38  T_h e upper limb

Acquired abnormalities
Acquired abnormalities
History Patients usually associate the onset of  their symptoms with an unusual event (trauma or excessive activity) even though the causation may not be as clear as the patient thinks. Even so, the onset (sudden or gradual) and duration are important details to establish, as is the age, occupation and hand dominance of the patient. Pain presenting in the shoulder (or anywhere in the upper limb) can arise from the nerves of  the neck, so the history should enquire about neck problems. Examination If  the patient can localise the pain to an exact point around or within the shoulder, then the problem is unlikely to be referred from the neck. Tests for inflammation and impingement involve trying to reproduce the pain by loading the limb in the position that creates the problem (e.g. Hawkins’ test for impingement; Figure 38.3 ). Tests for tears in structures such as the rotator cu ff look specifically for weakness, while appre hension tests check for instability (such as may predispose to recurrent shoulder dislocation). Richard J Hawkins , contemporary , Canadian orthopaedic surgeon. Investigations Radiographs are often of  limited value because most shoulder pain arises from soft-tissue structures. However, a reduced subacromial space may be clearly visible in full-thickness rotator cu ff tears ( Figure 38.4a ). The appearance of  a typical subacromial spur can be seen on the radiograph in Figure 38.4b and morphological variants of the acromion are shown in Figure 38.5 . Patients with impingement pain and rotator cu ff tears are much more likely to have a hooked acro - mion. The appearance of  a spur, which produces the hook, is usually due to calcification within the coracoacromial ligament - (CAL) insertion and it may be a secondary consequence of degenerative cu ff disease rather than a causative lesion.
Figure 38.2
Sprengel’s shoulder (right) of a 4-year-old girl.
(a)
Figure 38.4
(a)
Radio-
graph showing sclerosis
on the undersurface of
the acromion and the
greater tuberosity, with
reduced subacromial
space.
(b)
Radiograph
showing an acromial
spur and arthritis of the
acromioclavicular joint.
Figure 38.3
Hawkins’ impingement test. Impingement pain is repro
duced when the shoulder is internally rotated with 90° of forward
/f_l
exion, thereby locating the greater tuberosity and anterior rotator cuff
underneath the acromion and coracoacromial ligament.
(b)
Acromioclavicular arthritis
Spur
Both ultrasound and magnetic resonance imaging (MRI) allow the integrity and health of  the rotator cu ff to be checked whereas magnetic resonance (MR) arthrography also gives information on the integrity of the labrum of the glenohu meral joint ( Figure 38.6 ). Local anaesthetic injections may help to localise the source of  pain. For example, a painful arc on forward elevation (Neer’s sign) may be completely relieved by injecting local anaesthetic into the subacromial b ursa in cases of  subacromial impinge ment (Neer’s test positive). Rotator cuff degeneration and impingement The rotator cu ff moves in a confined space between the humeral head, the acromion and the CAL. Blood vessels cannot cross the glenohumeral joint cavity below the supraspinatus tendon or through the subacromial space above it, and vessels that enter Charles Sumner Neer II , 1917–2011, orthopedic surgeon, Columbia University , New Y ork, NY , USA, developed the first widely used shoulder arthroplasty . from the insertional and muscle belly ends become constricted when the tendon is tensioned around the curved humeral head when the cu ff is active. Blood flow is therefore limited, the - tendon is exposed to external forces as it operates in a confined space and its capacity for self-repair is limited. More than any other tendon, therefore, it is prone to age-related degeneration, leading to tendinosis and partial- and full-thickness tearing; the rate of  this is at least partly genetically determined. Even a - trivial injury can inhibit rotator cu ff function, so that it does not glide so easily in its subacromial space, starting a progression of  inflammation, swelling and pain in the subacromial region. This subacromial pain may be termed impingement, which is felt to be attributable to abrasion of  the cu ff and bursa on the undersurface of  the acromion. The impingement itself causes further bursal inflammation and pain, which further inhibits rotator cu ff function, and a vicious circle is set up. The likelihood of subacromial pain developing is increased in patients with a spur beneath the acromion, which is seen increasingly commonly with age ( Figure 38.5 ) and may be an e ff ect rather than a cause of  painful subacromial degeneration, as described earlier in this paragraph. The result is a painful arc of  movement for the patient, which corresponds to the position where the inflamed segment of  the supraspinatus tendon passes under the anterior acromial spur. The examiner may find that, although the patient cannot actively lift their arm through this segment (because of  the pain), passively lifting the arm for the patient enables them to continue with pain-free movement once the area of  impingement is passed ( Figure 38.7 ). Treatment Injection of  steroid into the inflamed subacromial bursa may break the cycle of  inflammation and impingement ( Figure 38.8 ), allowing rotator cu ff function to resume without impingement. Physiotherapy promotes normal cu ff activity once the pain has been relieved in this way . A commonly performed procedure is arthroscopic removal of  the subacromial spur, anteroinferior acromion and the CAL, which has been shown to give good relief  of  symptoms ( Figure 38.9 ), but there is no evidence that it either improves the long-term prognosis or reduces the risk of  rotator cu ff tears developing.
Figure 38.5
The three commonest acromial morphologies seen in adults. Children almost always have the
/f_l
at morphology.
Cuff tear
Figure 38.6
Magnetic resonance imaging scan showing a retracted
cuff tear.
Summary box 38.1 Rotator cuff degeneration and impingement /uni25CF /uni25CF /uni25CF Summary box 38.2 Treatment of subacromial impingement /uni25CF /uni25CF /uni25CF Rotator cuff tears The rotator cu ff has a relatively poor blood supply in the segment that glides between the humeral head and acromion, as described in Rotator cu ff degeneration and impinge ment . The cu ff thins with age and eventually develops defects that are termed tears, whether or not there has been any trauma involved in their appearance. This means that tears are more common in older adults, and at any age they do not heal spontaneously . Tears usually begin at the anterolateral edge of the supraspinatus, and progress posteriorly to involve the infraspinatus and teres minor tendons. This creates a bare area over the greater tuberosity , as the torn cu ff retracts medially ( Figure 38.10 ). History In the younger patient with a healthier cu ff the onset often requires relatively major trauma, e.g. breaking a fall from a motorcycle or significant height with the outstretched hand, but in older adults the onset may follow a simple fall, a painful period of  tendinitis or the condition may apparently occur spontaneously . Examination The patient may have a mixed picture of  subacromial pain and a tear, but if  the pain is removed by injection of  local - anaesthetic the weakness will persist. Symptomatic tears are
o
180
170
o
60
o
0
Figure 38.7
Arcs of shoulder girdle motion with subacromial impinge
ment pain between 60° and 120° of abduction, and acromioclavicular
joint pain between 170° and 180°.
Tendinosis and bursitis produce weakness secondary to pain
(often a painful arc)
A tendon tear produces weakness that is only secondarily
painful
Injection of local anaesthetic and retesting can distinguish
those who do from those who do not have a tear – weakness
persists if there is a signi
/f_i
cant tear
Non-operative treatment includes injections and rotator cuff
rehabilitation
Surgery may be indicated if symptoms persist beyond 3–6
months of non-surgical management
Surgery restores a
/f_l
at acromion and makes more room for
rotator cuff gliding but there is no evidence that it improves the
long-term outlook
o
120
Figure 38.8
Technique of administering an injection into the subacro
mial bursa.
(b)
(a)
Figure 38.9
(a)
Arthroscopic view of an acromial spur.
(b)
Arthroscopic
view after the acromial spur has been removed and the cuff decom
pressed.
associated with pain, weakness, limited active abduction, cu ff muscle wasting and hunching of the shoulder when attempting abduction ( Figure 38.11 ). Specific tests can localise the tear by identifying which muscles are a ff ected, e.g. the ‘empty can test’ for supraspinatus. Investigation Both ultrasound scanning, in the hands of  an experienced operator, and MRI are excellent tools for detecting rotator cu ff tears and assessing the tissue quality . Tears are classified as small (less than 1 /uni00A0 cm), intermediate (2–4 /uni00A0 cm) and large (more than 5 /uni00A0 cm). Treatment Treatment depends on the patient’s age, lifestyle and severity of  symptoms. Three to six months of  rehabilitation are required after surgical repair before resuming full overhead loading, so this is not an operation to be carried out in those who cannot rest the shoulder, including those who need it for weight-bearing through bilateral crutches. Arthroscopic or mini-open repair with subacromial decompression can be considered for all tears, but is likely to give a better outcome in the y oung than in the old. It may not be possible to repair large tears owing to their size, or the attempt at repair may be fruitless because of  fatty atrophy of the rotator cu ff and loss of  muscle contractility , in which case complex surgery , e.g. tendon transfers, patch grafts or reverse joint replacement ( Figure 38.12 ), will need to be considered. Summary box 38.3 Rotator cuff tears /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Frozen shoulder (adhesive capsulitis) This is an idiopathic condition causing sti ff ness and pain, most commonly a ff ecting females in their fifties. It is also associated with diabetes, heart and thyroid disease. History and examination Frozen shoulder is characterised by the onset of  severe pain that is often spontaneous, though patients may recall an episode of  minor trauma, which is of  unknown relevance. It may also complicate surgery or other painful shoulder condi - tions. The di ff erential diagnosis includes infection, fractures and rotator cu ff tear, though if  the sti ff ness is global and there is no redness or temperature then osteoarthritis is the main
zone
Normal
Full-thickness tear
Figure 38.10
Various stages of rotator cuff tear. Initial partial-thickness tears progress to full–thickness and
retracted tears but this process may be asymptomatic.
Figure 38.11
A 75-year-old man with a >5 cm retracted cuff tear
attempting to abduct his shoulder; the lack of a stable fulcrum pro
vided by the rotator cuff means that the deltoid is less effective and
can only abduct to 60°.
Partial-thickness tears
Chronic tear
Retracted chronic tear
Occur more commonly in older age groups
4–20% of 40- to 50-year-olds have asymptomatic rotator cuff
tears
Up to 30% of 70-year-olds have an asymptomatic full-
thickness tear
Acute tears may present with little pain but profound
weakness
Earlier repair after traumatic onset with acute loss of function
gives better results
alternative diagnosis. Initially there is severe pain but this improves with time. However, there is global loss of  active and passive movement, limited by pain. The pathognomonic sign is loss of  active external rotation. Radiographs are normal and distinguish it from osteoarthritis. Treatment The clinical course typically lasts 1–2 years, often consider ably longer in individuals with diabetes, and is divided into painful, sti ff ening (freezing and frozen) and thawing phases. If  untreated, frozen shoulder will resolve, and the majority of oblems. In the first phase patients are left with no functional pr of  the condition, treatment is pain relief. Corticosteroids can also be injected into the subacromial space or glenohumeral joint, although this is more often considered in the second phase. The latter can also be combined with a large volume (20–30 /uni00A0 mL) of  local anaesthetic to produce a distension injec tion. Despite the pain, the patient should be encouraged to perform as much active and passive movement as they can, and distension injections facilitate this. Operative options include manipulation under anaesthesia or arthroscopic release of the tight capsule, w hich usually produce pain relief  and are indicated for prolonged sti ff ness. Summary box 38.4 Frozen shoulder (adhesive capsulitis) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Calcium salt deposition within the supraspinatus tendon is believed to be part of  a degenerative process, possibly linked to the processes producing partial degenerative tears of  the tendon. However, large deposits can occur in relatively young individuals with acute calcific tendinitis. Calcific deposits can be found coincidentally on radiographs taken for other purposes, but acute calcific tendinitis is agonisingly painful and associated with florid opaque lesions on radiographs. There is a spectrum of  presentations between these two extremes History and examination In acute calcific tendinitis there is a rapid onset of  severe shoul - der pain with painful, restricted motion. However, in contrast to adhesive capsulitis, external rotation is usually possible. Subacromial calcific deposits can be seen on plain radiographs , ( Figure 38.13 ) and are well delineated on ultrasound scanning with the calcifications casting acoustic shadows. Treatment Subacromial corticosteroid injections may help and can be accompanied by needling, aspiration or flushing of  the deposits (barbotage). The condition is often self-limiting, with resorption of  the calcium deposits. Surgery for resistant cases includes arthroscopic or open subacromial decompression and release or excision of  the calcific deposits if they are prominent.
Figure 38.12
Reverse geometry total shoulder replacement.
Most commonly occurs in females in their
/f_i
fties
Spontaneous onset
Produces severe pain with reduced glenohumeral motion
Spontaneous resolution can occur over 1–2 years
Differential diagnoses: calci
/f_i
c tendinitis and rotator cuff tear
Injections, distension with saline, manipulation and surgical
release may all help
Acquired abnormalities
History Patients usually associate the onset of  their symptoms with an unusual event (trauma or excessive activity) even though the causation may not be as clear as the patient thinks. Even so, the onset (sudden or gradual) and duration are important details to establish, as is the age, occupation and hand dominance of the patient. Pain presenting in the shoulder (or anywhere in the upper limb) can arise from the nerves of  the neck, so the history should enquire about neck problems. Examination If  the patient can localise the pain to an exact point around or within the shoulder, then the problem is unlikely to be referred from the neck. Tests for inflammation and impingement involve trying to reproduce the pain by loading the limb in the position that creates the problem (e.g. Hawkins’ test for impingement; Figure 38.3 ). Tests for tears in structures such as the rotator cu ff look specifically for weakness, while appre hension tests check for instability (such as may predispose to recurrent shoulder dislocation). Richard J Hawkins , contemporary , Canadian orthopaedic surgeon. Investigations Radiographs are often of  limited value because most shoulder pain arises from soft-tissue structures. However, a reduced subacromial space may be clearly visible in full-thickness rotator cu ff tears ( Figure 38.4a ). The appearance of  a typical subacromial spur can be seen on the radiograph in Figure 38.4b and morphological variants of the acromion are shown in Figure 38.5 . Patients with impingement pain and rotator cu ff tears are much more likely to have a hooked acro - mion. The appearance of  a spur, which produces the hook, is usually due to calcification within the coracoacromial ligament - (CAL) insertion and it may be a secondary consequence of degenerative cu ff disease rather than a causative lesion.
Figure 38.2
Sprengel’s shoulder (right) of a 4-year-old girl.
(a)
Figure 38.4
(a)
Radio-
graph showing sclerosis
on the undersurface of
the acromion and the
greater tuberosity, with
reduced subacromial
space.
(b)
Radiograph
showing an acromial
spur and arthritis of the
acromioclavicular joint.
Figure 38.3
Hawkins’ impingement test. Impingement pain is repro
duced when the shoulder is internally rotated with 90° of forward
/f_l
exion, thereby locating the greater tuberosity and anterior rotator cuff
underneath the acromion and coracoacromial ligament.
(b)
Acromioclavicular arthritis
Spur
Both ultrasound and magnetic resonance imaging (MRI) allow the integrity and health of  the rotator cu ff to be checked whereas magnetic resonance (MR) arthrography also gives information on the integrity of the labrum of the glenohu meral joint ( Figure 38.6 ). Local anaesthetic injections may help to localise the source of  pain. For example, a painful arc on forward elevation (Neer’s sign) may be completely relieved by injecting local anaesthetic into the subacromial b ursa in cases of  subacromial impinge ment (Neer’s test positive). Rotator cuff degeneration and impingement The rotator cu ff moves in a confined space between the humeral head, the acromion and the CAL. Blood vessels cannot cross the glenohumeral joint cavity below the supraspinatus tendon or through the subacromial space above it, and vessels that enter Charles Sumner Neer II , 1917–2011, orthopedic surgeon, Columbia University , New Y ork, NY , USA, developed the first widely used shoulder arthroplasty . from the insertional and muscle belly ends become constricted when the tendon is tensioned around the curved humeral head when the cu ff is active. Blood flow is therefore limited, the - tendon is exposed to external forces as it operates in a confined space and its capacity for self-repair is limited. More than any other tendon, therefore, it is prone to age-related degeneration, leading to tendinosis and partial- and full-thickness tearing; the rate of  this is at least partly genetically determined. Even a - trivial injury can inhibit rotator cu ff function, so that it does not glide so easily in its subacromial space, starting a progression of  inflammation, swelling and pain in the subacromial region. This subacromial pain may be termed impingement, which is felt to be attributable to abrasion of  the cu ff and bursa on the undersurface of  the acromion. The impingement itself causes further bursal inflammation and pain, which further inhibits rotator cu ff function, and a vicious circle is set up. The likelihood of subacromial pain developing is increased in patients with a spur beneath the acromion, which is seen increasingly commonly with age ( Figure 38.5 ) and may be an e ff ect rather than a cause of  painful subacromial degeneration, as described earlier in this paragraph. The result is a painful arc of  movement for the patient, which corresponds to the position where the inflamed segment of  the supraspinatus tendon passes under the anterior acromial spur. The examiner may find that, although the patient cannot actively lift their arm through this segment (because of  the pain), passively lifting the arm for the patient enables them to continue with pain-free movement once the area of  impingement is passed ( Figure 38.7 ). Treatment Injection of  steroid into the inflamed subacromial bursa may break the cycle of  inflammation and impingement ( Figure 38.8 ), allowing rotator cu ff function to resume without impingement. Physiotherapy promotes normal cu ff activity once the pain has been relieved in this way . A commonly performed procedure is arthroscopic removal of  the subacromial spur, anteroinferior acromion and the CAL, which has been shown to give good relief  of  symptoms ( Figure 38.9 ), but there is no evidence that it either improves the long-term prognosis or reduces the risk of  rotator cu ff tears developing.
Figure 38.5
The three commonest acromial morphologies seen in adults. Children almost always have the
/f_l
at morphology.
Cuff tear
Figure 38.6
Magnetic resonance imaging scan showing a retracted
cuff tear.
Summary box 38.1 Rotator cuff degeneration and impingement /uni25CF /uni25CF /uni25CF Summary box 38.2 Treatment of subacromial impingement /uni25CF /uni25CF /uni25CF Rotator cuff tears The rotator cu ff has a relatively poor blood supply in the segment that glides between the humeral head and acromion, as described in Rotator cu ff degeneration and impinge ment . The cu ff thins with age and eventually develops defects that are termed tears, whether or not there has been any trauma involved in their appearance. This means that tears are more common in older adults, and at any age they do not heal spontaneously . Tears usually begin at the anterolateral edge of the supraspinatus, and progress posteriorly to involve the infraspinatus and teres minor tendons. This creates a bare area over the greater tuberosity , as the torn cu ff retracts medially ( Figure 38.10 ). History In the younger patient with a healthier cu ff the onset often requires relatively major trauma, e.g. breaking a fall from a motorcycle or significant height with the outstretched hand, but in older adults the onset may follow a simple fall, a painful period of  tendinitis or the condition may apparently occur spontaneously . Examination The patient may have a mixed picture of  subacromial pain and a tear, but if  the pain is removed by injection of  local - anaesthetic the weakness will persist. Symptomatic tears are
o
180
170
o
60
o
0
Figure 38.7
Arcs of shoulder girdle motion with subacromial impinge
ment pain between 60° and 120° of abduction, and acromioclavicular
joint pain between 170° and 180°.
Tendinosis and bursitis produce weakness secondary to pain
(often a painful arc)
A tendon tear produces weakness that is only secondarily
painful
Injection of local anaesthetic and retesting can distinguish
those who do from those who do not have a tear – weakness
persists if there is a signi
/f_i
cant tear
Non-operative treatment includes injections and rotator cuff
rehabilitation
Surgery may be indicated if symptoms persist beyond 3–6
months of non-surgical management
Surgery restores a
/f_l
at acromion and makes more room for
rotator cuff gliding but there is no evidence that it improves the
long-term outlook
o
120
Figure 38.8
Technique of administering an injection into the subacro
mial bursa.
(b)
(a)
Figure 38.9
(a)
Arthroscopic view of an acromial spur.
(b)
Arthroscopic
view after the acromial spur has been removed and the cuff decom
pressed.
associated with pain, weakness, limited active abduction, cu ff muscle wasting and hunching of the shoulder when attempting abduction ( Figure 38.11 ). Specific tests can localise the tear by identifying which muscles are a ff ected, e.g. the ‘empty can test’ for supraspinatus. Investigation Both ultrasound scanning, in the hands of  an experienced operator, and MRI are excellent tools for detecting rotator cu ff tears and assessing the tissue quality . Tears are classified as small (less than 1 /uni00A0 cm), intermediate (2–4 /uni00A0 cm) and large (more than 5 /uni00A0 cm). Treatment Treatment depends on the patient’s age, lifestyle and severity of  symptoms. Three to six months of  rehabilitation are required after surgical repair before resuming full overhead loading, so this is not an operation to be carried out in those who cannot rest the shoulder, including those who need it for weight-bearing through bilateral crutches. Arthroscopic or mini-open repair with subacromial decompression can be considered for all tears, but is likely to give a better outcome in the y oung than in the old. It may not be possible to repair large tears owing to their size, or the attempt at repair may be fruitless because of  fatty atrophy of the rotator cu ff and loss of  muscle contractility , in which case complex surgery , e.g. tendon transfers, patch grafts or reverse joint replacement ( Figure 38.12 ), will need to be considered. Summary box 38.3 Rotator cuff tears /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Frozen shoulder (adhesive capsulitis) This is an idiopathic condition causing sti ff ness and pain, most commonly a ff ecting females in their fifties. It is also associated with diabetes, heart and thyroid disease. History and examination Frozen shoulder is characterised by the onset of  severe pain that is often spontaneous, though patients may recall an episode of  minor trauma, which is of  unknown relevance. It may also complicate surgery or other painful shoulder condi - tions. The di ff erential diagnosis includes infection, fractures and rotator cu ff tear, though if  the sti ff ness is global and there is no redness or temperature then osteoarthritis is the main
zone
Normal
Full-thickness tear
Figure 38.10
Various stages of rotator cuff tear. Initial partial-thickness tears progress to full–thickness and
retracted tears but this process may be asymptomatic.
Figure 38.11
A 75-year-old man with a >5 cm retracted cuff tear
attempting to abduct his shoulder; the lack of a stable fulcrum pro
vided by the rotator cuff means that the deltoid is less effective and
can only abduct to 60°.
Partial-thickness tears
Chronic tear
Retracted chronic tear
Occur more commonly in older age groups
4–20% of 40- to 50-year-olds have asymptomatic rotator cuff
tears
Up to 30% of 70-year-olds have an asymptomatic full-
thickness tear
Acute tears may present with little pain but profound
weakness
Earlier repair after traumatic onset with acute loss of function
gives better results
alternative diagnosis. Initially there is severe pain but this improves with time. However, there is global loss of  active and passive movement, limited by pain. The pathognomonic sign is loss of  active external rotation. Radiographs are normal and distinguish it from osteoarthritis. Treatment The clinical course typically lasts 1–2 years, often consider ably longer in individuals with diabetes, and is divided into painful, sti ff ening (freezing and frozen) and thawing phases. If  untreated, frozen shoulder will resolve, and the majority of oblems. In the first phase patients are left with no functional pr of  the condition, treatment is pain relief. Corticosteroids can also be injected into the subacromial space or glenohumeral joint, although this is more often considered in the second phase. The latter can also be combined with a large volume (20–30 /uni00A0 mL) of  local anaesthetic to produce a distension injec tion. Despite the pain, the patient should be encouraged to perform as much active and passive movement as they can, and distension injections facilitate this. Operative options include manipulation under anaesthesia or arthroscopic release of the tight capsule, w hich usually produce pain relief  and are indicated for prolonged sti ff ness. Summary box 38.4 Frozen shoulder (adhesive capsulitis) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Calcium salt deposition within the supraspinatus tendon is believed to be part of  a degenerative process, possibly linked to the processes producing partial degenerative tears of  the tendon. However, large deposits can occur in relatively young individuals with acute calcific tendinitis. Calcific deposits can be found coincidentally on radiographs taken for other purposes, but acute calcific tendinitis is agonisingly painful and associated with florid opaque lesions on radiographs. There is a spectrum of  presentations between these two extremes History and examination In acute calcific tendinitis there is a rapid onset of  severe shoul - der pain with painful, restricted motion. However, in contrast to adhesive capsulitis, external rotation is usually possible. Subacromial calcific deposits can be seen on plain radiographs , ( Figure 38.13 ) and are well delineated on ultrasound scanning with the calcifications casting acoustic shadows. Treatment Subacromial corticosteroid injections may help and can be accompanied by needling, aspiration or flushing of  the deposits (barbotage). The condition is often self-limiting, with resorption of  the calcium deposits. Surgery for resistant cases includes arthroscopic or open subacromial decompression and release or excision of  the calcific deposits if they are prominent.
Figure 38.12
Reverse geometry total shoulder replacement.
Most commonly occurs in females in their
/f_i
fties
Spontaneous onset
Produces severe pain with reduced glenohumeral motion
Spontaneous resolution can occur over 1–2 years
Differential diagnoses: calci
/f_i
c tendinitis and rotator cuff tear
Injections, distension with saline, manipulation and surgical
release may all help
Acquired abnormalities
History Patients usually associate the onset of  their symptoms with an unusual event (trauma or excessive activity) even though the causation may not be as clear as the patient thinks. Even so, the onset (sudden or gradual) and duration are important details to establish, as is the age, occupation and hand dominance of the patient. Pain presenting in the shoulder (or anywhere in the upper limb) can arise from the nerves of  the neck, so the history should enquire about neck problems. Examination If  the patient can localise the pain to an exact point around or within the shoulder, then the problem is unlikely to be referred from the neck. Tests for inflammation and impingement involve trying to reproduce the pain by loading the limb in the position that creates the problem (e.g. Hawkins’ test for impingement; Figure 38.3 ). Tests for tears in structures such as the rotator cu ff look specifically for weakness, while appre hension tests check for instability (such as may predispose to recurrent shoulder dislocation). Richard J Hawkins , contemporary , Canadian orthopaedic surgeon. Investigations Radiographs are often of  limited value because most shoulder pain arises from soft-tissue structures. However, a reduced subacromial space may be clearly visible in full-thickness rotator cu ff tears ( Figure 38.4a ). The appearance of  a typical subacromial spur can be seen on the radiograph in Figure 38.4b and morphological variants of the acromion are shown in Figure 38.5 . Patients with impingement pain and rotator cu ff tears are much more likely to have a hooked acro - mion. The appearance of  a spur, which produces the hook, is usually due to calcification within the coracoacromial ligament - (CAL) insertion and it may be a secondary consequence of degenerative cu ff disease rather than a causative lesion.
Figure 38.2
Sprengel’s shoulder (right) of a 4-year-old girl.
(a)
Figure 38.4
(a)
Radio-
graph showing sclerosis
on the undersurface of
the acromion and the
greater tuberosity, with
reduced subacromial
space.
(b)
Radiograph
showing an acromial
spur and arthritis of the
acromioclavicular joint.
Figure 38.3
Hawkins’ impingement test. Impingement pain is repro
duced when the shoulder is internally rotated with 90° of forward
/f_l
exion, thereby locating the greater tuberosity and anterior rotator cuff
underneath the acromion and coracoacromial ligament.
(b)
Acromioclavicular arthritis
Spur
Both ultrasound and magnetic resonance imaging (MRI) allow the integrity and health of  the rotator cu ff to be checked whereas magnetic resonance (MR) arthrography also gives information on the integrity of the labrum of the glenohu meral joint ( Figure 38.6 ). Local anaesthetic injections may help to localise the source of  pain. For example, a painful arc on forward elevation (Neer’s sign) may be completely relieved by injecting local anaesthetic into the subacromial b ursa in cases of  subacromial impinge ment (Neer’s test positive). Rotator cuff degeneration and impingement The rotator cu ff moves in a confined space between the humeral head, the acromion and the CAL. Blood vessels cannot cross the glenohumeral joint cavity below the supraspinatus tendon or through the subacromial space above it, and vessels that enter Charles Sumner Neer II , 1917–2011, orthopedic surgeon, Columbia University , New Y ork, NY , USA, developed the first widely used shoulder arthroplasty . from the insertional and muscle belly ends become constricted when the tendon is tensioned around the curved humeral head when the cu ff is active. Blood flow is therefore limited, the - tendon is exposed to external forces as it operates in a confined space and its capacity for self-repair is limited. More than any other tendon, therefore, it is prone to age-related degeneration, leading to tendinosis and partial- and full-thickness tearing; the rate of  this is at least partly genetically determined. Even a - trivial injury can inhibit rotator cu ff function, so that it does not glide so easily in its subacromial space, starting a progression of  inflammation, swelling and pain in the subacromial region. This subacromial pain may be termed impingement, which is felt to be attributable to abrasion of  the cu ff and bursa on the undersurface of  the acromion. The impingement itself causes further bursal inflammation and pain, which further inhibits rotator cu ff function, and a vicious circle is set up. The likelihood of subacromial pain developing is increased in patients with a spur beneath the acromion, which is seen increasingly commonly with age ( Figure 38.5 ) and may be an e ff ect rather than a cause of  painful subacromial degeneration, as described earlier in this paragraph. The result is a painful arc of  movement for the patient, which corresponds to the position where the inflamed segment of  the supraspinatus tendon passes under the anterior acromial spur. The examiner may find that, although the patient cannot actively lift their arm through this segment (because of  the pain), passively lifting the arm for the patient enables them to continue with pain-free movement once the area of  impingement is passed ( Figure 38.7 ). Treatment Injection of  steroid into the inflamed subacromial bursa may break the cycle of  inflammation and impingement ( Figure 38.8 ), allowing rotator cu ff function to resume without impingement. Physiotherapy promotes normal cu ff activity once the pain has been relieved in this way . A commonly performed procedure is arthroscopic removal of  the subacromial spur, anteroinferior acromion and the CAL, which has been shown to give good relief  of  symptoms ( Figure 38.9 ), but there is no evidence that it either improves the long-term prognosis or reduces the risk of  rotator cu ff tears developing.
Figure 38.5
The three commonest acromial morphologies seen in adults. Children almost always have the
/f_l
at morphology.
Cuff tear
Figure 38.6
Magnetic resonance imaging scan showing a retracted
cuff tear.
Summary box 38.1 Rotator cuff degeneration and impingement /uni25CF /uni25CF /uni25CF Summary box 38.2 Treatment of subacromial impingement /uni25CF /uni25CF /uni25CF Rotator cuff tears The rotator cu ff has a relatively poor blood supply in the segment that glides between the humeral head and acromion, as described in Rotator cu ff degeneration and impinge ment . The cu ff thins with age and eventually develops defects that are termed tears, whether or not there has been any trauma involved in their appearance. This means that tears are more common in older adults, and at any age they do not heal spontaneously . Tears usually begin at the anterolateral edge of the supraspinatus, and progress posteriorly to involve the infraspinatus and teres minor tendons. This creates a bare area over the greater tuberosity , as the torn cu ff retracts medially ( Figure 38.10 ). History In the younger patient with a healthier cu ff the onset often requires relatively major trauma, e.g. breaking a fall from a motorcycle or significant height with the outstretched hand, but in older adults the onset may follow a simple fall, a painful period of  tendinitis or the condition may apparently occur spontaneously . Examination The patient may have a mixed picture of  subacromial pain and a tear, but if  the pain is removed by injection of  local - anaesthetic the weakness will persist. Symptomatic tears are
o
180
170
o
60
o
0
Figure 38.7
Arcs of shoulder girdle motion with subacromial impinge
ment pain between 60° and 120° of abduction, and acromioclavicular
joint pain between 170° and 180°.
Tendinosis and bursitis produce weakness secondary to pain
(often a painful arc)
A tendon tear produces weakness that is only secondarily
painful
Injection of local anaesthetic and retesting can distinguish
those who do from those who do not have a tear – weakness
persists if there is a signi
/f_i
cant tear
Non-operative treatment includes injections and rotator cuff
rehabilitation
Surgery may be indicated if symptoms persist beyond 3–6
months of non-surgical management
Surgery restores a
/f_l
at acromion and makes more room for
rotator cuff gliding but there is no evidence that it improves the
long-term outlook
o
120
Figure 38.8
Technique of administering an injection into the subacro
mial bursa.
(b)
(a)
Figure 38.9
(a)
Arthroscopic view of an acromial spur.
(b)
Arthroscopic
view after the acromial spur has been removed and the cuff decom
pressed.
associated with pain, weakness, limited active abduction, cu ff muscle wasting and hunching of the shoulder when attempting abduction ( Figure 38.11 ). Specific tests can localise the tear by identifying which muscles are a ff ected, e.g. the ‘empty can test’ for supraspinatus. Investigation Both ultrasound scanning, in the hands of  an experienced operator, and MRI are excellent tools for detecting rotator cu ff tears and assessing the tissue quality . Tears are classified as small (less than 1 /uni00A0 cm), intermediate (2–4 /uni00A0 cm) and large (more than 5 /uni00A0 cm). Treatment Treatment depends on the patient’s age, lifestyle and severity of  symptoms. Three to six months of  rehabilitation are required after surgical repair before resuming full overhead loading, so this is not an operation to be carried out in those who cannot rest the shoulder, including those who need it for weight-bearing through bilateral crutches. Arthroscopic or mini-open repair with subacromial decompression can be considered for all tears, but is likely to give a better outcome in the y oung than in the old. It may not be possible to repair large tears owing to their size, or the attempt at repair may be fruitless because of  fatty atrophy of the rotator cu ff and loss of  muscle contractility , in which case complex surgery , e.g. tendon transfers, patch grafts or reverse joint replacement ( Figure 38.12 ), will need to be considered. Summary box 38.3 Rotator cuff tears /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Frozen shoulder (adhesive capsulitis) This is an idiopathic condition causing sti ff ness and pain, most commonly a ff ecting females in their fifties. It is also associated with diabetes, heart and thyroid disease. History and examination Frozen shoulder is characterised by the onset of  severe pain that is often spontaneous, though patients may recall an episode of  minor trauma, which is of  unknown relevance. It may also complicate surgery or other painful shoulder condi - tions. The di ff erential diagnosis includes infection, fractures and rotator cu ff tear, though if  the sti ff ness is global and there is no redness or temperature then osteoarthritis is the main
zone
Normal
Full-thickness tear
Figure 38.10
Various stages of rotator cuff tear. Initial partial-thickness tears progress to full–thickness and
retracted tears but this process may be asymptomatic.
Figure 38.11
A 75-year-old man with a >5 cm retracted cuff tear
attempting to abduct his shoulder; the lack of a stable fulcrum pro
vided by the rotator cuff means that the deltoid is less effective and
can only abduct to 60°.
Partial-thickness tears
Chronic tear
Retracted chronic tear
Occur more commonly in older age groups
4–20% of 40- to 50-year-olds have asymptomatic rotator cuff
tears
Up to 30% of 70-year-olds have an asymptomatic full-
thickness tear
Acute tears may present with little pain but profound
weakness
Earlier repair after traumatic onset with acute loss of function
gives better results
alternative diagnosis. Initially there is severe pain but this improves with time. However, there is global loss of  active and passive movement, limited by pain. The pathognomonic sign is loss of  active external rotation. Radiographs are normal and distinguish it from osteoarthritis. Treatment The clinical course typically lasts 1–2 years, often consider ably longer in individuals with diabetes, and is divided into painful, sti ff ening (freezing and frozen) and thawing phases. If  untreated, frozen shoulder will resolve, and the majority of oblems. In the first phase patients are left with no functional pr of  the condition, treatment is pain relief. Corticosteroids can also be injected into the subacromial space or glenohumeral joint, although this is more often considered in the second phase. The latter can also be combined with a large volume (20–30 /uni00A0 mL) of  local anaesthetic to produce a distension injec tion. Despite the pain, the patient should be encouraged to perform as much active and passive movement as they can, and distension injections facilitate this. Operative options include manipulation under anaesthesia or arthroscopic release of the tight capsule, w hich usually produce pain relief  and are indicated for prolonged sti ff ness. Summary box 38.4 Frozen shoulder (adhesive capsulitis) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Calcium salt deposition within the supraspinatus tendon is believed to be part of  a degenerative process, possibly linked to the processes producing partial degenerative tears of  the tendon. However, large deposits can occur in relatively young individuals with acute calcific tendinitis. Calcific deposits can be found coincidentally on radiographs taken for other purposes, but acute calcific tendinitis is agonisingly painful and associated with florid opaque lesions on radiographs. There is a spectrum of  presentations between these two extremes History and examination In acute calcific tendinitis there is a rapid onset of  severe shoul - der pain with painful, restricted motion. However, in contrast to adhesive capsulitis, external rotation is usually possible. Subacromial calcific deposits can be seen on plain radiographs , ( Figure 38.13 ) and are well delineated on ultrasound scanning with the calcifications casting acoustic shadows. Treatment Subacromial corticosteroid injections may help and can be accompanied by needling, aspiration or flushing of  the deposits (barbotage). The condition is often self-limiting, with resorption of  the calcium deposits. Surgery for resistant cases includes arthroscopic or open subacromial decompression and release or excision of  the calcific deposits if they are prominent.
Figure 38.12
Reverse geometry total shoulder replacement.
Most commonly occurs in females in their
/f_i
fties
Spontaneous onset
Produces severe pain with reduced glenohumeral motion
Spontaneous resolution can occur over 1–2 years
Differential diagnoses: calci
/f_i
c tendinitis and rotator cuff tear
Injections, distension with saline, manipulation and surgical
release may all help

