinician
• Patient
– Ask about night pain – May lead to irreversible median nerve damage – Refer to hand surgeon if splint not helpful
– Start with wrist splints at night – F/u if symptoms no better
Carpal Tunnel Syndrome • Tinel’s • Median Nerve Compression (Durkin) • Phalen’s
Case Study • 53 y.o. male with diabetes c/o clicking in right ring finger joint – Worse in the mornings – Sometimes the finger “sticks”
Flexor Tendon • Normal Finger Cascade
Trigger Finger
Clinical messages • Clinician
• Patient
– Examine the volar MP joint of the finger – Increased risk in diabetics and rheumatoids
– Therapy is unreliable – Steroid injection has 70% success rate
Case Study • 27 y.o. male RHD (right‐hand dominant) male accidentally cut his left index finger while opening up frozen hamburger patties
Clinical messages • Clinician
• Patient
– Urgent hand surgery referral – Check digital sensation
– May need surgery
Case Study • 24 y.o. male fell on outstretched hand (FOOSH) while skateboarding on sidewalk, now has wrist pain
Clinical messages • Clinician
Radial Wrist Pain
– Thumb spica splint/ cast if h/o of FOOSH and snuffbox tenderness – Refer to orthopaedic surgeon
• Patient – Need to follow up for persistent wrist pain after falls
Case Study • 31 y.o. woman who has a 2 month old baby at home c/o right thumb/ wrist pain for the last month – Worse with picking up baby
Clinical messages • Clinician
Case Study • 67 y.o. woman c/o 1 year h/o of pain in her right wrist area – Worse with turning on ignition – Worse with twisting open bottle caps
P.E. & D.Dx. Summary • P.E. for – MC/ Phalanx Fx – Trigger Finger – FDS/ FDP Injuries – Carpal Tunnel Syndrome – Scaphoid Injury – CMC arthritis of the Thumb – DeQuervain’s Tendonitis – Scapho-Lunate Injury – TFCC Injury
• Patient
– Thumb spica splint and NSAIDs – Steroid injection is 70% effective
– Try not to extend the thumb, especially young mothers
Clinical messages • Clinician – Thumb spica splint – Steroid injections ONLY 40% effective
• Patient – Activity modification, ie, opening bottle caps
