Shoulder pain: The Hand - Dr Yacoob Omar Carrim - MBChB, Dipl Sleep Medicine

Surgical Anatomy of the Hand
Neurovascular Exam of the Hand
Functional Anatomy
Congenital Deformities of the Hand
Hand Infections
The Shoulder and the elbow

• Shoulder pain can arise from

1. Extrinsic 
2. Intrinsic causes 

• Shoulder pain is explained by clinical exam and not CT
• Physiotherapy has a significant contribution to the management if shoulder pathology
• Shoulder disorders are causes by:
1. Traumatic
1. Fractures of the proximal humerus
1. Children
1. Epiphyseal injuries are common
2. Considerable potential for modelling exists - therefore closed treatment may be sufficient.
3. Consider surgery when:
1.  the bony fragments threaten to puncture skin, or 
2. irreducible, severe displacement
3. Surgery Open reduction and internal fixation with Kirschner wires for fixation
2. Adults (NEER Classification)
1. Is the head of the humerus dislocated?
2. Is the anatomical or surgical neck fractured?
3. Have the soft tissue attachments - lesser and greater tuberosities been avulsed or broken off?
4. Assess the degree of displacement
5. Surgical management priciples:
1. avoid devascularising the fracture fragments
2. Reduce and maintain the soft tissue attachments (Lesser and Greater tuberosities)
3. reduce the dislocation
4. link the proximal humerus to the shaft
5. Choice of implants:
1. K Wire
2. wire sutures
3. wiring combined with an intermedullary nail
4. a buttress plate
2. Dislocation or fracture dislocation of the shoulder
1. Anterior
1. After reduction:
1. Young - strict immobilisation - strapping the arm to the body for 6-8 weeks
2. Elderly - early movement must be encouraged - to prevent stiffness
2. Posterior
1. Uncommon - suspect after severe trauma, epileptic fits and electrical shocks
2. Recurrent dislocations:
1. Suspect a deficiency in Mm Subscapularis
2. Assesment:
1. Look for multi-directional instability
2. Habitual dislocations - masquerading as repeated traumatic recurrent dislocations
3. Treatment:
1. Surgical - Bristow operation
2. Arthritis
1. Pyogenic Arthritis
2. Rheumatoid Arthritis
3. Tuberculosis arthritis
4. Osteoarthritis
3. Mechanical Derangement
1. Recurrent dislocation
2. painful arc syndrome
1. Causes:
1. acute calcification tendonitis
1. surgical drainage provides dramatic cure
2. chronic supraspinatus tendonitis
3. bicipital tendonitis
1. NSAIDS
2. rature of the tendon
1. Painless, hard round lump (retracted muscle belly) in the biceps
4. tears of the rotator cuff (partial or complete)
1. Elderly - physiotherapy
2. Active adults - surgical reconstruction
5. impingement syndrome
1. Surgical decompression of the subacromial space
2. release the coraco-acromial ligament
6. injuries of the greater tuberosity
2. General Treatment of Painful Arc Syndrome
1. Rest
2. Physiotherapy (ice, heat, ultrasound, friction, Maitland Exercises)
3. Local injections of cortisone and local anaesthetic in the subacromial bursa
4. analgesia and NSAIDS
5. reassurance
1. Rapture of the long tendon of the biceps
1. Other
1. Tendosynovitis of the long tendon of the biceps
2. "frozen" shoulder
3. Avascular necrosis