Arthritis of the elbow
Arthritis of the elbow
Rheumatoid arthritis Surgery may be required, especially in end-stage disease ( Figure 38.29 ). Arthroscopic or open radial head excision and synovectomy are e ff ective for painful, restricted pronation and supination. Elbow arthroplasty is e ff ective for pain relief  and functional restoration. Osteoarthritis Osteoarthritis of the elbow is usually primary ( Figure 38.30 ) or secondary to trauma. ). -
Figure 38.29
Typical end-stage unstable and destroyed rheumatoid
elbow.
Typical patients are middle-aged men in manual occupations. Symptoms can include pain, locking, crepitus and painful motion with loss of  terminal flexion and extension. Ulnar nerve entrapment symptoms may be present. Examination There is restriction of  extension and flexion with impingement pain as osteophytes and soft tissues are pressed together at the end of  the available range. Pronation and supination tend to be spared in comparison with rheumatoid arthritis but there may still be crepitus felt over the radiocapitellar joint on rotation and pain when this is done with the fist clenched (‘grip and grind’ test). Treatment Surgery should be considered only if  medical treatment fails. Arthrodesis may very rarely be o ff ered for those performing heavy manual work ( Figure 38.31 ) but is associated with significant residual functional loss. However, joint replace - ment will not survive long under heavy loading. Surgical debridement alleviates pain and increases range of  motion by removing anterior and posterior osteophytes, the thickened capsule and loose bodies through a lateral approach (lateral column procedure). In earlier stages the olecranon osteo - phytes can be accessed through the triceps tendon, creating an olecranon foramen by drilling through the olecranon fossa to access the coronoid tip osteophyte and any loose bodies (the so-called ‘OK’ procedure). Interposition arthroplasty (for example, Achilles tendon allograft) may be consider ed in younger patients, although it can be associated with signifi - cant bone loss with time, possibly restricting future treat - ments. Prosthetic joint arthroplasty provides more predictable symptomatic relief  ( Figure 38.32 ) but high activity levels are associated with early loosening. Summary box 38.9 Arthritis of the elbow /uni25CF /uni25CF /uni25CF
(b)
Figure 38.30 (a, b)
Radiographs showing osteoarthritis of the elbow
joint.
(b)
(a)
Figure 38.31 (a, b)
Ankylosed elbow after tuberculosis. Arthrodesis is
a surgical procedure to achieve the same end result, by excising the
articular surfaces and compression plating across the joint.
Excision of the radial head and synovectomy improves pain
and pronation–supination in rheumatoid arthritis
Total elbow replacement gives good results in rheumatoid and
low-demand osteoarthritic patients
Arthrodesis may be the only surgical option in a high-demand
manual labourer
Arthritis of the elbow
Rheumatoid arthritis Surgery may be required, especially in end-stage disease ( Figure 38.29 ). Arthroscopic or open radial head excision and synovectomy are e ff ective for painful, restricted pronation and supination. Elbow arthroplasty is e ff ective for pain relief  and functional restoration. Osteoarthritis Osteoarthritis of the elbow is usually primary ( Figure 38.30 ) or secondary to trauma. ). -
Figure 38.29
Typical end-stage unstable and destroyed rheumatoid
elbow.
Typical patients are middle-aged men in manual occupations. Symptoms can include pain, locking, crepitus and painful motion with loss of  terminal flexion and extension. Ulnar nerve entrapment symptoms may be present. Examination There is restriction of  extension and flexion with impingement pain as osteophytes and soft tissues are pressed together at the end of  the available range. Pronation and supination tend to be spared in comparison with rheumatoid arthritis but there may still be crepitus felt over the radiocapitellar joint on rotation and pain when this is done with the fist clenched (‘grip and grind’ test). Treatment Surgery should be considered only if  medical treatment fails. Arthrodesis may very rarely be o ff ered for those performing heavy manual work ( Figure 38.31 ) but is associated with significant residual functional loss. However, joint replace - ment will not survive long under heavy loading. Surgical debridement alleviates pain and increases range of  motion by removing anterior and posterior osteophytes, the thickened capsule and loose bodies through a lateral approach (lateral column procedure). In earlier stages the olecranon osteo - phytes can be accessed through the triceps tendon, creating an olecranon foramen by drilling through the olecranon fossa to access the coronoid tip osteophyte and any loose bodies (the so-called ‘OK’ procedure). Interposition arthroplasty (for example, Achilles tendon allograft) may be consider ed in younger patients, although it can be associated with signifi - cant bone loss with time, possibly restricting future treat - ments. Prosthetic joint arthroplasty provides more predictable symptomatic relief  ( Figure 38.32 ) but high activity levels are associated with early loosening. Summary box 38.9 Arthritis of the elbow /uni25CF /uni25CF /uni25CF
(b)
Figure 38.30 (a, b)
Radiographs showing osteoarthritis of the elbow
joint.
(b)
(a)
Figure 38.31 (a, b)
Ankylosed elbow after tuberculosis. Arthrodesis is
a surgical procedure to achieve the same end result, by excising the
articular surfaces and compression plating across the joint.
Excision of the radial head and synovectomy improves pain
and pronation–supination in rheumatoid arthritis
Total elbow replacement gives good results in rheumatoid and
low-demand osteoarthritic patients
Arthrodesis may be the only surgical option in a high-demand
manual labourer
Arthritis of the elbow
Rheumatoid arthritis Surgery may be required, especially in end-stage disease ( Figure 38.29 ). Arthroscopic or open radial head excision and synovectomy are e ff ective for painful, restricted pronation and supination. Elbow arthroplasty is e ff ective for pain relief  and functional restoration. Osteoarthritis Osteoarthritis of the elbow is usually primary ( Figure 38.30 ) or secondary to trauma. ). -
Figure 38.29
Typical end-stage unstable and destroyed rheumatoid
elbow.
Typical patients are middle-aged men in manual occupations. Symptoms can include pain, locking, crepitus and painful motion with loss of  terminal flexion and extension. Ulnar nerve entrapment symptoms may be present. Examination There is restriction of  extension and flexion with impingement pain as osteophytes and soft tissues are pressed together at the end of  the available range. Pronation and supination tend to be spared in comparison with rheumatoid arthritis but there may still be crepitus felt over the radiocapitellar joint on rotation and pain when this is done with the fist clenched (‘grip and grind’ test). Treatment Surgery should be considered only if  medical treatment fails. Arthrodesis may very rarely be o ff ered for those performing heavy manual work ( Figure 38.31 ) but is associated with significant residual functional loss. However, joint replace - ment will not survive long under heavy loading. Surgical debridement alleviates pain and increases range of  motion by removing anterior and posterior osteophytes, the thickened capsule and loose bodies through a lateral approach (lateral column procedure). In earlier stages the olecranon osteo - phytes can be accessed through the triceps tendon, creating an olecranon foramen by drilling through the olecranon fossa to access the coronoid tip osteophyte and any loose bodies (the so-called ‘OK’ procedure). Interposition arthroplasty (for example, Achilles tendon allograft) may be consider ed in younger patients, although it can be associated with signifi - cant bone loss with time, possibly restricting future treat - ments. Prosthetic joint arthroplasty provides more predictable symptomatic relief  ( Figure 38.32 ) but high activity levels are associated with early loosening. Summary box 38.9 Arthritis of the elbow /uni25CF /uni25CF /uni25CF
(b)
Figure 38.30 (a, b)
Radiographs showing osteoarthritis of the elbow
joint.
(b)
(a)
Figure 38.31 (a, b)
Ankylosed elbow after tuberculosis. Arthrodesis is
a surgical procedure to achieve the same end result, by excising the
articular surfaces and compression plating across the joint.
Excision of the radial head and synovectomy improves pain
and pronation–supination in rheumatoid arthritis
Total elbow replacement gives good results in rheumatoid and
low-demand osteoarthritic patients
Arthrodesis may be the only surgical option in a high-demand
manual labourer

Arthritis of the shoulder Rheumatoid arthritis
Arthritis of the shoulder Rheumatoid arthritis
The glenohumeral joint is commonly involved in rheumatoid - arthritis ( Figure 38.14 ). As is typical of  this condition, there is osteoporosis, destruction of  the articular cartilage and synovial proliferation with pannus formation. The rotator cu ff is weakened and frequently tears. Arthroscopic synovectomy may slow the progress of  the joint destruction and lead to a reduction in pain and improvement in range of  movement but has been e ff ectively superseded, in many locations, by the introduction of  biological therapies for rheumatoid disease. -
Figure 38.13
Radiograph demonstrating calci
/f_i
c tendinitis.
Intra-articular steroid injections may be helpful. Shoulder replacement is complicated by poor bone stock and anatomical shoulder replacement is further compromised by damage to the stabilising structures around the shoulder, especially the rotator cu ff . In these patients reverse shoulder replacement may be an option if  bone stock is preserved, although the patient should only expect a reduction in pain. Any increase in range of  movement is a bonus, though is more likely with reverse shoulder replacement. Summary box 38.5 Shoulder problems in rheumatoid arthritis /uni25CF /uni25CF /uni25CF Osteoarthritis of the shoulder Glenohumeral joint osteoarthritis is either primary ( Figure 38.15 ), secondary to trauma ( Figure 38.16 ) or end-stage rotator cu ff disease, i.e. cu ff arthropathy ( Figure 38.17 ). Treatment If  medical treatment has failed, the surgical options are arthroscopic debridement or joint arthroplasty . Debridement is not predictable and is often reserved for young, active patients to delay the need for arthroplasty . Both total shoulder replace ment ( Figure 38.18 ) and hemiarthroplasty ( Figure 38.19 good reported results in appropriate patients, although pain relief  is better with total arthroplasty , with the rate of  hemi arthroplasty falling as the rate of  total arthroplasty incr An anatomical total shoulder arthroplasty can be performed if the rotator cu ff is intact. However, in most patients with rheu matoid arthritis, and all patients with cu ff tear arthropathy , - ) have - eases. -
Figure 38.14
Rheumatoid arthritis of the shoulder.
Arthroscopic synovectomy may be effective but rarely needed
Rotator cuff tears are common
Glenohumeral joint replacement improves pain, but motion
depends on rotator cuff involvement
Figure 38.15
Osteoarthritis of the glenohumeral joint.
Figure 38.16
Post-traumatic arthritis with malunion of the proximal
humerus, collapse of the humeral head, subchondral sclerosis and
osteophytes.
Figure 38.17
A massive cuff tear that has led to superior migration of
the humeral head and secondary osteoarthritis of the glenohumeral
joint.
the cu ff is deficient and either a hemiarthroplasty or a reverse polarity total shoulder arthroplasty ( Figure 38.12 ) should be used. Shoulder arthroplasty is an e ff ective pain-relieving procedure, but less predictable in restoring motion, especially above shoulder level. Arthrodesis of  the joint is an alternative in younger patients with a history of  sepsis or neurological problems ( Figure 38.20 ). It is also used after brachial plexus injury , when nerve repair estores hand and elbow function but the shoulder remains r flail because of  loss of  the C5 supply . Good scapulothoracic control, tested by the ability to shrug the shoulder powerfully , is a prerequisite to successful arthrodesis. Patients retain a mod - erate range of  movement at the shoulder girdle as a result of scapulothoracic motion, which normally makes up approxi - mately one-third of apparent shoulder elevation, the remain - ing two-thirds being glenohumeral movement, which is lost in arthrodesis. Summary box 38.6 Arthritis of the shoulder /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Figure 38.18
Anatomical total shoulder replacement performed for
osteoarthritis. An intact rotator cuff is essential.
Figure 38.19
Shoulder hemiarthroplasty can be performed for arthritis,
particularly if there is a de
/f_i
cient rotator cuff or in very young, active
patients with a well-preserved glenoid.
Figure 38.20
Arthrodesis of the shoulder.
Severe cases are treated with hemiarthroplasty or total
shoulder arthroplasty
Anatomical total shoulder replacement should not be
performed if the rotator cuff is de
/f_i
cient but reverse shoulder
replacement is appropriate
Pain relief is good following arthroplasty, although
improvement in range of motion is less predictable
Glenohumeral arthrodesis is an option in the young or those
with a history of sepsis
Post arthrodesis, motion is fair but is entirely scapulothoracic
Acromioclavicular joint (ACJ) arthritis is common and is often asymptomatic, noted as an incidental finding on radiographs ( Figure 38.4b ). Symptoms typically arise in males aged 20–50 years. Inferior osteophytes can impinge on the underlying rotator cu ff . History and examination There may be a history of  trauma to the ACJ. Pain is activity related and worse when using the arm overhead. There is prominence of  the lateral end of  the clavicle. The joint line is tender. Flexing and adducting the arm to place the hand around the opposite shoulder reproduces pain. There is a high painful arc, pain being worst for the last 20–30° of  elevation. If symptoms are related to inferior osteophytes, impingement symptoms and signs can also be present. Treatment An intra-articular corticosteroid injection will usually help; even if  the e ff ect is short-lived it localises the problem accurately . Surgery involves arthroscopic or open excision of  the lateral 0.5–1 /uni00A0 cm of  the clavicle ( Figure 38.21 ). This gives good pain relief. In patients with symptoms that are predominantly those of  impingement, arthroscopic removal of  the inferior osteo phytes with subacromial decompression should be performed. Summary box 38.7 ACJ problems /uni25CF /uni25CF /uni25CF /uni25CF
ACJ arthritis is common and is often asymptomatic
It may become symptomatic secondary to trauma or repetitive
overload
Intra-articular steroid and local anaesthetic injection may
relieve symptoms
Excision of the lateral end of the clavicle gives good results
Arthritis of the shoulder Rheumatoid arthritis
The glenohumeral joint is commonly involved in rheumatoid - arthritis ( Figure 38.14 ). As is typical of  this condition, there is osteoporosis, destruction of  the articular cartilage and synovial proliferation with pannus formation. The rotator cu ff is weakened and frequently tears. Arthroscopic synovectomy may slow the progress of  the joint destruction and lead to a reduction in pain and improvement in range of  movement but has been e ff ectively superseded, in many locations, by the introduction of  biological therapies for rheumatoid disease. -
Figure 38.13
Radiograph demonstrating calci
/f_i
c tendinitis.
Intra-articular steroid injections may be helpful. Shoulder replacement is complicated by poor bone stock and anatomical shoulder replacement is further compromised by damage to the stabilising structures around the shoulder, especially the rotator cu ff . In these patients reverse shoulder replacement may be an option if  bone stock is preserved, although the patient should only expect a reduction in pain. Any increase in range of  movement is a bonus, though is more likely with reverse shoulder replacement. Summary box 38.5 Shoulder problems in rheumatoid arthritis /uni25CF /uni25CF /uni25CF Osteoarthritis of the shoulder Glenohumeral joint osteoarthritis is either primary ( Figure 38.15 ), secondary to trauma ( Figure 38.16 ) or end-stage rotator cu ff disease, i.e. cu ff arthropathy ( Figure 38.17 ). Treatment If  medical treatment has failed, the surgical options are arthroscopic debridement or joint arthroplasty . Debridement is not predictable and is often reserved for young, active patients to delay the need for arthroplasty . Both total shoulder replace ment ( Figure 38.18 ) and hemiarthroplasty ( Figure 38.19 good reported results in appropriate patients, although pain relief  is better with total arthroplasty , with the rate of  hemi arthroplasty falling as the rate of  total arthroplasty incr An anatomical total shoulder arthroplasty can be performed if the rotator cu ff is intact. However, in most patients with rheu matoid arthritis, and all patients with cu ff tear arthropathy , - ) have - eases. -
Figure 38.14
Rheumatoid arthritis of the shoulder.
Arthroscopic synovectomy may be effective but rarely needed
Rotator cuff tears are common
Glenohumeral joint replacement improves pain, but motion
depends on rotator cuff involvement
Figure 38.15
Osteoarthritis of the glenohumeral joint.
Figure 38.16
Post-traumatic arthritis with malunion of the proximal
humerus, collapse of the humeral head, subchondral sclerosis and
osteophytes.
Figure 38.17
A massive cuff tear that has led to superior migration of
the humeral head and secondary osteoarthritis of the glenohumeral
joint.
the cu ff is deficient and either a hemiarthroplasty or a reverse polarity total shoulder arthroplasty ( Figure 38.12 ) should be used. Shoulder arthroplasty is an e ff ective pain-relieving procedure, but less predictable in restoring motion, especially above shoulder level. Arthrodesis of  the joint is an alternative in younger patients with a history of  sepsis or neurological problems ( Figure 38.20 ). It is also used after brachial plexus injury , when nerve repair estores hand and elbow function but the shoulder remains r flail because of  loss of  the C5 supply . Good scapulothoracic control, tested by the ability to shrug the shoulder powerfully , is a prerequisite to successful arthrodesis. Patients retain a mod - erate range of  movement at the shoulder girdle as a result of scapulothoracic motion, which normally makes up approxi - mately one-third of apparent shoulder elevation, the remain - ing two-thirds being glenohumeral movement, which is lost in arthrodesis. Summary box 38.6 Arthritis of the shoulder /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Figure 38.18
Anatomical total shoulder replacement performed for
osteoarthritis. An intact rotator cuff is essential.
Figure 38.19
Shoulder hemiarthroplasty can be performed for arthritis,
particularly if there is a de
/f_i
cient rotator cuff or in very young, active
patients with a well-preserved glenoid.
Figure 38.20
Arthrodesis of the shoulder.
Severe cases are treated with hemiarthroplasty or total
shoulder arthroplasty
Anatomical total shoulder replacement should not be
performed if the rotator cuff is de
/f_i
cient but reverse shoulder
replacement is appropriate
Pain relief is good following arthroplasty, although
improvement in range of motion is less predictable
Glenohumeral arthrodesis is an option in the young or those
with a history of sepsis
Post arthrodesis, motion is fair but is entirely scapulothoracic
Acromioclavicular joint (ACJ) arthritis is common and is often asymptomatic, noted as an incidental finding on radiographs ( Figure 38.4b ). Symptoms typically arise in males aged 20–50 years. Inferior osteophytes can impinge on the underlying rotator cu ff . History and examination There may be a history of  trauma to the ACJ. Pain is activity related and worse when using the arm overhead. There is prominence of  the lateral end of  the clavicle. The joint line is tender. Flexing and adducting the arm to place the hand around the opposite shoulder reproduces pain. There is a high painful arc, pain being worst for the last 20–30° of  elevation. If symptoms are related to inferior osteophytes, impingement symptoms and signs can also be present. Treatment An intra-articular corticosteroid injection will usually help; even if  the e ff ect is short-lived it localises the problem accurately . Surgery involves arthroscopic or open excision of  the lateral 0.5–1 /uni00A0 cm of  the clavicle ( Figure 38.21 ). This gives good pain relief. In patients with symptoms that are predominantly those of  impingement, arthroscopic removal of  the inferior osteo phytes with subacromial decompression should be performed. Summary box 38.7 ACJ problems /uni25CF /uni25CF /uni25CF /uni25CF
ACJ arthritis is common and is often asymptomatic
It may become symptomatic secondary to trauma or repetitive
overload
Intra-articular steroid and local anaesthetic injection may
relieve symptoms
Excision of the lateral end of the clavicle gives good results
Arthritis of the shoulder Rheumatoid arthritis
The glenohumeral joint is commonly involved in rheumatoid - arthritis ( Figure 38.14 ). As is typical of  this condition, there is osteoporosis, destruction of  the articular cartilage and synovial proliferation with pannus formation. The rotator cu ff is weakened and frequently tears. Arthroscopic synovectomy may slow the progress of  the joint destruction and lead to a reduction in pain and improvement in range of  movement but has been e ff ectively superseded, in many locations, by the introduction of  biological therapies for rheumatoid disease. -
Figure 38.13
Radiograph demonstrating calci
/f_i
c tendinitis.
Intra-articular steroid injections may be helpful. Shoulder replacement is complicated by poor bone stock and anatomical shoulder replacement is further compromised by damage to the stabilising structures around the shoulder, especially the rotator cu ff . In these patients reverse shoulder replacement may be an option if  bone stock is preserved, although the patient should only expect a reduction in pain. Any increase in range of  movement is a bonus, though is more likely with reverse shoulder replacement. Summary box 38.5 Shoulder problems in rheumatoid arthritis /uni25CF /uni25CF /uni25CF Osteoarthritis of the shoulder Glenohumeral joint osteoarthritis is either primary ( Figure 38.15 ), secondary to trauma ( Figure 38.16 ) or end-stage rotator cu ff disease, i.e. cu ff arthropathy ( Figure 38.17 ). Treatment If  medical treatment has failed, the surgical options are arthroscopic debridement or joint arthroplasty . Debridement is not predictable and is often reserved for young, active patients to delay the need for arthroplasty . Both total shoulder replace ment ( Figure 38.18 ) and hemiarthroplasty ( Figure 38.19 good reported results in appropriate patients, although pain relief  is better with total arthroplasty , with the rate of  hemi arthroplasty falling as the rate of  total arthroplasty incr An anatomical total shoulder arthroplasty can be performed if the rotator cu ff is intact. However, in most patients with rheu matoid arthritis, and all patients with cu ff tear arthropathy , - ) have - eases. -
Figure 38.14
Rheumatoid arthritis of the shoulder.
Arthroscopic synovectomy may be effective but rarely needed
Rotator cuff tears are common
Glenohumeral joint replacement improves pain, but motion
depends on rotator cuff involvement
Figure 38.15
Osteoarthritis of the glenohumeral joint.
Figure 38.16
Post-traumatic arthritis with malunion of the proximal
humerus, collapse of the humeral head, subchondral sclerosis and
osteophytes.
Figure 38.17
A massive cuff tear that has led to superior migration of
the humeral head and secondary osteoarthritis of the glenohumeral
joint.
the cu ff is deficient and either a hemiarthroplasty or a reverse polarity total shoulder arthroplasty ( Figure 38.12 ) should be used. Shoulder arthroplasty is an e ff ective pain-relieving procedure, but less predictable in restoring motion, especially above shoulder level. Arthrodesis of  the joint is an alternative in younger patients with a history of  sepsis or neurological problems ( Figure 38.20 ). It is also used after brachial plexus injury , when nerve repair estores hand and elbow function but the shoulder remains r flail because of  loss of  the C5 supply . Good scapulothoracic control, tested by the ability to shrug the shoulder powerfully , is a prerequisite to successful arthrodesis. Patients retain a mod - erate range of  movement at the shoulder girdle as a result of scapulothoracic motion, which normally makes up approxi - mately one-third of apparent shoulder elevation, the remain - ing two-thirds being glenohumeral movement, which is lost in arthrodesis. Summary box 38.6 Arthritis of the shoulder /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Figure 38.18
Anatomical total shoulder replacement performed for
osteoarthritis. An intact rotator cuff is essential.
Figure 38.19
Shoulder hemiarthroplasty can be performed for arthritis,
particularly if there is a de
/f_i
cient rotator cuff or in very young, active
patients with a well-preserved glenoid.
Figure 38.20
Arthrodesis of the shoulder.
Severe cases are treated with hemiarthroplasty or total
shoulder arthroplasty
Anatomical total shoulder replacement should not be
performed if the rotator cuff is de
/f_i
cient but reverse shoulder
replacement is appropriate
Pain relief is good following arthroplasty, although
improvement in range of motion is less predictable
Glenohumeral arthrodesis is an option in the young or those
with a history of sepsis
Post arthrodesis, motion is fair but is entirely scapulothoracic
Acromioclavicular joint (ACJ) arthritis is common and is often asymptomatic, noted as an incidental finding on radiographs ( Figure 38.4b ). Symptoms typically arise in males aged 20–50 years. Inferior osteophytes can impinge on the underlying rotator cu ff . History and examination There may be a history of  trauma to the ACJ. Pain is activity related and worse when using the arm overhead. There is prominence of  the lateral end of  the clavicle. The joint line is tender. Flexing and adducting the arm to place the hand around the opposite shoulder reproduces pain. There is a high painful arc, pain being worst for the last 20–30° of  elevation. If symptoms are related to inferior osteophytes, impingement symptoms and signs can also be present. Treatment An intra-articular corticosteroid injection will usually help; even if  the e ff ect is short-lived it localises the problem accurately . Surgery involves arthroscopic or open excision of  the lateral 0.5–1 /uni00A0 cm of  the clavicle ( Figure 38.21 ). This gives good pain relief. In patients with symptoms that are predominantly those of  impingement, arthroscopic removal of  the inferior osteo phytes with subacromial decompression should be performed. Summary box 38.7 ACJ problems /uni25CF /uni25CF /uni25CF /uni25CF
ACJ arthritis is common and is often asymptomatic
It may become symptomatic secondary to trauma or repetitive
overload
Intra-articular steroid and local anaesthetic injection may
relieve symptoms
Excision of the lateral end of the clavicle gives good results

Arthritis
Arthritis
Rheumatoid arthritis Rheumatoid arthritis presents with classic symptoms: morning sti ff ness, symmetrical arthritis, hand deformities and rheuma - toid nodules. Diagnostic criteria include seropositive rheu - matoid factor and radiographic changes ( Table 38.1 ). The - inflamed rheumatoid synovium (pannus) destroys ligaments, tendons and joints, producing pain, deformity and loss of function. Typical rheumatoid defor mities in the hand include boutonnière ( Figure 38.46 ), swan neck ( Figure 38.47 ) and radial drift of  the wrist (due to supination of  the carpus), with compensatory ulnar deviation of  the MCPJs ( Figure 38.48 ). Pannus can cause extensor tendon ruptures, classically starting with the little finger and progressing stepwise in a radial direc - tion (Vaughan-Jackson syndrome). With progressive deformity and instability of  the wrist and hand, activities such as key - pinch and the opening of  jars become impossible to perform. - The treatment should be dictated by the pa tient’s levels of pain and disability , not purely on the basis of  deformity . -
TABLE 38.1
Radiographic differences between
rheumatoid and osteoarthritis.
Rheumatoid arthritis
Osteoarthritis
Periarticular osteoporosis/
Subchondral sclerosis and
subchondral erosions
cysts
Periarticular soft-tissue swelling
Less pronounced swelling
Joint space narrowing
Joint space narrowing
Marginal erosions
Marginal osteophytes
Joint deformity/malalignment
Less pronounced deformities
Ankylosis
Less common ankylosis
Summary box 38.13 Manifestations of rheumatoid arthritis in the hand /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The primary indications for surgery are: (i) pain relief; (ii) functional improvement; (iii) to prevent disease progres - sion; and (iv) cosmesis. Patients may require many surgical procedures over time and a helpful axiom is to start proximally and work distally , alternating between motion-sacrificing and motion-sparing procedures. T he various procedures that can be considered are: 1 Synovectomy: improves pain, increases function and pre - vents tendon rupture. 2 Trigger finger releases and nerve decompression surgery (carpal tunnel syndrome). 3 Distal ulna excision: reduces pain, prevents extensor ten - don rupture or protects repaired extensor tendons. Dis - tal ulna excision leads to instability and so, in the young patient, a constrained ulnar head arthroplasty is preferred. 4 Arthrodesis of  the wrist, thumb and some of  the smaller joints: gives good pain relief  and creates a stable axis against which other parts can function. 5 MCPJ and IPJ replacements: provide pain relief  and func - tional improvement. Total wrist arthroplasty will also pro - vide good pain relief  and some motion ( Figure 38.49 ). 6 Tendon reconstructions: some ruptured tendons can cause significant morbidity ( Figure 38.50 ) and are often treated by either a tendon transfer or a local joint fusion. Osteoarthritis Wrist The radiocarpal joint can develop primary or secondary osteo - arthritis (after intra-articular trauma or infection). If  conserva - tive measures have failed then operative management includes limited or total wrist arthrodesis and total wrist replacement.
Rupture
Figure 38.46
Boutonnière deformity.
Figure 38.47
Swan neck deformity.
Figure 38.48
Rheumatoid hand showing ulnar drift at the metacarpo
phalangeal joints, which is seen compensating for radial deviation at
the wrist joint.
Swan neck, boutonnière
/f_i
nger deformities
Extensor tendon ruptures (Vaughan-Jackson syndrome)
Flexor tendon synovitis or rupture
MCPJs:
/f_l
exion, ulnar deviation, subluxation, dislocation
Wrist: radial deviation, carpal supination, prominent ulnar head
(caput ulnae), extensor tenosynovitis
Figure 38.49
Total wrist replacement.
Hand Females are more commonly a ff ected than males. The commonly a ff ected joints are the distal interphalangeal (Heberden’s nodes), proximal interphalangeal (PIP) (Bouchard’s nodes) and the thumb carpometacarpal joints ( Figure 38.51 ). Symptoms rarely correlate with the appear ance, either clinically or radiographically . Treatment includes splinting, physiotherapy and steroid injections. Surgical options include arthrodesis for distal interphalangeal (DIP) and PIP joints ( Figure 38.52 ), joint replacement (PIP and MCPJs) and excision arthroplasty (excision of  the trapezium [trapeziectomy] for thumb carpometacarpal joint arthritis). Joint arthrodesis eliminates pain at the expense of  motion, but function is often well preserved. Other forms of arthritis in the hand Psoriasis particularly a ff ects the IPJs, but is asymmetrical in nature and causes fusiform swelling of  the digits along with nail changes. Gout causes pain, joint swelling and redness, as well as occasionally tophi (monosodium urate crystal deposits), and can be di ffi cult to di ff erentiate from septic arthritis. Serum urate is not always raised in acute attacks but finding negatively birefringent sodium urate crystals on microscopy of  aspirated joint fluid is diagnostic.
Figure 38.50
Rupture of the extensor tendons to the little and ring
/f_i
ngers.
Arthritis
Rheumatoid arthritis Rheumatoid arthritis presents with classic symptoms: morning sti ff ness, symmetrical arthritis, hand deformities and rheuma - toid nodules. Diagnostic criteria include seropositive rheu - matoid factor and radiographic changes ( Table 38.1 ). The - inflamed rheumatoid synovium (pannus) destroys ligaments, tendons and joints, producing pain, deformity and loss of function. Typical rheumatoid defor mities in the hand include boutonnière ( Figure 38.46 ), swan neck ( Figure 38.47 ) and radial drift of  the wrist (due to supination of  the carpus), with compensatory ulnar deviation of  the MCPJs ( Figure 38.48 ). Pannus can cause extensor tendon ruptures, classically starting with the little finger and progressing stepwise in a radial direc - tion (Vaughan-Jackson syndrome). With progressive deformity and instability of  the wrist and hand, activities such as key - pinch and the opening of  jars become impossible to perform. - The treatment should be dictated by the pa tient’s levels of pain and disability , not purely on the basis of  deformity . -
TABLE 38.1
Radiographic differences between
rheumatoid and osteoarthritis.
Rheumatoid arthritis
Osteoarthritis
Periarticular osteoporosis/
Subchondral sclerosis and
subchondral erosions
cysts
Periarticular soft-tissue swelling
Less pronounced swelling
Joint space narrowing
Joint space narrowing
Marginal erosions
Marginal osteophytes
Joint deformity/malalignment
Less pronounced deformities
Ankylosis
Less common ankylosis
Summary box 38.13 Manifestations of rheumatoid arthritis in the hand /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The primary indications for surgery are: (i) pain relief; (ii) functional improvement; (iii) to prevent disease progres - sion; and (iv) cosmesis. Patients may require many surgical procedures over time and a helpful axiom is to start proximally and work distally , alternating between motion-sacrificing and motion-sparing procedures. T he various procedures that can be considered are: 1 Synovectomy: improves pain, increases function and pre - vents tendon rupture. 2 Trigger finger releases and nerve decompression surgery (carpal tunnel syndrome). 3 Distal ulna excision: reduces pain, prevents extensor ten - don rupture or protects repaired extensor tendons. Dis - tal ulna excision leads to instability and so, in the young patient, a constrained ulnar head arthroplasty is preferred. 4 Arthrodesis of  the wrist, thumb and some of  the smaller joints: gives good pain relief  and creates a stable axis against which other parts can function. 5 MCPJ and IPJ replacements: provide pain relief  and func - tional improvement. Total wrist arthroplasty will also pro - vide good pain relief  and some motion ( Figure 38.49 ). 6 Tendon reconstructions: some ruptured tendons can cause significant morbidity ( Figure 38.50 ) and are often treated by either a tendon transfer or a local joint fusion. Osteoarthritis Wrist The radiocarpal joint can develop primary or secondary osteo - arthritis (after intra-articular trauma or infection). If  conserva - tive measures have failed then operative management includes limited or total wrist arthrodesis and total wrist replacement.
Rupture
Figure 38.46
Boutonnière deformity.
Figure 38.47
Swan neck deformity.
Figure 38.48
Rheumatoid hand showing ulnar drift at the metacarpo
phalangeal joints, which is seen compensating for radial deviation at
the wrist joint.
Swan neck, boutonnière
/f_i
nger deformities
Extensor tendon ruptures (Vaughan-Jackson syndrome)
Flexor tendon synovitis or rupture
MCPJs:
/f_l
exion, ulnar deviation, subluxation, dislocation
Wrist: radial deviation, carpal supination, prominent ulnar head
(caput ulnae), extensor tenosynovitis
Figure 38.49
Total wrist replacement.
Hand Females are more commonly a ff ected than males. The commonly a ff ected joints are the distal interphalangeal (Heberden’s nodes), proximal interphalangeal (PIP) (Bouchard’s nodes) and the thumb carpometacarpal joints ( Figure 38.51 ). Symptoms rarely correlate with the appear ance, either clinically or radiographically . Treatment includes splinting, physiotherapy and steroid injections. Surgical options include arthrodesis for distal interphalangeal (DIP) and PIP joints ( Figure 38.52 ), joint replacement (PIP and MCPJs) and excision arthroplasty (excision of  the trapezium [trapeziectomy] for thumb carpometacarpal joint arthritis). Joint arthrodesis eliminates pain at the expense of  motion, but function is often well preserved. Other forms of arthritis in the hand Psoriasis particularly a ff ects the IPJs, but is asymmetrical in nature and causes fusiform swelling of  the digits along with nail changes. Gout causes pain, joint swelling and redness, as well as occasionally tophi (monosodium urate crystal deposits), and can be di ffi cult to di ff erentiate from septic arthritis. Serum urate is not always raised in acute attacks but finding negatively birefringent sodium urate crystals on microscopy of  aspirated joint fluid is diagnostic.
Figure 38.50
Rupture of the extensor tendons to the little and ring
/f_i
ngers.
Arthritis
Rheumatoid arthritis Rheumatoid arthritis presents with classic symptoms: morning sti ff ness, symmetrical arthritis, hand deformities and rheuma - toid nodules. Diagnostic criteria include seropositive rheu - matoid factor and radiographic changes ( Table 38.1 ). The - inflamed rheumatoid synovium (pannus) destroys ligaments, tendons and joints, producing pain, deformity and loss of function. Typical rheumatoid defor mities in the hand include boutonnière ( Figure 38.46 ), swan neck ( Figure 38.47 ) and radial drift of  the wrist (due to supination of  the carpus), with compensatory ulnar deviation of  the MCPJs ( Figure 38.48 ). Pannus can cause extensor tendon ruptures, classically starting with the little finger and progressing stepwise in a radial direc - tion (Vaughan-Jackson syndrome). With progressive deformity and instability of  the wrist and hand, activities such as key - pinch and the opening of  jars become impossible to perform. - The treatment should be dictated by the pa tient’s levels of pain and disability , not purely on the basis of  deformity . -
TABLE 38.1
Radiographic differences between
rheumatoid and osteoarthritis.
Rheumatoid arthritis
Osteoarthritis
Periarticular osteoporosis/
Subchondral sclerosis and
subchondral erosions
cysts
Periarticular soft-tissue swelling
Less pronounced swelling
Joint space narrowing
Joint space narrowing
Marginal erosions
Marginal osteophytes
Joint deformity/malalignment
Less pronounced deformities
Ankylosis
Less common ankylosis
Summary box 38.13 Manifestations of rheumatoid arthritis in the hand /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The primary indications for surgery are: (i) pain relief; (ii) functional improvement; (iii) to prevent disease progres - sion; and (iv) cosmesis. Patients may require many surgical procedures over time and a helpful axiom is to start proximally and work distally , alternating between motion-sacrificing and motion-sparing procedures. T he various procedures that can be considered are: 1 Synovectomy: improves pain, increases function and pre - vents tendon rupture. 2 Trigger finger releases and nerve decompression surgery (carpal tunnel syndrome). 3 Distal ulna excision: reduces pain, prevents extensor ten - don rupture or protects repaired extensor tendons. Dis - tal ulna excision leads to instability and so, in the young patient, a constrained ulnar head arthroplasty is preferred. 4 Arthrodesis of  the wrist, thumb and some of  the smaller joints: gives good pain relief  and creates a stable axis against which other parts can function. 5 MCPJ and IPJ replacements: provide pain relief  and func - tional improvement. Total wrist arthroplasty will also pro - vide good pain relief  and some motion ( Figure 38.49 ). 6 Tendon reconstructions: some ruptured tendons can cause significant morbidity ( Figure 38.50 ) and are often treated by either a tendon transfer or a local joint fusion. Osteoarthritis Wrist The radiocarpal joint can develop primary or secondary osteo - arthritis (after intra-articular trauma or infection). If  conserva - tive measures have failed then operative management includes limited or total wrist arthrodesis and total wrist replacement.
Rupture
Figure 38.46
Boutonnière deformity.
Figure 38.47
Swan neck deformity.
Figure 38.48
Rheumatoid hand showing ulnar drift at the metacarpo
phalangeal joints, which is seen compensating for radial deviation at
the wrist joint.
Swan neck, boutonnière
/f_i
nger deformities
Extensor tendon ruptures (Vaughan-Jackson syndrome)
Flexor tendon synovitis or rupture
MCPJs:
/f_l
exion, ulnar deviation, subluxation, dislocation
Wrist: radial deviation, carpal supination, prominent ulnar head
(caput ulnae), extensor tenosynovitis
Figure 38.49
Total wrist replacement.
Hand Females are more commonly a ff ected than males. The commonly a ff ected joints are the distal interphalangeal (Heberden’s nodes), proximal interphalangeal (PIP) (Bouchard’s nodes) and the thumb carpometacarpal joints ( Figure 38.51 ). Symptoms rarely correlate with the appear ance, either clinically or radiographically . Treatment includes splinting, physiotherapy and steroid injections. Surgical options include arthrodesis for distal interphalangeal (DIP) and PIP joints ( Figure 38.52 ), joint replacement (PIP and MCPJs) and excision arthroplasty (excision of  the trapezium [trapeziectomy] for thumb carpometacarpal joint arthritis). Joint arthrodesis eliminates pain at the expense of  motion, but function is often well preserved. Other forms of arthritis in the hand Psoriasis particularly a ff ects the IPJs, but is asymmetrical in nature and causes fusiform swelling of  the digits along with nail changes. Gout causes pain, joint swelling and redness, as well as occasionally tophi (monosodium urate crystal deposits), and can be di ffi cult to di ff erentiate from septic arthritis. Serum urate is not always raised in acute attacks but finding negatively birefringent sodium urate crystals on microscopy of  aspirated joint fluid is diagnostic.
Figure 38.50
Rupture of the extensor tendons to the little and ring
/f_i
ngers.

Avascular necrosis of carpal bones
Avascular necrosis of carpal bones
Idiopathic avascular necrosis of the lunate (Kienböck’s disease; Figure 38.57 ) or scaphoid (Preiser’s disease) can occur. The clinical presentation is of  wrist pain and the diagnosis can be Robert Kienböck , 1871–1953, Professor of  Radiology , Vienna, Austria, described this condition in 1910. Georg K F Preiser , 1876–1913, German orthopaedic surgeon, published the first study on the vascular supply of  the scaphoid bone in 1910. the condition is that it leads to collapse of  the avascular carpal bones and subsequent arthritis of  the carpus, which may be best treated with a partial or complete fusion of  the wrist. This will at least give a str ong and painless wrist. The limitation in movement caused by arthrodesis procedures is not as great as might be expected.
(a)
Figure 38.58 (a)
Clinical and
(b)
/uni00A0
surgical appearance of a dorsal wrist ganglion.
Avascular necrosis of carpal bones
Idiopathic avascular necrosis of the lunate (Kienböck’s disease; Figure 38.57 ) or scaphoid (Preiser’s disease) can occur. The clinical presentation is of  wrist pain and the diagnosis can be Robert Kienböck , 1871–1953, Professor of  Radiology , Vienna, Austria, described this condition in 1910. Georg K F Preiser , 1876–1913, German orthopaedic surgeon, published the first study on the vascular supply of  the scaphoid bone in 1910. the condition is that it leads to collapse of  the avascular carpal bones and subsequent arthritis of  the carpus, which may be best treated with a partial or complete fusion of  the wrist. This will at least give a str ong and painless wrist. The limitation in movement caused by arthrodesis procedures is not as great as might be expected.
(a)
Figure 38.58 (a)
Clinical and
(b)
/uni00A0
surgical appearance of a dorsal wrist ganglion.
Avascular necrosis of carpal bones
Idiopathic avascular necrosis of the lunate (Kienböck’s disease; Figure 38.57 ) or scaphoid (Preiser’s disease) can occur. The clinical presentation is of  wrist pain and the diagnosis can be Robert Kienböck , 1871–1953, Professor of  Radiology , Vienna, Austria, described this condition in 1910. Georg K F Preiser , 1876–1913, German orthopaedic surgeon, published the first study on the vascular supply of  the scaphoid bone in 1910. the condition is that it leads to collapse of  the avascular carpal bones and subsequent arthritis of  the carpus, which may be best treated with a partial or complete fusion of  the wrist. This will at least give a str ong and painless wrist. The limitation in movement caused by arthrodesis procedures is not as great as might be expected.
(a)
Figure 38.58 (a)
Clinical and
(b)
/uni00A0
surgical appearance of a dorsal wrist ganglion.

Classification of glenohumeral instability
Classification of glenohumeral instability
/uni25CF Traumatic : unidirectional; involuntary; surgery is usu - ally successful. /uni25CF Atraumatic : multidirectional, painful; involuntary; re - sponds to surgery . /uni25CF Habitual : voluntary , with ligament laxity , painless; sur - gery usually contraindicated. Recurrent traumatic anterior instability History Traumatic shoulder dislocation is the commonest of  all dislocations, usually first presenting in patients under 25. The shoulder usually dislocates anteroinferiorly and initially there is a notable traumatic event. Subsequent dislocations usually require less force. The shoulder may sublux and relocate, or actually dislocate (complete separation of  the joint surfaces). Examination Assuming that the patient presents with a history of  instability following a previous anterior dislocation (after which the joint was reduced), examination of  the shoulder reveals a full range of  motion. However, with forced abduction and external rotation the patient experiences apprehension (a sense of impending doom as the patient feels the shoulder about to re-dislocate!) ( Figure 38.23 ). Investigations On computed tomography (CT) or MR arthrography ( Figure 38.24 ) detachment of  the anteroinferior labrum (Bankart’s lesion) ( Figures 38.25 and 38.26 ) and damage to the humeral head (Hill–Sachs lesion) can often be seen. On CT without arthrography only the bone lesions will be seen, which can also include a marginal fracture of  the anteroinferior glenoid margin (bony Bankart). Arthur Sydney Blundell Bankart , 1879–1951, orthopaedic surgeon, The Middlesex Hospital, London, UK. Harold Arthur Hill , 1901–1973, radiologist, San Francisco, CA, USA. Maurice David Sachs , 1909–1987, radiologist, San Francisco, CA, USA. Treatment The relative indications for surgery are repeated dislocations, or symptoms of instability that persist after reduction of the first dislocation, that are interfering with the patient’s quality of  life. Anterior instability can be treated with arthroscopic or open repair of  the Bankart lesion with retensioning of  the stretched anterior/inferior capsule, which prevents further dislocations in up to 90–95% of  patients. Bony defects of  the glenoid, and occasionally large Hill–Sachs lesions, may have to
Figure 38.23
Apprehension test for anterior instability.
A
B
Figure 38.25
Schematic representation of Bankart’s lesion, which forms a spectrum of pathology from minor labral detachment (B) to large
detachments with glenoid rim fractures (bony Bankart; E).
Bankart
lesion
(b)
Posterior
labral injury
Figure 38.24
(a)
Magnetic resonance (MR) arthrogram showing an
anterior Bankart lesion.
(b)
MR arthrogram showing a posterior labral
injury.
C
D
E
be grafted. For the less common recurrent posterior instability , repair of the damaged labrum and tightening of the posterior capsule is needed. Posterior dislocation of the shoulder This is a relatively rare event and is easy to miss. The clue is often in the history , as the patient will often have had either an electric shock or an epileptic fit or been subject to severe restraint when their arm has been forced up their back Recurrent traumatic shoulder instability /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF (a half-Nelson) – all are mechanisms producing forced internal rotation of  the glenohumeral joint. The patient may be in severe pain but can be di ffi cult to examine properly if  they are post-ictal or are recovering from an electric shock. For the same reason, the radiographer may only be able to get an anteroposterior view of the shoulder; on this view , the shoulder may look normal to the unwary ( Figure 38.27 ). It is the high ‘index of  suspicion’ from the his - tory that gives the best chance of  making the diagnosis. Treatment This dislocation may be di ffi cult to reduce if  the posterior margin of  the glenoid is embedded in the humeral head (a ‘locked’ posterior dislocation), so that open reduction is needed. A number of  techniques are available, such as gently abducting the internally rotated arm above shoulder height while maintaining axial traction then externally rotating the arm before returning it down to the side – the reduced shoulder
Figure 38.26
An end-on view of the glenoid labrum, demonstrating
anteroinferior labral detachment (red) with the rotator cuff muscles
(brown), long head of biceps tendon and labrum (grey).
(b)
(a)
(c)
(d)
An appreciable force leads to the
/f_i
rst dislocation or
subluxation
Subsequent dislocations/subluxations require less force
The commonest direction of dislocation is anteroinferior
There is a positive apprehension sign
Surgical treatment repairs the labral lesion and reverses
traumatic laxity of the capsule
Figure 38.27
Posterior dislocation of the shoulder.
(a)
Anteroposterior view;
(b)
origin of the light bulb sign;
/uni00A0
(c)
axial projection demonstrating how much easier it is
to visualise the injury on this view;
(d)
axial projection
highlighting this joint and further demonstrating the
impacted fracture in the humeral head, or anterior
Hill–Sachs lesion.
should then be placed in an external rotation brace to allow the stretched and torn posterior structures an opportunity to heal. Atraumatic instability History There is usually no history of an initial injury . Instability may be multidirectional and is usually associated with subluxation rather than dislocation. The patient is often able to reduce the shoulder without assistance. Examination Generalised ligament laxity is common (see Beighton score in Chapter 35 ). Apprehension tests are positive, but often in more than one direction. Anterior and posterior drawing of the humeral head allows laxity to be tested in these directions, whereas downward traction on the humerus may produce a ‘sulcus sign’ as the deltoid is sucked into the space created by inferior subluxation of  the humeral head ( Figure 38.28 Overactivity of  muscle groups such as pectoralis major should be sought, as this gives an avenue of  treatment through reha bilitation. Treatment Specialist physiotherapy should be tried first in these patients, aiming to improve both the proprioception and firing patterns of  the muscles around the shoulder (for instance, biofeedback to control an overactive pectoralis major or strengthening of underactive muscle groups). If  this fails then surgery may be considered, by way of  capsular tightening. Habitual dislocation Habitual dislocators are patients who can sublux the shoulder at will, usually either anteroinferiorly or posteriorly . The manoeuvre is painless. Patients have generalised joint laxity and may subluxate the shoulder as a ‘party trick’. which may then allow the capsule to tighten naturally with age. They may benefit from assessment and advice from a specialist physiotherapist. Surgery is associated with a high failure ra te and should be avoided.
Figure 38.28
Generalised laxity can be appreciated by drawing the
humeral head in anterior and posterior directions and feeling it slide up
to, and possibly even over, the glenoid rim. A sulcus will be produced
under the acromion if the humerus is drawn inferiorly (sulcus sign).
Classification of glenohumeral instability
/uni25CF Traumatic : unidirectional; involuntary; surgery is usu - ally successful. /uni25CF Atraumatic : multidirectional, painful; involuntary; re - sponds to surgery . /uni25CF Habitual : voluntary , with ligament laxity , painless; sur - gery usually contraindicated. Recurrent traumatic anterior instability History Traumatic shoulder dislocation is the commonest of  all dislocations, usually first presenting in patients under 25. The shoulder usually dislocates anteroinferiorly and initially there is a notable traumatic event. Subsequent dislocations usually require less force. The shoulder may sublux and relocate, or actually dislocate (complete separation of  the joint surfaces). Examination Assuming that the patient presents with a history of  instability following a previous anterior dislocation (after which the joint was reduced), examination of  the shoulder reveals a full range of  motion. However, with forced abduction and external rotation the patient experiences apprehension (a sense of impending doom as the patient feels the shoulder about to re-dislocate!) ( Figure 38.23 ). Investigations On computed tomography (CT) or MR arthrography ( Figure 38.24 ) detachment of  the anteroinferior labrum (Bankart’s lesion) ( Figures 38.25 and 38.26 ) and damage to the humeral head (Hill–Sachs lesion) can often be seen. On CT without arthrography only the bone lesions will be seen, which can also include a marginal fracture of  the anteroinferior glenoid margin (bony Bankart). Arthur Sydney Blundell Bankart , 1879–1951, orthopaedic surgeon, The Middlesex Hospital, London, UK. Harold Arthur Hill , 1901–1973, radiologist, San Francisco, CA, USA. Maurice David Sachs , 1909–1987, radiologist, San Francisco, CA, USA. Treatment The relative indications for surgery are repeated dislocations, or symptoms of instability that persist after reduction of the first dislocation, that are interfering with the patient’s quality of  life. Anterior instability can be treated with arthroscopic or open repair of  the Bankart lesion with retensioning of  the stretched anterior/inferior capsule, which prevents further dislocations in up to 90–95% of  patients. Bony defects of  the glenoid, and occasionally large Hill–Sachs lesions, may have to
Figure 38.23
Apprehension test for anterior instability.
A
B
Figure 38.25
Schematic representation of Bankart’s lesion, which forms a spectrum of pathology from minor labral detachment (B) to large
detachments with glenoid rim fractures (bony Bankart; E).
Bankart
lesion
(b)
Posterior
labral injury
Figure 38.24
(a)
Magnetic resonance (MR) arthrogram showing an
anterior Bankart lesion.
(b)
MR arthrogram showing a posterior labral
injury.
C
D
E
be grafted. For the less common recurrent posterior instability , repair of the damaged labrum and tightening of the posterior capsule is needed. Posterior dislocation of the shoulder This is a relatively rare event and is easy to miss. The clue is often in the history , as the patient will often have had either an electric shock or an epileptic fit or been subject to severe restraint when their arm has been forced up their back Recurrent traumatic shoulder instability /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF (a half-Nelson) – all are mechanisms producing forced internal rotation of  the glenohumeral joint. The patient may be in severe pain but can be di ffi cult to examine properly if  they are post-ictal or are recovering from an electric shock. For the same reason, the radiographer may only be able to get an anteroposterior view of the shoulder; on this view , the shoulder may look normal to the unwary ( Figure 38.27 ). It is the high ‘index of  suspicion’ from the his - tory that gives the best chance of  making the diagnosis. Treatment This dislocation may be di ffi cult to reduce if  the posterior margin of  the glenoid is embedded in the humeral head (a ‘locked’ posterior dislocation), so that open reduction is needed. A number of  techniques are available, such as gently abducting the internally rotated arm above shoulder height while maintaining axial traction then externally rotating the arm before returning it down to the side – the reduced shoulder
Figure 38.26
An end-on view of the glenoid labrum, demonstrating
anteroinferior labral detachment (red) with the rotator cuff muscles
(brown), long head of biceps tendon and labrum (grey).
(b)
(a)
(c)
(d)
An appreciable force leads to the
/f_i
rst dislocation or
subluxation
Subsequent dislocations/subluxations require less force
The commonest direction of dislocation is anteroinferior
There is a positive apprehension sign
Surgical treatment repairs the labral lesion and reverses
traumatic laxity of the capsule
Figure 38.27
Posterior dislocation of the shoulder.
(a)
Anteroposterior view;
(b)
origin of the light bulb sign;
/uni00A0
(c)
axial projection demonstrating how much easier it is
to visualise the injury on this view;
(d)
axial projection
highlighting this joint and further demonstrating the
impacted fracture in the humeral head, or anterior
Hill–Sachs lesion.
should then be placed in an external rotation brace to allow the stretched and torn posterior structures an opportunity to heal. Atraumatic instability History There is usually no history of an initial injury . Instability may be multidirectional and is usually associated with subluxation rather than dislocation. The patient is often able to reduce the shoulder without assistance. Examination Generalised ligament laxity is common (see Beighton score in Chapter 35 ). Apprehension tests are positive, but often in more than one direction. Anterior and posterior drawing of the humeral head allows laxity to be tested in these directions, whereas downward traction on the humerus may produce a ‘sulcus sign’ as the deltoid is sucked into the space created by inferior subluxation of  the humeral head ( Figure 38.28 Overactivity of  muscle groups such as pectoralis major should be sought, as this gives an avenue of  treatment through reha bilitation. Treatment Specialist physiotherapy should be tried first in these patients, aiming to improve both the proprioception and firing patterns of  the muscles around the shoulder (for instance, biofeedback to control an overactive pectoralis major or strengthening of underactive muscle groups). If  this fails then surgery may be considered, by way of  capsular tightening. Habitual dislocation Habitual dislocators are patients who can sublux the shoulder at will, usually either anteroinferiorly or posteriorly . The manoeuvre is painless. Patients have generalised joint laxity and may subluxate the shoulder as a ‘party trick’. which may then allow the capsule to tighten naturally with age. They may benefit from assessment and advice from a specialist physiotherapist. Surgery is associated with a high failure ra te and should be avoided.
Figure 38.28
Generalised laxity can be appreciated by drawing the
humeral head in anterior and posterior directions and feeling it slide up
to, and possibly even over, the glenoid rim. A sulcus will be produced
under the acromion if the humerus is drawn inferiorly (sulcus sign).
Classification of glenohumeral instability
/uni25CF Traumatic : unidirectional; involuntary; surgery is usu - ally successful. /uni25CF Atraumatic : multidirectional, painful; involuntary; re - sponds to surgery . /uni25CF Habitual : voluntary , with ligament laxity , painless; sur - gery usually contraindicated. Recurrent traumatic anterior instability History Traumatic shoulder dislocation is the commonest of  all dislocations, usually first presenting in patients under 25. The shoulder usually dislocates anteroinferiorly and initially there is a notable traumatic event. Subsequent dislocations usually require less force. The shoulder may sublux and relocate, or actually dislocate (complete separation of  the joint surfaces). Examination Assuming that the patient presents with a history of  instability following a previous anterior dislocation (after which the joint was reduced), examination of  the shoulder reveals a full range of  motion. However, with forced abduction and external rotation the patient experiences apprehension (a sense of impending doom as the patient feels the shoulder about to re-dislocate!) ( Figure 38.23 ). Investigations On computed tomography (CT) or MR arthrography ( Figure 38.24 ) detachment of  the anteroinferior labrum (Bankart’s lesion) ( Figures 38.25 and 38.26 ) and damage to the humeral head (Hill–Sachs lesion) can often be seen. On CT without arthrography only the bone lesions will be seen, which can also include a marginal fracture of  the anteroinferior glenoid margin (bony Bankart). Arthur Sydney Blundell Bankart , 1879–1951, orthopaedic surgeon, The Middlesex Hospital, London, UK. Harold Arthur Hill , 1901–1973, radiologist, San Francisco, CA, USA. Maurice David Sachs , 1909–1987, radiologist, San Francisco, CA, USA. Treatment The relative indications for surgery are repeated dislocations, or symptoms of instability that persist after reduction of the first dislocation, that are interfering with the patient’s quality of  life. Anterior instability can be treated with arthroscopic or open repair of  the Bankart lesion with retensioning of  the stretched anterior/inferior capsule, which prevents further dislocations in up to 90–95% of  patients. Bony defects of  the glenoid, and occasionally large Hill–Sachs lesions, may have to
Figure 38.23
Apprehension test for anterior instability.
A
B
Figure 38.25
Schematic representation of Bankart’s lesion, which forms a spectrum of pathology from minor labral detachment (B) to large
detachments with glenoid rim fractures (bony Bankart; E).
Bankart
lesion
(b)
Posterior
labral injury
Figure 38.24
(a)
Magnetic resonance (MR) arthrogram showing an
anterior Bankart lesion.
(b)
MR arthrogram showing a posterior labral
injury.
C
D
E
be grafted. For the less common recurrent posterior instability , repair of the damaged labrum and tightening of the posterior capsule is needed. Posterior dislocation of the shoulder This is a relatively rare event and is easy to miss. The clue is often in the history , as the patient will often have had either an electric shock or an epileptic fit or been subject to severe restraint when their arm has been forced up their back Recurrent traumatic shoulder instability /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF (a half-Nelson) – all are mechanisms producing forced internal rotation of  the glenohumeral joint. The patient may be in severe pain but can be di ffi cult to examine properly if  they are post-ictal or are recovering from an electric shock. For the same reason, the radiographer may only be able to get an anteroposterior view of the shoulder; on this view , the shoulder may look normal to the unwary ( Figure 38.27 ). It is the high ‘index of  suspicion’ from the his - tory that gives the best chance of  making the diagnosis. Treatment This dislocation may be di ffi cult to reduce if  the posterior margin of  the glenoid is embedded in the humeral head (a ‘locked’ posterior dislocation), so that open reduction is needed. A number of  techniques are available, such as gently abducting the internally rotated arm above shoulder height while maintaining axial traction then externally rotating the arm before returning it down to the side – the reduced shoulder
Figure 38.26
An end-on view of the glenoid labrum, demonstrating
anteroinferior labral detachment (red) with the rotator cuff muscles
(brown), long head of biceps tendon and labrum (grey).
(b)
(a)
(c)
(d)
An appreciable force leads to the
/f_i
rst dislocation or
subluxation
Subsequent dislocations/subluxations require less force
The commonest direction of dislocation is anteroinferior
There is a positive apprehension sign
Surgical treatment repairs the labral lesion and reverses
traumatic laxity of the capsule
Figure 38.27
Posterior dislocation of the shoulder.
(a)
Anteroposterior view;
(b)
origin of the light bulb sign;
/uni00A0
(c)
axial projection demonstrating how much easier it is
to visualise the injury on this view;
(d)
axial projection
highlighting this joint and further demonstrating the
impacted fracture in the humeral head, or anterior
Hill–Sachs lesion.
should then be placed in an external rotation brace to allow the stretched and torn posterior structures an opportunity to heal. Atraumatic instability History There is usually no history of an initial injury . Instability may be multidirectional and is usually associated with subluxation rather than dislocation. The patient is often able to reduce the shoulder without assistance. Examination Generalised ligament laxity is common (see Beighton score in Chapter 35 ). Apprehension tests are positive, but often in more than one direction. Anterior and posterior drawing of the humeral head allows laxity to be tested in these directions, whereas downward traction on the humerus may produce a ‘sulcus sign’ as the deltoid is sucked into the space created by inferior subluxation of  the humeral head ( Figure 38.28 Overactivity of  muscle groups such as pectoralis major should be sought, as this gives an avenue of  treatment through reha bilitation. Treatment Specialist physiotherapy should be tried first in these patients, aiming to improve both the proprioception and firing patterns of  the muscles around the shoulder (for instance, biofeedback to control an overactive pectoralis major or strengthening of underactive muscle groups). If  this fails then surgery may be considered, by way of  capsular tightening. Habitual dislocation Habitual dislocators are patients who can sublux the shoulder at will, usually either anteroinferiorly or posteriorly . The manoeuvre is painless. Patients have generalised joint laxity and may subluxate the shoulder as a ‘party trick’. which may then allow the capsule to tighten naturally with age. They may benefit from assessment and advice from a specialist physiotherapist. Surgery is associated with a high failure ra te and should be avoided.
Figure 38.28
Generalised laxity can be appreciated by drawing the
humeral head in anterior and posterior directions and feeling it slide up
to, and possibly even over, the glenoid rim. A sulcus will be produced
under the acromion if the humerus is drawn inferiorly (sulcus sign).

Clinical history and physical examination
Clinical history and physical examination
History Asking about the patient’s occupation, hobbies (sport, musical instruments, fine art) and hand dominance are important when taking a history . In considering the problem concerned there are a number of  symptoms that patients complain of: pain, swelling, sti ff ness, instability and pins and needles are commonly encountered in the hand and wrist. Sometimes these present together and sometimes in isolation, but all a ff ect the function of  the hand. It is vital to ask which of  these issues causes the functional deficit, since there is no value in fusing a painful finger that is sti ff if  the main concern of  the patient is the sti ff ness rather than the pain. A history of  other medical comorbidities is important to glean, since these may well be part of  the pathology or alter the management strategies that can be considered, e.g. carpal tunnel syndrome may be the first presentation of  diabetes mellitus. Examination The examination of the hand should assess sensation, move - ment, power and clinically relevant special tests for the issues encountered. Perfusion is seen (pink is well perfused) and felt (slightly warm to the touch with palpable radial and ulnar pulses). Sensory innervation of  the median (radial 3.5 volar digits), ulnar (ulnar 1.5 volar digits) and radial (first dorsal web space and back of  the hand) nerves is r equired. To test the motor innervation one can assess the abductor pollicis brevis for the median nerve and the first dorsal interosseous muscle for the ulnar nerve. The radial nerve does not supply any muscles in the hand but supplies the muscles that drive wrist extension. In assessing movement and power, one should start by evaluating functional combined movements such as grip, ‘thumbs up’, flat hand, palm up (supination) and palm down (pronation) as well as wrist movements (flexion, extension, radial and ulnar deviation). After that, a more detailed assess - ment of  each individual muscle/tendon group is required. While assessing movements, obvious side-to-side asymmetry may be encountered, such as rotational malalignment of  the digits ( Figure 38.42 ). There are also a n umber of  special tests relevant to di ff erent pathologies seen.
Figure 38.41
Froment’s sign tests the adductor pollicis. The patient is
asked to hold a piece of paper in a side pinch between the thumb and
the index
/f_i
nger. The examiner attempts to pull the paper out. Owing
to weakness of the adductor pollicis, the patient will compensate by
/f_l
exing the
/f_l
exor pollicis longus, which is supplied by the anterior
interosseous nerve (median nerve).
Clinical history and physical examination
History Asking about the patient’s occupation, hobbies (sport, musical instruments, fine art) and hand dominance are important when taking a history . In considering the problem concerned there are a number of  symptoms that patients complain of: pain, swelling, sti ff ness, instability and pins and needles are commonly encountered in the hand and wrist. Sometimes these present together and sometimes in isolation, but all a ff ect the function of  the hand. It is vital to ask which of  these issues causes the functional deficit, since there is no value in fusing a painful finger that is sti ff if  the main concern of  the patient is the sti ff ness rather than the pain. A history of  other medical comorbidities is important to glean, since these may well be part of  the pathology or alter the management strategies that can be considered, e.g. carpal tunnel syndrome may be the first presentation of  diabetes mellitus. Examination The examination of the hand should assess sensation, move - ment, power and clinically relevant special tests for the issues encountered. Perfusion is seen (pink is well perfused) and felt (slightly warm to the touch with palpable radial and ulnar pulses). Sensory innervation of  the median (radial 3.5 volar digits), ulnar (ulnar 1.5 volar digits) and radial (first dorsal web space and back of  the hand) nerves is r equired. To test the motor innervation one can assess the abductor pollicis brevis for the median nerve and the first dorsal interosseous muscle for the ulnar nerve. The radial nerve does not supply any muscles in the hand but supplies the muscles that drive wrist extension. In assessing movement and power, one should start by evaluating functional combined movements such as grip, ‘thumbs up’, flat hand, palm up (supination) and palm down (pronation) as well as wrist movements (flexion, extension, radial and ulnar deviation). After that, a more detailed assess - ment of  each individual muscle/tendon group is required. While assessing movements, obvious side-to-side asymmetry may be encountered, such as rotational malalignment of  the digits ( Figure 38.42 ). There are also a n umber of  special tests relevant to di ff erent pathologies seen.
Figure 38.41
Froment’s sign tests the adductor pollicis. The patient is
asked to hold a piece of paper in a side pinch between the thumb and
the index
/f_i
nger. The examiner attempts to pull the paper out. Owing
to weakness of the adductor pollicis, the patient will compensate by
/f_l
exing the
/f_l
exor pollicis longus, which is supplied by the anterior
interosseous nerve (median nerve).
Clinical history and physical examination
History Asking about the patient’s occupation, hobbies (sport, musical instruments, fine art) and hand dominance are important when taking a history . In considering the problem concerned there are a number of  symptoms that patients complain of: pain, swelling, sti ff ness, instability and pins and needles are commonly encountered in the hand and wrist. Sometimes these present together and sometimes in isolation, but all a ff ect the function of  the hand. It is vital to ask which of  these issues causes the functional deficit, since there is no value in fusing a painful finger that is sti ff if  the main concern of  the patient is the sti ff ness rather than the pain. A history of  other medical comorbidities is important to glean, since these may well be part of  the pathology or alter the management strategies that can be considered, e.g. carpal tunnel syndrome may be the first presentation of  diabetes mellitus. Examination The examination of the hand should assess sensation, move - ment, power and clinically relevant special tests for the issues encountered. Perfusion is seen (pink is well perfused) and felt (slightly warm to the touch with palpable radial and ulnar pulses). Sensory innervation of  the median (radial 3.5 volar digits), ulnar (ulnar 1.5 volar digits) and radial (first dorsal web space and back of  the hand) nerves is r equired. To test the motor innervation one can assess the abductor pollicis brevis for the median nerve and the first dorsal interosseous muscle for the ulnar nerve. The radial nerve does not supply any muscles in the hand but supplies the muscles that drive wrist extension. In assessing movement and power, one should start by evaluating functional combined movements such as grip, ‘thumbs up’, flat hand, palm up (supination) and palm down (pronation) as well as wrist movements (flexion, extension, radial and ulnar deviation). After that, a more detailed assess - ment of  each individual muscle/tendon group is required. While assessing movements, obvious side-to-side asymmetry may be encountered, such as rotational malalignment of  the digits ( Figure 38.42 ). There are also a n umber of  special tests relevant to di ff erent pathologies seen.
Figure 38.41
Froment’s sign tests the adductor pollicis. The patient is
asked to hold a piece of paper in a side pinch between the thumb and
the index
/f_i
nger. The examiner attempts to pull the paper out. Owing
to weakness of the adductor pollicis, the patient will compensate by
/f_l
exing the
/f_l
exor pollicis longus, which is supplied by the anterior
interosseous nerve (median nerve).

Compressive neuropathies
Compressive neuropathies
Median nerve (carpal tunnel syndrome) The majority of cases of carpal tunnel syndrome are idiopathic. It is, however, associated with diabetes, thyroid disorders, alcoholism, amyloidosis, inflammatory arthritis, pregnancy and obesity . Harry Finkelstein , 1883–1975, American surgeon, one of  the cofounders of  the Hospital for Joint Diseases, New Y ork, NY , USA. George S Phalen , contemporary , orthopaedic surgeon and Chief  of  Hand Surgery , The Cleveland Clinic, Cleveland, OH, USA. He helped to establish the American Society for Surgery of  the Hand. John A Durkan , contemporary , American surgeon, specialist in orthopaedic and sports medicine. Jean Casimir Felix Guyon , 1831–1920, Professor of  Genitourinary Surgery , Paris, France. The patient presents with tingling and infrequently numbness of  the volar aspects of  the radial three and a half  digits. Patients also complain of being woken at night by pain and tingling, and that hanging their hand out of the bed provides relief. They may also complain of  clumsiness when picking up small objects or when carrying heavy ones. Symptoms and signs are often bilateral. Examination Wasting of  the thenar eminence is visible ( Figure 38.56 ) in chronic severe cases, and there is sometimes weakness specifically of  the abductor pollicis brevis. The tests for carpal tunnel compression are described in Chapter 35 but the most reliable are: (i) Tinel’s – percussion over the carpal tunnel and (ii) Phalen’s test – reproduction of paraesthesia with full prolonged wrist flexion. More recently , Durkan’s compression test, in which digital pressure over the carpal tunnel reproduces the symptoms, has been shown to be highly sensitive and specific. Electrophysiological studies may confirm the diagnosis, with evidence of  slowing of  nerve conduction through the carpal tunnel, however they can also be normal. Non-operative treatment includes night splintage of  the wrist in extension and steroid injections. If  surgery is required the median nerve is surgically decompressed by incising the roof of  the tunnel (transverse carpal ligament), as either an open or an endoscopic percutaneous procedure. Summary box 38.15 Carpal tunnel syndrome /uni25CF /uni25CF /uni25CF /uni25CF Ulnar nerve (Guyon’s tunnel syndrome) Ulnar nerve compression in Guyon’s canal can lead to tingling and numbness in the ring and little fingers with hypothenar wasting. There is preservation of  dorsal sensation over the little and ring fingers, because, although these areas are innervated by the ulnar nerve, the dorsal sensory branches are given o ff prior to Guyon’s canal and are thus una ff ected. Compression is usually due to a ganglion, ulnar artery aneurysm or a fracture of  the hook of  hamate.
Figure 38.56
Thenar muscle wasting in carpal tunnel syndrome.
Night pain is common and relieved by shaking the hand
Thenar wasting is an advanced sign
Tinel’s, Phalen’s and Durkan’s tests are useful
Treatment includes splints and surgical decompression
Figure 38.57
Avascular necrosis of the lunate (Kienböck’s).
Compressive neuropathies
Median nerve (carpal tunnel syndrome) The majority of cases of carpal tunnel syndrome are idiopathic. It is, however, associated with diabetes, thyroid disorders, alcoholism, amyloidosis, inflammatory arthritis, pregnancy and obesity . Harry Finkelstein , 1883–1975, American surgeon, one of  the cofounders of  the Hospital for Joint Diseases, New Y ork, NY , USA. George S Phalen , contemporary , orthopaedic surgeon and Chief  of  Hand Surgery , The Cleveland Clinic, Cleveland, OH, USA. He helped to establish the American Society for Surgery of  the Hand. John A Durkan , contemporary , American surgeon, specialist in orthopaedic and sports medicine. Jean Casimir Felix Guyon , 1831–1920, Professor of  Genitourinary Surgery , Paris, France. The patient presents with tingling and infrequently numbness of  the volar aspects of  the radial three and a half  digits. Patients also complain of being woken at night by pain and tingling, and that hanging their hand out of the bed provides relief. They may also complain of  clumsiness when picking up small objects or when carrying heavy ones. Symptoms and signs are often bilateral. Examination Wasting of  the thenar eminence is visible ( Figure 38.56 ) in chronic severe cases, and there is sometimes weakness specifically of  the abductor pollicis brevis. The tests for carpal tunnel compression are described in Chapter 35 but the most reliable are: (i) Tinel’s – percussion over the carpal tunnel and (ii) Phalen’s test – reproduction of paraesthesia with full prolonged wrist flexion. More recently , Durkan’s compression test, in which digital pressure over the carpal tunnel reproduces the symptoms, has been shown to be highly sensitive and specific. Electrophysiological studies may confirm the diagnosis, with evidence of  slowing of  nerve conduction through the carpal tunnel, however they can also be normal. Non-operative treatment includes night splintage of  the wrist in extension and steroid injections. If  surgery is required the median nerve is surgically decompressed by incising the roof of  the tunnel (transverse carpal ligament), as either an open or an endoscopic percutaneous procedure. Summary box 38.15 Carpal tunnel syndrome /uni25CF /uni25CF /uni25CF /uni25CF Ulnar nerve (Guyon’s tunnel syndrome) Ulnar nerve compression in Guyon’s canal can lead to tingling and numbness in the ring and little fingers with hypothenar wasting. There is preservation of  dorsal sensation over the little and ring fingers, because, although these areas are innervated by the ulnar nerve, the dorsal sensory branches are given o ff prior to Guyon’s canal and are thus una ff ected. Compression is usually due to a ganglion, ulnar artery aneurysm or a fracture of  the hook of  hamate.
Figure 38.56
Thenar muscle wasting in carpal tunnel syndrome.
Night pain is common and relieved by shaking the hand
Thenar wasting is an advanced sign
Tinel’s, Phalen’s and Durkan’s tests are useful
Treatment includes splints and surgical decompression
Figure 38.57
Avascular necrosis of the lunate (Kienböck’s).
Compressive neuropathies
Median nerve (carpal tunnel syndrome) The majority of cases of carpal tunnel syndrome are idiopathic. It is, however, associated with diabetes, thyroid disorders, alcoholism, amyloidosis, inflammatory arthritis, pregnancy and obesity . Harry Finkelstein , 1883–1975, American surgeon, one of  the cofounders of  the Hospital for Joint Diseases, New Y ork, NY , USA. George S Phalen , contemporary , orthopaedic surgeon and Chief  of  Hand Surgery , The Cleveland Clinic, Cleveland, OH, USA. He helped to establish the American Society for Surgery of  the Hand. John A Durkan , contemporary , American surgeon, specialist in orthopaedic and sports medicine. Jean Casimir Felix Guyon , 1831–1920, Professor of  Genitourinary Surgery , Paris, France. The patient presents with tingling and infrequently numbness of  the volar aspects of  the radial three and a half  digits. Patients also complain of being woken at night by pain and tingling, and that hanging their hand out of the bed provides relief. They may also complain of  clumsiness when picking up small objects or when carrying heavy ones. Symptoms and signs are often bilateral. Examination Wasting of  the thenar eminence is visible ( Figure 38.56 ) in chronic severe cases, and there is sometimes weakness specifically of  the abductor pollicis brevis. The tests for carpal tunnel compression are described in Chapter 35 but the most reliable are: (i) Tinel’s – percussion over the carpal tunnel and (ii) Phalen’s test – reproduction of paraesthesia with full prolonged wrist flexion. More recently , Durkan’s compression test, in which digital pressure over the carpal tunnel reproduces the symptoms, has been shown to be highly sensitive and specific. Electrophysiological studies may confirm the diagnosis, with evidence of  slowing of  nerve conduction through the carpal tunnel, however they can also be normal. Non-operative treatment includes night splintage of  the wrist in extension and steroid injections. If  surgery is required the median nerve is surgically decompressed by incising the roof of  the tunnel (transverse carpal ligament), as either an open or an endoscopic percutaneous procedure. Summary box 38.15 Carpal tunnel syndrome /uni25CF /uni25CF /uni25CF /uni25CF Ulnar nerve (Guyon’s tunnel syndrome) Ulnar nerve compression in Guyon’s canal can lead to tingling and numbness in the ring and little fingers with hypothenar wasting. There is preservation of  dorsal sensation over the little and ring fingers, because, although these areas are innervated by the ulnar nerve, the dorsal sensory branches are given o ff prior to Guyon’s canal and are thus una ff ected. Compression is usually due to a ganglion, ulnar artery aneurysm or a fracture of  the hook of  hamate.
Figure 38.56
Thenar muscle wasting in carpal tunnel syndrome.
Night pain is common and relieved by shaking the hand
Thenar wasting is an advanced sign
Tinel’s, Phalen’s and Durkan’s tests are useful
Treatment includes splints and surgical decompression
Figure 38.57
Avascular necrosis of the lunate (Kienböck’s).

Congenital abnormalities
Congenital abnormalities
Sprengel’s shoulder The commonest congenital abnormality is due to abnormal scapular descent from its embryonic midcervical position. The typical presentation is a high, small, rotated scapula that remains connected to the cervical spine by a bony bar, fibrous band or an omovertebral body ( Figure 38.2 ). Other congenital deformities impacting on upper limb function are rib abnormalities and cervical or thoracic abnormalities, including scoliosis and Klippel–Feil syndrome (congenital fusion of  cervical vertebrae). Pseudarthrosis of  the clavicle is a congenital abnormality that can be mistaken for a birth-related fracture. In later life it can be mistaken for a non-union when radiographs are taken after trauma and attempts to plate and graft the lesion are usually doomed to failure. Congenital abnormalities
Sprengel’s shoulder The commonest congenital abnormality is due to abnormal scapular descent from its embryonic midcervical position. The typical presentation is a high, small, rotated scapula that remains connected to the cervical spine by a bony bar, fibrous band or an omovertebral body ( Figure 38.2 ). Other congenital deformities impacting on upper limb function are rib abnormalities and cervical or thoracic abnormalities, including scoliosis and Klippel–Feil syndrome (congenital fusion of  cervical vertebrae). Pseudarthrosis of  the clavicle is a congenital abnormality that can be mistaken for a birth-related fracture. In later life it can be mistaken for a non-union when radiographs are taken after trauma and attempts to plate and graft the lesion are usually doomed to failure. Congenital abnormalities
Sprengel’s shoulder The commonest congenital abnormality is due to abnormal scapular descent from its embryonic midcervical position. The typical presentation is a high, small, rotated scapula that remains connected to the cervical spine by a bony bar, fibrous band or an omovertebral body ( Figure 38.2 ). Other congenital deformities impacting on upper limb function are rib abnormalities and cervical or thoracic abnormalities, including scoliosis and Klippel–Feil syndrome (congenital fusion of  cervical vertebrae). Pseudarthrosis of  the clavicle is a congenital abnormality that can be mistaken for a birth-related fracture. In later life it can be mistaken for a non-union when radiographs are taken after trauma and attempts to plate and graft the lesion are usually doomed to failure.

Congenital malformations
Congenital malformations
There are many congenital malformations of  the upper limb and these are discussed in Chapter 44 . A classification summarising the main congenital defects and based on aetiology appears as Table 38.2 .
(b)
Figure 38.59
Volar wrist ganglion.
TABLE 38.2
Congenital malformations (hand and wrist).
A Defects in formation due to arrested development
B Defects in differentiation/separation
C Duplications
D Excess development/hyperplasia
E Insuf
/f_i
cient development/hypoplasia
F Constricting (amniotic) bands
G Generalised skeletal anomalies
Congenital malformations
There are many congenital malformations of  the upper limb and these are discussed in Chapter 44 . A classification summarising the main congenital defects and based on aetiology appears as Table 38.2 .
(b)
Figure 38.59
Volar wrist ganglion.
TABLE 38.2
Congenital malformations (hand and wrist).
A Defects in formation due to arrested development
B Defects in differentiation/separation
C Duplications
D Excess development/hyperplasia
E Insuf
/f_i
cient development/hypoplasia
F Constricting (amniotic) bands
G Generalised skeletal anomalies
Congenital malformations
There are many congenital malformations of  the upper limb and these are discussed in Chapter 44 . A classification summarising the main congenital defects and based on aetiology appears as Table 38.2 .
(b)
Figure 38.59
Volar wrist ganglion.
TABLE 38.2
Congenital malformations (hand and wrist).
A Defects in formation due to arrested development
B Defects in differentiation/separation
C Duplications
D Excess development/hyperplasia
E Insuf
/f_i
cient development/hypoplasia
F Constricting (amniotic) bands
G Generalised skeletal anomalies

DISORDERS OF THE ELBOW Anatomy and function
DISORDERS OF THE ELBOW Anatomy and function
The elbow joint allows flexion and extension through the ulnohumeral articulation as well as rotation of  the radial head, which articulates with both the capitellum of  the distal humerus (radiocapitellar joint) and the proximal ulna (proximal radioulnar joint [PRUJ]). The rotation of  the radius at the PRUJ, in concert with the distal radioulnar joint and interosseous membrane, permits pronation and supination of  the forearm. The elbow joint possesses a slim soft-tissue envelope, traversed by multiple neurovascular structures. At the front, from medial to lateral, are found the median nerve, brachial artery and radial nerve. At the back, just behind the medial epicondyle is found the ulnar nerve. DISORDERS OF THE ELBOW Anatomy and function
The elbow joint allows flexion and extension through the ulnohumeral articulation as well as rotation of  the radial head, which articulates with both the capitellum of  the distal humerus (radiocapitellar joint) and the proximal ulna (proximal radioulnar joint [PRUJ]). The rotation of  the radius at the PRUJ, in concert with the distal radioulnar joint and interosseous membrane, permits pronation and supination of  the forearm. The elbow joint possesses a slim soft-tissue envelope, traversed by multiple neurovascular structures. At the front, from medial to lateral, are found the median nerve, brachial artery and radial nerve. At the back, just behind the medial epicondyle is found the ulnar nerve. DISORDERS OF THE ELBOW Anatomy and function
The elbow joint allows flexion and extension through the ulnohumeral articulation as well as rotation of  the radial head, which articulates with both the capitellum of  the distal humerus (radiocapitellar joint) and the proximal ulna (proximal radioulnar joint [PRUJ]). The rotation of  the radius at the PRUJ, in concert with the distal radioulnar joint and interosseous membrane, permits pronation and supination of  the forearm. The elbow joint possesses a slim soft-tissue envelope, traversed by multiple neurovascular structures. At the front, from medial to lateral, are found the median nerve, brachial artery and radial nerve. At the back, just behind the medial epicondyle is found the ulnar nerve.

De Quervain’s disease
De Quervain’s disease
De Quervain’s disease is caused by tenosynovitis of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) in the first dorsal wrist extensor compartment (1st EC). It is predom - inantly seen in middle-aged females and is associated with - pregnancy (new mother’s wrist) and inflammatory arthritis. The clinical features are radial wrist pain, tenderness, swelling ( Figure 38.55 ) and a positive Finkelstein’s test (pain over the 1st EC associated with ulnar deviation of the wrist when the thumb is clasped in the palm). The management options are non-steroidal anti-inflammatories, splintage, steroid injections and surgical release of  the extensor retinaculum of  the first dorsal compartment. If  surgery is considered, careful attention should be paid to fully releasing the APL and EPB, which frequently consist of  bundles of  separate tendon slips that lie in separate sheaths.
Figure 38.55
De Quervain’s disease.
De Quervain’s disease
De Quervain’s disease is caused by tenosynovitis of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) in the first dorsal wrist extensor compartment (1st EC). It is predom - inantly seen in middle-aged females and is associated with - pregnancy (new mother’s wrist) and inflammatory arthritis. The clinical features are radial wrist pain, tenderness, swelling ( Figure 38.55 ) and a positive Finkelstein’s test (pain over the 1st EC associated with ulnar deviation of the wrist when the thumb is clasped in the palm). The management options are non-steroidal anti-inflammatories, splintage, steroid injections and surgical release of  the extensor retinaculum of  the first dorsal compartment. If  surgery is considered, careful attention should be paid to fully releasing the APL and EPB, which frequently consist of  bundles of  separate tendon slips that lie in separate sheaths.
Figure 38.55
De Quervain’s disease.
De Quervain’s disease
De Quervain’s disease is caused by tenosynovitis of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) in the first dorsal wrist extensor compartment (1st EC). It is predom - inantly seen in middle-aged females and is associated with - pregnancy (new mother’s wrist) and inflammatory arthritis. The clinical features are radial wrist pain, tenderness, swelling ( Figure 38.55 ) and a positive Finkelstein’s test (pain over the 1st EC associated with ulnar deviation of the wrist when the thumb is clasped in the palm). The management options are non-steroidal anti-inflammatories, splintage, steroid injections and surgical release of  the extensor retinaculum of  the first dorsal compartment. If  surgery is considered, careful attention should be paid to fully releasing the APL and EPB, which frequently consist of  bundles of  separate tendon slips that lie in separate sheaths.
Figure 38.55
De Quervain’s disease.

Dislocation of the shoulder and instability of the glenohumeral joint
Dislocation of the shoulder and instability of the glenohumeral joint
Three broad groups of  shoulder instability exist.

Dislocation of the shoulder and instability of the
Dislocation of the shoulder and instability of the glenohumeral joint
Three broad groups of  shoulder instability exist. Dislocation of the shoulder and instability of the glenohumeral joint
Three broad groups of  shoulder instability exist.

Dupuytren’s contracture
Dupuytren’s contracture
Dupuytren’s contracture is most often characterised as an autosomal dominant condition, common in northern Europe, predominantly in men in the fifth to seventh decades of  life. Four out of  seven cases occur in those with a family history but there are also many sporadic cases. It is associated with smoking, trauma, epilepsy , hypothyroidism, alcoholic cirrhosis and possibly human immunodeficiency virus (HIV) infection. William Heberden (Senior) , 1710–1801, physician, who practised first in Cambridge and from 1748 in London, UK, described these nodes in 1802. Charles Jacques Bouchard , 1837–1915, physician, Dean of  the Faculty of  Medicine, Paris, France. Baron Guillaume Dupuytren , 1777–1835, surgeon, Hôtel Dieu, Paris, France, described this condition in 1831. - It also appears very frequently as a clinical case in postgraduate examinations! The characteristic features are palmar nodules, skin puckering, cords of  the palm and digits, and flexion
Figure 38.51
Hand deformities secondary to osteoarthritis.
(a)
(b)
Figure 38.52
Radiographs of the distal interphalangeal (DIPJ) and
proximal interphalangeal (PIPJ) joints treated with DIPJ arthrodesis
and PIPJ arthroplasty/joint replacement.
(a)
Preoperative image;
(b)
/uni00A0
after surgery.
contractures of  the digits ( Figure 38.53 ). It is commonest on the ulnar side of  the hand. Garrod’s knuckle pads (thickened skin on the dorsum of the PIP joint) are another feature visible on examination and seen in more severe forms of  the disease ( Figure 38.54 ). The condition can also produce cords in the penis, causing it to become curved (Peyronie’s disease) and may also produce plantar thickening on the sole of  the foot (Ledderhose disease). Intervention is indicated when the patient cannot put the a ff ected hand flat on the table owing to fixed deformity (‘table-top test’) or when any flexion contrac ture develops in the PIP joint. Milder cases may be treated Sir Archibald Edward Garrod , 1857–1936, Regius Professor of  Medicine, University of  Oxford, Oxford, UK, described this condition in 1893. Francois de la Peyronie , 1678–1747, surgeon to King Louis XIV of  France and founder of  the Royal Academy of  Surgery , Paris, France. Georg Ledderhose , 1855–1925, German surgeon, described this disease in 1894. Fritz de Quervain , 1868–1940, Professor of  Surgery , Berne, Switzerland, described this form of  tenosynovitis in 1895 severe cases are managed surgically . Great care should be taken during surgery to avoid damage to the digital nerves, whic h y be trapped in the fibrous tissue. At the end of  surgery , ma it may not be possible to obtain primary closure of  the skin, so one should consider performing Z-plasties to lengthen the skin, full-thickness skin grafting taken from the anteromedial proximal forearm (hairless) or occasionally leaving an open wound to heal by secondary intention. In late-stage disease a fixed contracture of  the MCPJs and PIP joints may develop. In these cases excision of the fibrous bands may produce no improvement in the condition; if the contracted finger is preventing useful function of the hand, amputation may have to be considered. Summary box 38.14 Dupuytren’s contracture /uni25CF /uni25CF /uni25CF /uni25CF
Figure 38.53
Dupuytren’s contracture of the little
/f_i
nger metacarpo
phalangeal joint with a signi
/f_i
cant palmar cord.
Figure 38.54
Garrod’s knuckle pads.
Autosomal dominant inheritance but many sporadic cases
Fibroblastic hyperplasia with resultant skin nodules, cords and
deformities
Intervention is indicated if hand cannot be placed
/f_l
at
Severe disease is signi
/f_i
ed if hand cannot be placed
/f_l
at;
severe
/f_i
xed
/f_l
exion deformities may mean that amputation is
the only surgical option
Dupuytren’s contracture
Dupuytren’s contracture is most often characterised as an autosomal dominant condition, common in northern Europe, predominantly in men in the fifth to seventh decades of  life. Four out of  seven cases occur in those with a family history but there are also many sporadic cases. It is associated with smoking, trauma, epilepsy , hypothyroidism, alcoholic cirrhosis and possibly human immunodeficiency virus (HIV) infection. William Heberden (Senior) , 1710–1801, physician, who practised first in Cambridge and from 1748 in London, UK, described these nodes in 1802. Charles Jacques Bouchard , 1837–1915, physician, Dean of  the Faculty of  Medicine, Paris, France. Baron Guillaume Dupuytren , 1777–1835, surgeon, Hôtel Dieu, Paris, France, described this condition in 1831. - It also appears very frequently as a clinical case in postgraduate examinations! The characteristic features are palmar nodules, skin puckering, cords of  the palm and digits, and flexion
Figure 38.51
Hand deformities secondary to osteoarthritis.
(a)
(b)
Figure 38.52
Radiographs of the distal interphalangeal (DIPJ) and
proximal interphalangeal (PIPJ) joints treated with DIPJ arthrodesis
and PIPJ arthroplasty/joint replacement.
(a)
Preoperative image;
(b)
/uni00A0
after surgery.
contractures of  the digits ( Figure 38.53 ). It is commonest on the ulnar side of  the hand. Garrod’s knuckle pads (thickened skin on the dorsum of the PIP joint) are another feature visible on examination and seen in more severe forms of  the disease ( Figure 38.54 ). The condition can also produce cords in the penis, causing it to become curved (Peyronie’s disease) and may also produce plantar thickening on the sole of  the foot (Ledderhose disease). Intervention is indicated when the patient cannot put the a ff ected hand flat on the table owing to fixed deformity (‘table-top test’) or when any flexion contrac ture develops in the PIP joint. Milder cases may be treated Sir Archibald Edward Garrod , 1857–1936, Regius Professor of  Medicine, University of  Oxford, Oxford, UK, described this condition in 1893. Francois de la Peyronie , 1678–1747, surgeon to King Louis XIV of  France and founder of  the Royal Academy of  Surgery , Paris, France. Georg Ledderhose , 1855–1925, German surgeon, described this disease in 1894. Fritz de Quervain , 1868–1940, Professor of  Surgery , Berne, Switzerland, described this form of  tenosynovitis in 1895 severe cases are managed surgically . Great care should be taken during surgery to avoid damage to the digital nerves, whic h y be trapped in the fibrous tissue. At the end of  surgery , ma it may not be possible to obtain primary closure of  the skin, so one should consider performing Z-plasties to lengthen the skin, full-thickness skin grafting taken from the anteromedial proximal forearm (hairless) or occasionally leaving an open wound to heal by secondary intention. In late-stage disease a fixed contracture of  the MCPJs and PIP joints may develop. In these cases excision of the fibrous bands may produce no improvement in the condition; if the contracted finger is preventing useful function of the hand, amputation may have to be considered. Summary box 38.14 Dupuytren’s contracture /uni25CF /uni25CF /uni25CF /uni25CF
Figure 38.53
Dupuytren’s contracture of the little
/f_i
nger metacarpo
phalangeal joint with a signi
/f_i
cant palmar cord.
Figure 38.54
Garrod’s knuckle pads.
Autosomal dominant inheritance but many sporadic cases
Fibroblastic hyperplasia with resultant skin nodules, cords and
deformities
Intervention is indicated if hand cannot be placed
/f_l
at
Severe disease is signi
/f_i
ed if hand cannot be placed
/f_l
at;
severe
/f_i
xed
/f_l
exion deformities may mean that amputation is
the only surgical option
Dupuytren’s contracture
Dupuytren’s contracture is most often characterised as an autosomal dominant condition, common in northern Europe, predominantly in men in the fifth to seventh decades of  life. Four out of  seven cases occur in those with a family history but there are also many sporadic cases. It is associated with smoking, trauma, epilepsy , hypothyroidism, alcoholic cirrhosis and possibly human immunodeficiency virus (HIV) infection. William Heberden (Senior) , 1710–1801, physician, who practised first in Cambridge and from 1748 in London, UK, described these nodes in 1802. Charles Jacques Bouchard , 1837–1915, physician, Dean of  the Faculty of  Medicine, Paris, France. Baron Guillaume Dupuytren , 1777–1835, surgeon, Hôtel Dieu, Paris, France, described this condition in 1831. - It also appears very frequently as a clinical case in postgraduate examinations! The characteristic features are palmar nodules, skin puckering, cords of  the palm and digits, and flexion
Figure 38.51
Hand deformities secondary to osteoarthritis.
(a)
(b)
Figure 38.52
Radiographs of the distal interphalangeal (DIPJ) and
proximal interphalangeal (PIPJ) joints treated with DIPJ arthrodesis
and PIPJ arthroplasty/joint replacement.
(a)
Preoperative image;
(b)
/uni00A0
after surgery.
contractures of  the digits ( Figure 38.53 ). It is commonest on the ulnar side of  the hand. Garrod’s knuckle pads (thickened skin on the dorsum of the PIP joint) are another feature visible on examination and seen in more severe forms of  the disease ( Figure 38.54 ). The condition can also produce cords in the penis, causing it to become curved (Peyronie’s disease) and may also produce plantar thickening on the sole of  the foot (Ledderhose disease). Intervention is indicated when the patient cannot put the a ff ected hand flat on the table owing to fixed deformity (‘table-top test’) or when any flexion contrac ture develops in the PIP joint. Milder cases may be treated Sir Archibald Edward Garrod , 1857–1936, Regius Professor of  Medicine, University of  Oxford, Oxford, UK, described this condition in 1893. Francois de la Peyronie , 1678–1747, surgeon to King Louis XIV of  France and founder of  the Royal Academy of  Surgery , Paris, France. Georg Ledderhose , 1855–1925, German surgeon, described this disease in 1894. Fritz de Quervain , 1868–1940, Professor of  Surgery , Berne, Switzerland, described this form of  tenosynovitis in 1895 severe cases are managed surgically . Great care should be taken during surgery to avoid damage to the digital nerves, whic h y be trapped in the fibrous tissue. At the end of  surgery , ma it may not be possible to obtain primary closure of  the skin, so one should consider performing Z-plasties to lengthen the skin, full-thickness skin grafting taken from the anteromedial proximal forearm (hairless) or occasionally leaving an open wound to heal by secondary intention. In late-stage disease a fixed contracture of  the MCPJs and PIP joints may develop. In these cases excision of the fibrous bands may produce no improvement in the condition; if the contracted finger is preventing useful function of the hand, amputation may have to be considered. Summary box 38.14 Dupuytren’s contracture /uni25CF /uni25CF /uni25CF /uni25CF
Figure 38.53
Dupuytren’s contracture of the little
/f_i
nger metacarpo
phalangeal joint with a signi
/f_i
cant palmar cord.
Figure 38.54
Garrod’s knuckle pads.
Autosomal dominant inheritance but many sporadic cases
Fibroblastic hyperplasia with resultant skin nodules, cords and
deformities
Intervention is indicated if hand cannot be placed
/f_l
at
Severe disease is signi
/f_i
ed if hand cannot be placed
/f_l
at;
severe
/f_i
xed
/f_l
exion deformities may mean that amputation is
the only surgical option

FURTHER READING
FURTHER READING
Burden EG, Batten TJ, Smith CD et al . Reverse shoulder arthroplasty: a systematic review and meta analysis of  complications and patient outcomes dependent on prosthesis design. Bone Joint J 103-B (5): 813–21. Carr AJ, Cooper CD, Campbell AK et al . Clinical e ff ectiveness and cost-e ff ectiveness of  open and arthroscopic rotator cu ff repair (the UK Rotator Cu ff Surgery [UKUFF] randomised trial). T echnol Assess 2015; 19 (80): 1–218. Gill DR, Morrey BF . The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study . J Bone Joint Surg Am 1998; 80 : 1327–35. Mizuno N, Denard PJ, Raiss P et al . Long-term results of  the Latarjet procedure for anterior instability of  the shoulder. J Shoulder Elbow Surg 2014; 23 (11): 1691–9. Joseph Kirner , 1888–1964, Chief  Physician, Waldshut Hospital, Baden, Germany . Bernard Jean Antonin Marfan , 1858–1942, physician, L’Hôpital des Enfants-Malades, Paris, France, described this syndrome in 1896. Henry Hubert Turner , 1892–1970, Professor of  Medicine, University of  Oklahoma, Oklahoma City , OK, USA. John Langdon Haydon Down (sometimes given as Langdon-Down), 1828–1896, physician, The London Hospital, London, UK. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg [Am] 1972; 54 - A : 41–50. O’Driscoll SW , Bell DF , Morrey BF . Posterolateral rotatory instability 2021; of  the elbow . J Bone Joint Surg Am 1991; 73 : 440–6. Poppen NK, Walker PS. Normal and abnormal motion of  the shoulder. J Bone Joint Surg [Am] 1976; 58 - A : 195–201. Rangan A, Brearley SD, Keding A et al . Management of  adults Health with primary frozen shoulder in secondary care (UK FROST): a multicentre, three-arm, superiority randomised clinical trial. Lancet 2020; 396 : 977–89. Rowe CR, Patel D, Southmayd WW . The Bankart procedure: long- term end-result study . J Bone Joint Surg [Am] 1978; 60 - A : 1–16. Singh JA, Sperling JW , Schleck S et al . Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elbow Surg 2012; 21 (11): 1534–41.
Figure 38.60
Myxoid cyst with changes in the nail.
1 Transverse agenesis
2 Longitudinal agenesis
(a)
radial ray aplasia; (b) median ray aplasia; (c) ulnar ray aplasia
3 Thumb aplasia/hypoplasia
1 Syndactyly
2 Camptodactyly
3 Clinodactyly
4 Kirner’s deformity
5 Radioulnar synostosis
1 Supernumerary phalanges
2 Supernumerary digits (polydactyly)
Macrodactyly
Thumb hypoplasia
Simple amniotic band syndrome
Marfan, Turner and Down syndromes
FURTHER READING
Burden EG, Batten TJ, Smith CD et al . Reverse shoulder arthroplasty: a systematic review and meta analysis of  complications and patient outcomes dependent on prosthesis design. Bone Joint J 103-B (5): 813–21. Carr AJ, Cooper CD, Campbell AK et al . Clinical e ff ectiveness and cost-e ff ectiveness of  open and arthroscopic rotator cu ff repair (the UK Rotator Cu ff Surgery [UKUFF] randomised trial). T echnol Assess 2015; 19 (80): 1–218. Gill DR, Morrey BF . The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study . J Bone Joint Surg Am 1998; 80 : 1327–35. Mizuno N, Denard PJ, Raiss P et al . Long-term results of  the Latarjet procedure for anterior instability of  the shoulder. J Shoulder Elbow Surg 2014; 23 (11): 1691–9. Joseph Kirner , 1888–1964, Chief  Physician, Waldshut Hospital, Baden, Germany . Bernard Jean Antonin Marfan , 1858–1942, physician, L’Hôpital des Enfants-Malades, Paris, France, described this syndrome in 1896. Henry Hubert Turner , 1892–1970, Professor of  Medicine, University of  Oklahoma, Oklahoma City , OK, USA. John Langdon Haydon Down (sometimes given as Langdon-Down), 1828–1896, physician, The London Hospital, London, UK. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg [Am] 1972; 54 - A : 41–50. O’Driscoll SW , Bell DF , Morrey BF . Posterolateral rotatory instability 2021; of  the elbow . J Bone Joint Surg Am 1991; 73 : 440–6. Poppen NK, Walker PS. Normal and abnormal motion of  the shoulder. J Bone Joint Surg [Am] 1976; 58 - A : 195–201. Rangan A, Brearley SD, Keding A et al . Management of  adults Health with primary frozen shoulder in secondary care (UK FROST): a multicentre, three-arm, superiority randomised clinical trial. Lancet 2020; 396 : 977–89. Rowe CR, Patel D, Southmayd WW . The Bankart procedure: long- term end-result study . J Bone Joint Surg [Am] 1978; 60 - A : 1–16. Singh JA, Sperling JW , Schleck S et al . Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elbow Surg 2012; 21 (11): 1534–41.
Figure 38.60
Myxoid cyst with changes in the nail.
1 Transverse agenesis
2 Longitudinal agenesis
(a)
radial ray aplasia; (b) median ray aplasia; (c) ulnar ray aplasia
3 Thumb aplasia/hypoplasia
1 Syndactyly
2 Camptodactyly
3 Clinodactyly
4 Kirner’s deformity
5 Radioulnar synostosis
1 Supernumerary phalanges
2 Supernumerary digits (polydactyly)
Macrodactyly
Thumb hypoplasia
Simple amniotic band syndrome
Marfan, Turner and Down syndromes
FURTHER READING
Burden EG, Batten TJ, Smith CD et al . Reverse shoulder arthroplasty: a systematic review and meta analysis of  complications and patient outcomes dependent on prosthesis design. Bone Joint J 103-B (5): 813–21. Carr AJ, Cooper CD, Campbell AK et al . Clinical e ff ectiveness and cost-e ff ectiveness of  open and arthroscopic rotator cu ff repair (the UK Rotator Cu ff Surgery [UKUFF] randomised trial). T echnol Assess 2015; 19 (80): 1–218. Gill DR, Morrey BF . The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study . J Bone Joint Surg Am 1998; 80 : 1327–35. Mizuno N, Denard PJ, Raiss P et al . Long-term results of  the Latarjet procedure for anterior instability of  the shoulder. J Shoulder Elbow Surg 2014; 23 (11): 1691–9. Joseph Kirner , 1888–1964, Chief  Physician, Waldshut Hospital, Baden, Germany . Bernard Jean Antonin Marfan , 1858–1942, physician, L’Hôpital des Enfants-Malades, Paris, France, described this syndrome in 1896. Henry Hubert Turner , 1892–1970, Professor of  Medicine, University of  Oklahoma, Oklahoma City , OK, USA. John Langdon Haydon Down (sometimes given as Langdon-Down), 1828–1896, physician, The London Hospital, London, UK. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg [Am] 1972; 54 - A : 41–50. O’Driscoll SW , Bell DF , Morrey BF . Posterolateral rotatory instability 2021; of  the elbow . J Bone Joint Surg Am 1991; 73 : 440–6. Poppen NK, Walker PS. Normal and abnormal motion of  the shoulder. J Bone Joint Surg [Am] 1976; 58 - A : 195–201. Rangan A, Brearley SD, Keding A et al . Management of  adults Health with primary frozen shoulder in secondary care (UK FROST): a multicentre, three-arm, superiority randomised clinical trial. Lancet 2020; 396 : 977–89. Rowe CR, Patel D, Southmayd WW . The Bankart procedure: long- term end-result study . J Bone Joint Surg [Am] 1978; 60 - A : 1–16. Singh JA, Sperling JW , Schleck S et al . Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elbow Surg 2012; 21 (11): 1534–41.
Figure 38.60
Myxoid cyst with changes in the nail.
1 Transverse agenesis
2 Longitudinal agenesis
(a)
radial ray aplasia; (b) median ray aplasia; (c) ulnar ray aplasia
3 Thumb aplasia/hypoplasia
1 Syndactyly
2 Camptodactyly
3 Clinodactyly
4 Kirner’s deformity
5 Radioulnar synostosis
1 Supernumerary phalanges
2 Supernumerary digits (polydactyly)
Macrodactyly
Thumb hypoplasia
Simple amniotic band syndrome
Marfan, Turner and Down syndromes

Ganglion cysts
Ganglion cysts
Ganglion cysts are the commonest cause of  a swelling in the hand and they are found most often on the dorsal ( Figure 38.58 ) and volar ( Figure 38.59 ) surfaces of  the wrist, over the dorsum of  the DIP joint (digital mucous cyst) or within the flexor tendon sheath at the base of  the finger (seed ganglion). Dorsal and volar wrist ganglions can cause discomfort. The swellings are smooth, fluctuant and transilluminate brightly . Mucous cysts may discharge and can cause nail changes ( Figure 38.60 ). Seed ganglions can be painful when gripping. Aspiration or surgical excision can be considered. Patients should be informed regarding possible recurrence. Ganglion cysts
Ganglion cysts are the commonest cause of  a swelling in the hand and they are found most often on the dorsal ( Figure 38.58 ) and volar ( Figure 38.59 ) surfaces of  the wrist, over the dorsum of  the DIP joint (digital mucous cyst) or within the flexor tendon sheath at the base of  the finger (seed ganglion). Dorsal and volar wrist ganglions can cause discomfort. The swellings are smooth, fluctuant and transilluminate brightly . Mucous cysts may discharge and can cause nail changes ( Figure 38.60 ). Seed ganglions can be painful when gripping. Aspiration or surgical excision can be considered. Patients should be informed regarding possible recurrence. Ganglion cysts
Ganglion cysts are the commonest cause of  a swelling in the hand and they are found most often on the dorsal ( Figure 38.58 ) and volar ( Figure 38.59 ) surfaces of  the wrist, over the dorsum of  the DIP joint (digital mucous cyst) or within the flexor tendon sheath at the base of  the finger (seed ganglion). Dorsal and volar wrist ganglions can cause discomfort. The swellings are smooth, fluctuant and transilluminate brightly . Mucous cysts may discharge and can cause nail changes ( Figure 38.60 ). Seed ganglions can be painful when gripping. Aspiration or surgical excision can be considered. Patients should be informed regarding possible recurrence.

HAND AND WRIST
HAND AND WRIST
The hand and wrist work in concert to interact with the environment in which they are placed. The index finger works against the thumb for pinch grip; the thumb can press against the side of  the flexed index finger for a key-pinch grip; the tips of  the thumb, index and middle fingers provide a tripod pinch; all fingers curl for hook grip while the little and ring fingers provide the most power when making a fist. A mobile and stable wrist is required to optimise hand function through maximising range of  movement and strength. HAND AND WRIST
The hand and wrist work in concert to interact with the environment in which they are placed. The index finger works against the thumb for pinch grip; the thumb can press against the side of  the flexed index finger for a key-pinch grip; the tips of  the thumb, index and middle fingers provide a tripod pinch; all fingers curl for hook grip while the little and ring fingers provide the most power when making a fist. A mobile and stable wrist is required to optimise hand function through maximising range of  movement and strength. HAND AND WRIST
The hand and wrist work in concert to interact with the environment in which they are placed. The index finger works against the thumb for pinch grip; the thumb can press against the side of  the flexed index finger for a key-pinch grip; the tips of  the thumb, index and middle fingers provide a tripod pinch; all fingers curl for hook grip while the little and ring fingers provide the most power when making a fist. A mobile and stable wrist is required to optimise hand function through maximising range of  movement and strength.

Infections
Infections
Paronychia Nail bed infection is the most common hand infection ( Figure 38.45 ). After initial inflammation, pus accumulates beside and sometimes under the nail. It is best treated with incision, drainage and appropriate antibiotic therapy . This is occasionally facilitated by partial nail removal to allow full drainage of  the collection. Felon A felon is an abscess within the specialised fibrous septae of the fingertip pulp. It causes intense pain and may lead to terminal phalangeal osteomyelitis. Incision and drainage through the midline of  the pulp of  the finger in the location of  maximal swelling, followed by intravenous antibiotics, are recommended. Flexor tendon sheath infection Flexor tendon sheath infections present with Kanavel’s cardi nal signs: /uni25CF the a ff ected finger is held in flexion; /uni25CF there is uniform swelling over the tendon and digit; /uni25CF tender to the touch; /uni25CF pain on passive extension of  the finger. Flexor sheath anatomy is important to understand, since infection within flexors 2 (index) to 4 (ring) is usually confined to that finger, whereas infections arising in the sheath of  the thumb or little finger may e xtend via the radial and ulnar bur sae, respectively , towards the wrist. Treatment is by open irriga tion throughout the tendon sheath course; small incisions are made at the proximal and distal ends of the a ff ected sheath and the sheath is washed out, delivering irrig ation via a small naso gastric or feeding tube. The whole finger may require opening if  the viability of  the digit is threatened. This is followed by what is often an extended course of  intravenous antibiotics. If infection is untreated tendon adhesions and necrosis occur. Infection can spread proximally , damaging the whole hand. Summary box 38.12 Treatment of hand infections /uni25CF /uni25CF /uni25CF Allen B Kanavel , 1874–1938, Professor of  Surgery , Northwestern University Medical School and President of  the American College of  Surgeons (1931–1932). Boutonnière is French for ‘buttonhole’. Oliver J Vaughan-Jackson , 1907–2003, consultant orthopaedic surgeon, The London Hospital, London, UK, and a specialist in hand surgery . Tuberculosis may involve the tenosynovium, joints or bone. The most dramatic form is a compound palmar ganglion, with synovial swelling proximal and distal to the transverse carpal ligament, occasionally causing symptoms of  carpal tunnel syndrome. The diagnosis is made by taking a biopsy . Synovec - tomy should be performed and the patient treated with the appropriate antibiotics. Deep palmar infections These infections occur in the palm but may be limited to a web space. The whole hand becomes swollen and tender as pus collects on either side of  the septum. Treatment is incision and drainage with thorough washout of  the wound. It is important that all deep spaces are opened: incisions on both the dorsal and volar aspects of  the hand may be needed. If  in doubt, an ultrasound scan or MRI can delineate the extent of  the collections within the deep palmar spaces.
Figure 38.45
Acute paronychia.
Elevate and splint in a functional position and give intravenous
antibiotics
Surgical drainage should include tendon sheath irrigation
Early mobilisation
Infections
Paronychia Nail bed infection is the most common hand infection ( Figure 38.45 ). After initial inflammation, pus accumulates beside and sometimes under the nail. It is best treated with incision, drainage and appropriate antibiotic therapy . This is occasionally facilitated by partial nail removal to allow full drainage of  the collection. Felon A felon is an abscess within the specialised fibrous septae of the fingertip pulp. It causes intense pain and may lead to terminal phalangeal osteomyelitis. Incision and drainage through the midline of  the pulp of  the finger in the location of  maximal swelling, followed by intravenous antibiotics, are recommended. Flexor tendon sheath infection Flexor tendon sheath infections present with Kanavel’s cardi nal signs: /uni25CF the a ff ected finger is held in flexion; /uni25CF there is uniform swelling over the tendon and digit; /uni25CF tender to the touch; /uni25CF pain on passive extension of  the finger. Flexor sheath anatomy is important to understand, since infection within flexors 2 (index) to 4 (ring) is usually confined to that finger, whereas infections arising in the sheath of  the thumb or little finger may e xtend via the radial and ulnar bur sae, respectively , towards the wrist. Treatment is by open irriga tion throughout the tendon sheath course; small incisions are made at the proximal and distal ends of the a ff ected sheath and the sheath is washed out, delivering irrig ation via a small naso gastric or feeding tube. The whole finger may require opening if  the viability of  the digit is threatened. This is followed by what is often an extended course of  intravenous antibiotics. If infection is untreated tendon adhesions and necrosis occur. Infection can spread proximally , damaging the whole hand. Summary box 38.12 Treatment of hand infections /uni25CF /uni25CF /uni25CF Allen B Kanavel , 1874–1938, Professor of  Surgery , Northwestern University Medical School and President of  the American College of  Surgeons (1931–1932). Boutonnière is French for ‘buttonhole’. Oliver J Vaughan-Jackson , 1907–2003, consultant orthopaedic surgeon, The London Hospital, London, UK, and a specialist in hand surgery . Tuberculosis may involve the tenosynovium, joints or bone. The most dramatic form is a compound palmar ganglion, with synovial swelling proximal and distal to the transverse carpal ligament, occasionally causing symptoms of  carpal tunnel syndrome. The diagnosis is made by taking a biopsy . Synovec - tomy should be performed and the patient treated with the appropriate antibiotics. Deep palmar infections These infections occur in the palm but may be limited to a web space. The whole hand becomes swollen and tender as pus collects on either side of  the septum. Treatment is incision and drainage with thorough washout of  the wound. It is important that all deep spaces are opened: incisions on both the dorsal and volar aspects of  the hand may be needed. If  in doubt, an ultrasound scan or MRI can delineate the extent of  the collections within the deep palmar spaces.
Figure 38.45
Acute paronychia.
Elevate and splint in a functional position and give intravenous
antibiotics
Surgical drainage should include tendon sheath irrigation
Early mobilisation
Infections
Paronychia Nail bed infection is the most common hand infection ( Figure 38.45 ). After initial inflammation, pus accumulates beside and sometimes under the nail. It is best treated with incision, drainage and appropriate antibiotic therapy . This is occasionally facilitated by partial nail removal to allow full drainage of  the collection. Felon A felon is an abscess within the specialised fibrous septae of the fingertip pulp. It causes intense pain and may lead to terminal phalangeal osteomyelitis. Incision and drainage through the midline of  the pulp of  the finger in the location of  maximal swelling, followed by intravenous antibiotics, are recommended. Flexor tendon sheath infection Flexor tendon sheath infections present with Kanavel’s cardi nal signs: /uni25CF the a ff ected finger is held in flexion; /uni25CF there is uniform swelling over the tendon and digit; /uni25CF tender to the touch; /uni25CF pain on passive extension of  the finger. Flexor sheath anatomy is important to understand, since infection within flexors 2 (index) to 4 (ring) is usually confined to that finger, whereas infections arising in the sheath of  the thumb or little finger may e xtend via the radial and ulnar bur sae, respectively , towards the wrist. Treatment is by open irriga tion throughout the tendon sheath course; small incisions are made at the proximal and distal ends of the a ff ected sheath and the sheath is washed out, delivering irrig ation via a small naso gastric or feeding tube. The whole finger may require opening if  the viability of  the digit is threatened. This is followed by what is often an extended course of  intravenous antibiotics. If infection is untreated tendon adhesions and necrosis occur. Infection can spread proximally , damaging the whole hand. Summary box 38.12 Treatment of hand infections /uni25CF /uni25CF /uni25CF Allen B Kanavel , 1874–1938, Professor of  Surgery , Northwestern University Medical School and President of  the American College of  Surgeons (1931–1932). Boutonnière is French for ‘buttonhole’. Oliver J Vaughan-Jackson , 1907–2003, consultant orthopaedic surgeon, The London Hospital, London, UK, and a specialist in hand surgery . Tuberculosis may involve the tenosynovium, joints or bone. The most dramatic form is a compound palmar ganglion, with synovial swelling proximal and distal to the transverse carpal ligament, occasionally causing symptoms of  carpal tunnel syndrome. The diagnosis is made by taking a biopsy . Synovec - tomy should be performed and the patient treated with the appropriate antibiotics. Deep palmar infections These infections occur in the palm but may be limited to a web space. The whole hand becomes swollen and tender as pus collects on either side of  the septum. Treatment is incision and drainage with thorough washout of  the wound. It is important that all deep spaces are opened: incisions on both the dorsal and volar aspects of  the hand may be needed. If  in doubt, an ultrasound scan or MRI can delineate the extent of  the collections within the deep palmar spaces.
Figure 38.45
Acute paronychia.
Elevate and splint in a functional position and give intravenous
antibiotics
Surgical drainage should include tendon sheath irrigation
Early mobilisation

Introduction
Introduction
No content extracted automatically.

Investigations
Investigations
Radiographs can be used to assess for arthritis or bone tumours. Electrophysiological studies may be required to evaluate nerve function, assessing both sensory and motor supply . Ultrasound is a very useful investigation as it can assess soft tissues in a dynamic way while the patient is asked to perform movements, identifying issues such as tendon instability . In addition, since the hand has a thin soft-tissue envelope, many structures can be seen very well with ultrasound that would not normally be evaluated (e.g. erosions within the joints of  the fingers as an early sign of  inflammatory joint disease). MRI is useful for diagnosing avascular necrosis, ligament injuries or to charac terise soft-tissue tumours. Hand swelling and stiffness Swelling followed by sti ff ness is the arch enemy of  hand reha bilitation. The hand will swell after injury , surgery or infection. In response, the wrist flexes and then there is compensatory metacarpophalangeal joint (MCPJ) extension and interpha langeal joint (IPJ) flexion. If action is not taken swiftly , this position will become permanent, as collateral ligaments shrink and tissues fibrose. Hand elevation to reduce swelling, splintage in the position of  safety to prevent collateral shortening (Edin b urgh position: wrist extension, MCPJ flexion, IPJ extension) and early mobilisation prevent permanent sti ff ness. Summary box 38.11 General principles of treatment /uni25CF /uni25CF /uni25CF Thumb ulnar collateral ligament injury Chronic thumb overuse or overloading leads to stretching of the ulnar collateral ligament and instability (gamekeeper’s thumb). The ligament can also rupture acutely if  the thumb is forcibly abducted (skier’s thumb). If  valgus stress on exam ination causes significant opening of  the joint on the ulnar side then the ligament needs to be repaired surgically , as the adductor aponeurosis interposes between the torn end of  the ligament and its insertion ( Figure 38.43 ), pr eventing healing and causing chronic instability . - - - - Triangular fibrocartilage complex The triangular fibrocartilage complex (TFCC) consists of the ulnocarpal ligaments, extensor carpi ulnaris tendon sheath and a meniscus-like structure between the distal ulna and the carpus. It is continuous with the dorsal and volar wrist capsules and stabilises the distal radioulnar joint. It can undergo traumatic or degenerative tears, presenting with ulna-sided wrist pain and distal radioulnar instability . An MRI arthrogram or wrist arthroscopy aids diagnosis ( Figure 38.44 ). Peripheral tears of  the TFCC can be repaired open or arthroscopically , while central degenerative tears can be arthroscopically debrided.
Figure 38.42
Rotational deformity of the little
/f_i
nger.
Avoid swelling and stiffness by:
Elevation – reduce swelling
Splintage – avoid contractures
Movement – pump away swelling and encourage suppleness
collateral
ligament
Figure 38.43
Magnetic resonance imaging showing rupture of the
ulnar collateral ligament of the thumb (skier’s thumb).
Figure 38.44
Magnetic resonance arthrogram showing peripheral
detachment of the triangular
/f_i
brocartilage complex.
Investigations
Radiographs can be used to assess for arthritis or bone tumours. Electrophysiological studies may be required to evaluate nerve function, assessing both sensory and motor supply . Ultrasound is a very useful investigation as it can assess soft tissues in a dynamic way while the patient is asked to perform movements, identifying issues such as tendon instability . In addition, since the hand has a thin soft-tissue envelope, many structures can be seen very well with ultrasound that would not normally be evaluated (e.g. erosions within the joints of  the fingers as an early sign of  inflammatory joint disease). MRI is useful for diagnosing avascular necrosis, ligament injuries or to charac terise soft-tissue tumours. Hand swelling and stiffness Swelling followed by sti ff ness is the arch enemy of  hand reha bilitation. The hand will swell after injury , surgery or infection. In response, the wrist flexes and then there is compensatory metacarpophalangeal joint (MCPJ) extension and interpha langeal joint (IPJ) flexion. If action is not taken swiftly , this position will become permanent, as collateral ligaments shrink and tissues fibrose. Hand elevation to reduce swelling, splintage in the position of  safety to prevent collateral shortening (Edin b urgh position: wrist extension, MCPJ flexion, IPJ extension) and early mobilisation prevent permanent sti ff ness. Summary box 38.11 General principles of treatment /uni25CF /uni25CF /uni25CF Thumb ulnar collateral ligament injury Chronic thumb overuse or overloading leads to stretching of the ulnar collateral ligament and instability (gamekeeper’s thumb). The ligament can also rupture acutely if  the thumb is forcibly abducted (skier’s thumb). If  valgus stress on exam ination causes significant opening of  the joint on the ulnar side then the ligament needs to be repaired surgically , as the adductor aponeurosis interposes between the torn end of  the ligament and its insertion ( Figure 38.43 ), pr eventing healing and causing chronic instability . - - - - Triangular fibrocartilage complex The triangular fibrocartilage complex (TFCC) consists of the ulnocarpal ligaments, extensor carpi ulnaris tendon sheath and a meniscus-like structure between the distal ulna and the carpus. It is continuous with the dorsal and volar wrist capsules and stabilises the distal radioulnar joint. It can undergo traumatic or degenerative tears, presenting with ulna-sided wrist pain and distal radioulnar instability . An MRI arthrogram or wrist arthroscopy aids diagnosis ( Figure 38.44 ). Peripheral tears of  the TFCC can be repaired open or arthroscopically , while central degenerative tears can be arthroscopically debrided.
Figure 38.42
Rotational deformity of the little
/f_i
nger.
Avoid swelling and stiffness by:
Elevation – reduce swelling
Splintage – avoid contractures
Movement – pump away swelling and encourage suppleness
collateral
ligament
Figure 38.43
Magnetic resonance imaging showing rupture of the
ulnar collateral ligament of the thumb (skier’s thumb).
Figure 38.44
Magnetic resonance arthrogram showing peripheral
detachment of the triangular
/f_i
brocartilage complex.
Investigations
Radiographs can be used to assess for arthritis or bone tumours. Electrophysiological studies may be required to evaluate nerve function, assessing both sensory and motor supply . Ultrasound is a very useful investigation as it can assess soft tissues in a dynamic way while the patient is asked to perform movements, identifying issues such as tendon instability . In addition, since the hand has a thin soft-tissue envelope, many structures can be seen very well with ultrasound that would not normally be evaluated (e.g. erosions within the joints of  the fingers as an early sign of  inflammatory joint disease). MRI is useful for diagnosing avascular necrosis, ligament injuries or to charac terise soft-tissue tumours. Hand swelling and stiffness Swelling followed by sti ff ness is the arch enemy of  hand reha bilitation. The hand will swell after injury , surgery or infection. In response, the wrist flexes and then there is compensatory metacarpophalangeal joint (MCPJ) extension and interpha langeal joint (IPJ) flexion. If action is not taken swiftly , this position will become permanent, as collateral ligaments shrink and tissues fibrose. Hand elevation to reduce swelling, splintage in the position of  safety to prevent collateral shortening (Edin b urgh position: wrist extension, MCPJ flexion, IPJ extension) and early mobilisation prevent permanent sti ff ness. Summary box 38.11 General principles of treatment /uni25CF /uni25CF /uni25CF Thumb ulnar collateral ligament injury Chronic thumb overuse or overloading leads to stretching of the ulnar collateral ligament and instability (gamekeeper’s thumb). The ligament can also rupture acutely if  the thumb is forcibly abducted (skier’s thumb). If  valgus stress on exam ination causes significant opening of  the joint on the ulnar side then the ligament needs to be repaired surgically , as the adductor aponeurosis interposes between the torn end of  the ligament and its insertion ( Figure 38.43 ), pr eventing healing and causing chronic instability . - - - - Triangular fibrocartilage complex The triangular fibrocartilage complex (TFCC) consists of the ulnocarpal ligaments, extensor carpi ulnaris tendon sheath and a meniscus-like structure between the distal ulna and the carpus. It is continuous with the dorsal and volar wrist capsules and stabilises the distal radioulnar joint. It can undergo traumatic or degenerative tears, presenting with ulna-sided wrist pain and distal radioulnar instability . An MRI arthrogram or wrist arthroscopy aids diagnosis ( Figure 38.44 ). Peripheral tears of  the TFCC can be repaired open or arthroscopically , while central degenerative tears can be arthroscopically debrided.
Figure 38.42
Rotational deformity of the little
/f_i
nger.
Avoid swelling and stiffness by:
Elevation – reduce swelling
Splintage – avoid contractures
Movement – pump away swelling and encourage suppleness
collateral
ligament
Figure 38.43
Magnetic resonance imaging showing rupture of the
ulnar collateral ligament of the thumb (skier’s thumb).
Figure 38.44
Magnetic resonance arthrogram showing peripheral
detachment of the triangular
/f_i
brocartilage complex.

Learning objectives
Learning objectives
To understand: Anatomy and physiology relevant to upper limb • pathology Learning objectives
To understand: Anatomy and physiology relevant to upper limb • pathology Learning objectives
To understand: Anatomy and physiology relevant to upper limb • pathology

Long head of biceps tendon rupture
Long head of biceps tendon rupture
Rupture of  the long head of  biceps usually occurs in older adults and is due to constriction and degeneration of  the tendon in the bicipital groove, especially at the superior end, beneath the anterior acromion. It is associated with rotator cu ff tears. Most patients present with few symptoms, although they often seek advice because of  the bulge they notice in their arm. History and examination Patients feel a sense of  ‘something giving way’ in front of  the shoulder, sometimes with relief  of  pain if  there was any present beforehand due to biceps tendinitis. The upper arm is bruised and elbow flexion produces a swelling in the front and middle of the arm ( Figure 38.22 ). The lump will be permanent and is initially tender. Power is slightly diminished in the early stages, when there may also be cramping pains on use of  the arm. Treatment Reassurance that pain and bruising will resolve is su ffi cient. Power improves over several months and surgery (biceps tenodesis) is not needed for function, although it may help the cosmetic appearance. -
Figure 38.21
Arthroscopic end-on view of the clavicle after excision
of its distal end.
Figure 38.22
Bruising and change in the upper arm shape due to
rupture of the long head of biceps.
Long head of biceps tendon rupture
Rupture of  the long head of  biceps usually occurs in older adults and is due to constriction and degeneration of  the tendon in the bicipital groove, especially at the superior end, beneath the anterior acromion. It is associated with rotator cu ff tears. Most patients present with few symptoms, although they often seek advice because of  the bulge they notice in their arm. History and examination Patients feel a sense of  ‘something giving way’ in front of  the shoulder, sometimes with relief  of  pain if  there was any present beforehand due to biceps tendinitis. The upper arm is bruised and elbow flexion produces a swelling in the front and middle of the arm ( Figure 38.22 ). The lump will be permanent and is initially tender. Power is slightly diminished in the early stages, when there may also be cramping pains on use of  the arm. Treatment Reassurance that pain and bruising will resolve is su ffi cient. Power improves over several months and surgery (biceps tenodesis) is not needed for function, although it may help the cosmetic appearance. -
Figure 38.21
Arthroscopic end-on view of the clavicle after excision
of its distal end.
Figure 38.22
Bruising and change in the upper arm shape due to
rupture of the long head of biceps.
Long head of biceps tendon rupture
Rupture of  the long head of  biceps usually occurs in older adults and is due to constriction and degeneration of  the tendon in the bicipital groove, especially at the superior end, beneath the anterior acromion. It is associated with rotator cu ff tears. Most patients present with few symptoms, although they often seek advice because of  the bulge they notice in their arm. History and examination Patients feel a sense of  ‘something giving way’ in front of  the shoulder, sometimes with relief  of  pain if  there was any present beforehand due to biceps tendinitis. The upper arm is bruised and elbow flexion produces a swelling in the front and middle of the arm ( Figure 38.22 ). The lump will be permanent and is initially tender. Power is slightly diminished in the early stages, when there may also be cramping pains on use of  the arm. Treatment Reassurance that pain and bruising will resolve is su ffi cient. Power improves over several months and surgery (biceps tenodesis) is not needed for function, although it may help the cosmetic appearance. -
Figure 38.21
Arthroscopic end-on view of the clavicle after excision
of its distal end.
Figure 38.22
Bruising and change in the upper arm shape due to
rupture of the long head of biceps.

Loose bodies in the elbow
Loose bodies in the elbow
The common causes are osteoarthritis, osteochondritis disse - cans in the young ( Figure 38.33 ) and synovial chondromatosis ( Figure 38.34 ). Patients describe sudden pain and locking, and the need to manipulate the elbow for relief. Plain radiographs will usually confirm the diagnosis ( Figure 38.35 ) but if  there is doubt a CT or MR arthrogram will demonstrate filling defects in the intra-articular contrast. Arthroscopic clearance of  the joint produces good results ( Figure 38.36 ).
Figure 38.32 (a, b)
Linked total elbow replace
ment.
Figure 38.33
Osteochondritis dissecans of the capitellum (Panner’s
disease).
Loose bodies in the elbow
The common causes are osteoarthritis, osteochondritis disse - cans in the young ( Figure 38.33 ) and synovial chondromatosis ( Figure 38.34 ). Patients describe sudden pain and locking, and the need to manipulate the elbow for relief. Plain radiographs will usually confirm the diagnosis ( Figure 38.35 ) but if  there is doubt a CT or MR arthrogram will demonstrate filling defects in the intra-articular contrast. Arthroscopic clearance of  the joint produces good results ( Figure 38.36 ).
Figure 38.32 (a, b)
Linked total elbow replace
ment.
Figure 38.33
Osteochondritis dissecans of the capitellum (Panner’s
disease).
Loose bodies in the elbow
The common causes are osteoarthritis, osteochondritis disse - cans in the young ( Figure 38.33 ) and synovial chondromatosis ( Figure 38.34 ). Patients describe sudden pain and locking, and the need to manipulate the elbow for relief. Plain radiographs will usually confirm the diagnosis ( Figure 38.35 ) but if  there is doubt a CT or MR arthrogram will demonstrate filling defects in the intra-articular contrast. Arthroscopic clearance of  the joint produces good results ( Figure 38.36 ).
Figure 38.32 (a, b)
Linked total elbow replace
ment.
Figure 38.33
Osteochondritis dissecans of the capitellum (Panner’s
disease).

Olecranon bursitis
Olecranon bursitis
This is a relatively common disorder in which the point of  the elbow becomes red, warm, swollen and painful. Initially , septic arthritis may be suspected. However, on examination signs and symptoms are confined to the extensor aspect of  the elbow ( Figure 38.37 ), over the olecranon, and movement within an arc of  30–130° is almost always possible. Most cases settle with anti-inflammatory drugs. If  the patient is pyrexial antibiotics should be given. Formal drainage of  the bursa is indicated if purulent material is present. Chronic olecranon bursitis may be associated with calcific nodules of  the bursal lining ( Figure 38.38 ). These can be excised if  they prove troublesome. Hans Jessen Panner , 1871–1930, radiologist, Copenhagen, Denmark, described this condition in 1927. Sir John Struthers , 1823–1899, Professor of  Anatomy , University of  Aberdeen, Aberdeen, UK. Jules Tinel , 1879–1952, physician, Hôpital Beaujon, Paris, France.
Figure 38.34
Synovial chondromatosis.
Olecranon bursitis
This is a relatively common disorder in which the point of  the elbow becomes red, warm, swollen and painful. Initially , septic arthritis may be suspected. However, on examination signs and symptoms are confined to the extensor aspect of  the elbow ( Figure 38.37 ), over the olecranon, and movement within an arc of  30–130° is almost always possible. Most cases settle with anti-inflammatory drugs. If  the patient is pyrexial antibiotics should be given. Formal drainage of  the bursa is indicated if purulent material is present. Chronic olecranon bursitis may be associated with calcific nodules of  the bursal lining ( Figure 38.38 ). These can be excised if  they prove troublesome. Hans Jessen Panner , 1871–1930, radiologist, Copenhagen, Denmark, described this condition in 1927. Sir John Struthers , 1823–1899, Professor of  Anatomy , University of  Aberdeen, Aberdeen, UK. Jules Tinel , 1879–1952, physician, Hôpital Beaujon, Paris, France.
Figure 38.34
Synovial chondromatosis.
Olecranon bursitis
This is a relatively common disorder in which the point of  the elbow becomes red, warm, swollen and painful. Initially , septic arthritis may be suspected. However, on examination signs and symptoms are confined to the extensor aspect of  the elbow ( Figure 38.37 ), over the olecranon, and movement within an arc of  30–130° is almost always possible. Most cases settle with anti-inflammatory drugs. If  the patient is pyrexial antibiotics should be given. Formal drainage of  the bursa is indicated if purulent material is present. Chronic olecranon bursitis may be associated with calcific nodules of  the bursal lining ( Figure 38.38 ). These can be excised if  they prove troublesome. Hans Jessen Panner , 1871–1930, radiologist, Copenhagen, Denmark, described this condition in 1927. Sir John Struthers , 1823–1899, Professor of  Anatomy , University of  Aberdeen, Aberdeen, UK. Jules Tinel , 1879–1952, physician, Hôpital Beaujon, Paris, France.
Figure 38.34
Synovial chondromatosis.

SHOULDER GIRDLE Anatomy and function
SHOULDER GIRDLE Anatomy and function
The shoulder girdle (clavicle, scapula and the humerus, which articulates directly with the scapula at the glenohumeral joint) is controlled and supported by muscles crossing between the spine, thorax, scapula and humerus. The sternoclavicular joint is the only synovial joint between the upper limb and the axial skeleton. The glenohumeral joint is most closely controlled by the deltoid and rotator cu ff muscles (subscapularis, supraspi natus, infraspinatus and teres minor), although 26 muscles in Otto Gerhard Karl Sprengel , 1852–1915, surgeon, Grossherzogliches Krankenhaus (the Grand Ducal Hospital), Brunswick, Germany , described congenital high scapula in 1891. Maurice Klippel , 1858–1942, neurologist, Hôpital Tenon, Paris, France. André Feil , 1884–1955, neurologist, Paris, France. Klippel and Feil described this condition in a joint paper in 1912. total act across this articulation, which controls the upper limb with respect to the torso. The scapula is integral to shoulder motion, both gliding and rotating on the posterolateral surface of  the thorax. Of  the 180° of  elevation possible at the shoulder, around 50° is provided by scapular rotation on the chest while the clavicle elevates 30–60° concurrently . The remainder of  the range of  elevation occurs at the glenohumeral joint. During elevation both the humerus and clavicle rotate signifi - cantly: external rotation of the humerus bringing the greater tuberosity and cu ff attachments from beneath the acromion, - where they would otherwise limit the range ( Figure 38.1 ).
o
90
o
130
o
50
o
50
o
30–60
Figure 38.1
Relative motion of the elements of the shoulder girdle.
To be able to explain:
The diagnosis and treatment of common upper limb
•
conditions
SHOULDER GIRDLE Anatomy and function
The shoulder girdle (clavicle, scapula and the humerus, which articulates directly with the scapula at the glenohumeral joint) is controlled and supported by muscles crossing between the spine, thorax, scapula and humerus. The sternoclavicular joint is the only synovial joint between the upper limb and the axial skeleton. The glenohumeral joint is most closely controlled by the deltoid and rotator cu ff muscles (subscapularis, supraspi natus, infraspinatus and teres minor), although 26 muscles in Otto Gerhard Karl Sprengel , 1852–1915, surgeon, Grossherzogliches Krankenhaus (the Grand Ducal Hospital), Brunswick, Germany , described congenital high scapula in 1891. Maurice Klippel , 1858–1942, neurologist, Hôpital Tenon, Paris, France. André Feil , 1884–1955, neurologist, Paris, France. Klippel and Feil described this condition in a joint paper in 1912. total act across this articulation, which controls the upper limb with respect to the torso. The scapula is integral to shoulder motion, both gliding and rotating on the posterolateral surface of  the thorax. Of  the 180° of  elevation possible at the shoulder, around 50° is provided by scapular rotation on the chest while the clavicle elevates 30–60° concurrently . The remainder of  the range of  elevation occurs at the glenohumeral joint. During elevation both the humerus and clavicle rotate signifi - cantly: external rotation of the humerus bringing the greater tuberosity and cu ff attachments from beneath the acromion, - where they would otherwise limit the range ( Figure 38.1 ).
o
90
o
130
o
50
o
50
o
30–60
Figure 38.1
Relative motion of the elements of the shoulder girdle.
To be able to explain:
The diagnosis and treatment of common upper limb
•
conditions
SHOULDER GIRDLE Anatomy and function
The shoulder girdle (clavicle, scapula and the humerus, which articulates directly with the scapula at the glenohumeral joint) is controlled and supported by muscles crossing between the spine, thorax, scapula and humerus. The sternoclavicular joint is the only synovial joint between the upper limb and the axial skeleton. The glenohumeral joint is most closely controlled by the deltoid and rotator cu ff muscles (subscapularis, supraspi natus, infraspinatus and teres minor), although 26 muscles in Otto Gerhard Karl Sprengel , 1852–1915, surgeon, Grossherzogliches Krankenhaus (the Grand Ducal Hospital), Brunswick, Germany , described congenital high scapula in 1891. Maurice Klippel , 1858–1942, neurologist, Hôpital Tenon, Paris, France. André Feil , 1884–1955, neurologist, Paris, France. Klippel and Feil described this condition in a joint paper in 1912. total act across this articulation, which controls the upper limb with respect to the torso. The scapula is integral to shoulder motion, both gliding and rotating on the posterolateral surface of  the thorax. Of  the 180° of  elevation possible at the shoulder, around 50° is provided by scapular rotation on the chest while the clavicle elevates 30–60° concurrently . The remainder of  the range of  elevation occurs at the glenohumeral joint. During elevation both the humerus and clavicle rotate signifi - cantly: external rotation of the humerus bringing the greater tuberosity and cu ff attachments from beneath the acromion, - where they would otherwise limit the range ( Figure 38.1 ).
o
90
o
130
o
50
o
50
o
30–60
Figure 38.1
Relative motion of the elements of the shoulder girdle.
To be able to explain:
The diagnosis and treatment of common upper limb
•
conditions

TUMOURS OF THE UPPER LIMB
TUMOURS OF THE UPPER LIMB
Tumours are discussed in Chapter 42 . TUMOURS OF THE UPPER LIMB
Tumours are discussed in Chapter 42 . TUMOURS OF THE UPPER LIMB
Tumours are discussed in Chapter 42 .

Tendon disorders Trigger digit
Tendon disorders Trigger digit
Triggering occurs in the fingers or in the thumb as a result of  a size mismatch between the flexor tendon and the sheath (usually at the A1 pulley) in which it glides. The patient complains of  painful locking or snapping of the finger, usually when attempting to straighten a bent finger. Occasionally , it may present as a finger that is too painful to bend, associa ted with pain and tenderness at the A1 pulley . There is often a palpable nodule in the tendon. Management is a steroid injection into the sheath; if  this fails surgical tendon sheath (A1 pulley) release should be performed under local anaesthesia, taking care not to cut too much of  the pulley and create bowstringing of  the flexor tendon. Trigger digits, especially the thumb, can occur in infants and in such cases usually resolve spontaneously . Tendon disorders Trigger digit
Triggering occurs in the fingers or in the thumb as a result of  a size mismatch between the flexor tendon and the sheath (usually at the A1 pulley) in which it glides. The patient complains of  painful locking or snapping of the finger, usually when attempting to straighten a bent finger. Occasionally , it may present as a finger that is too painful to bend, associa ted with pain and tenderness at the A1 pulley . There is often a palpable nodule in the tendon. Management is a steroid injection into the sheath; if  this fails surgical tendon sheath (A1 pulley) release should be performed under local anaesthesia, taking care not to cut too much of  the pulley and create bowstringing of  the flexor tendon. Trigger digits, especially the thumb, can occur in infants and in such cases usually resolve spontaneously . Tendon disorders Trigger digit
Triggering occurs in the fingers or in the thumb as a result of  a size mismatch between the flexor tendon and the sheath (usually at the A1 pulley) in which it glides. The patient complains of  painful locking or snapping of the finger, usually when attempting to straighten a bent finger. Occasionally , it may present as a finger that is too painful to bend, associa ted with pain and tenderness at the A1 pulley . There is often a palpable nodule in the tendon. Management is a steroid injection into the sheath; if  this fails surgical tendon sheath (A1 pulley) release should be performed under local anaesthesia, taking care not to cut too much of  the pulley and create bowstringing of  the flexor tendon. Trigger digits, especially the thumb, can occur in infants and in such cases usually resolve spontaneously .

Tennis elbow (lateral epicondylitis) and golfer’s
Tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis)
These are discussed in Chapters 35 and 36 .

Tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis)
Tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis)
These are discussed in Chapters 35 and 36 .

Tennis elbow (lateral epicondylitis) and golfer’s
Tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis)
These are discussed in Chapters 35 and 36 .

Ulnar nerve compression
Ulnar nerve compression
Compression of the ulnar nerve most commonly occurs in the cubital tunnel (behind the medial epicondyle) within the arcade of Struthers. It may become compressed by the medial intermuscular septum as the nerve passes into the posterior compartment of  the distal humerus. Distally it may also become compressed as the nerve passes between the heads of the flexor carpi ulnaris ( Figure 38.39 ). History and examination Patients describe tingling/numbness in the little and ring fingers. A positive Tinel’s sign is usually present at the compres - sion site, with wasting and weakness of  the intrinsic muscles of  the hand ( Figure 38.40 ). Froment’s sign may be positive if there is weakness of  the adductor pollicis ( Figure 38.41 ). Nerve conduction studies have an unpredictable diagnostic value in the early stages. Radiographs may confirm medial osteophytes or loose bodies if  compression is secondary to arthritis. Jules Froment , 1878–1946, Professor of  Clinical Medicine, Lyons, France. Treatment Splints preventing elbow flexion at night may be useful if only night symptoms are a problem for the patient. If  symptoms persist, surgery can be performed; options include simple nerve decompression (most cases), partial medial epicondylectomy and/or anterior transposition of  the nerve. Transposition is necessary in cases of  valgus deformity or if  the nerve is unstable after decompression.
Figure 38.35
Radiographs showing loose bodies in the elbow (arrow).
Figure 38.36
Loose bodies removed arthroscopically from the patient
in
Figure 38.35
.
Figure 38.37
Olecranon bursitis.
Figure 38.38
Large chronic olecranon bursa with dense calci
/f_i
c deposit.
(a)
Ulnar nerve
MCL
FCU muscle belly
Fibrous arch of FCU
(b)
Figure 38.39
(a)
Anatomy of the cubital tunnel site for ulnar nerve
compression, with
(b)
a view of arthroscopic ulnar nerve decompres
sion. FCU,
/f_l
exor carpi ulnaris; MCL, medial collateral ligament.
Summary box 38.10 Other common elbow problems /uni25CF /uni25CF /uni25CF
Figure 38.40
Intrinsic muscle wasting on the left due to ulnar neu
ropathy.
Loose bodies cause locking and can be removed
arthroscopically
If the ulnar nerve is compressed, weakness and wasting will
be seen in the hands
Simple decompression is usually successful
Ulnar nerve compression
Compression of the ulnar nerve most commonly occurs in the cubital tunnel (behind the medial epicondyle) within the arcade of Struthers. It may become compressed by the medial intermuscular septum as the nerve passes into the posterior compartment of  the distal humerus. Distally it may also become compressed as the nerve passes between the heads of the flexor carpi ulnaris ( Figure 38.39 ). History and examination Patients describe tingling/numbness in the little and ring fingers. A positive Tinel’s sign is usually present at the compres - sion site, with wasting and weakness of  the intrinsic muscles of  the hand ( Figure 38.40 ). Froment’s sign may be positive if there is weakness of  the adductor pollicis ( Figure 38.41 ). Nerve conduction studies have an unpredictable diagnostic value in the early stages. Radiographs may confirm medial osteophytes or loose bodies if  compression is secondary to arthritis. Jules Froment , 1878–1946, Professor of  Clinical Medicine, Lyons, France. Treatment Splints preventing elbow flexion at night may be useful if only night symptoms are a problem for the patient. If  symptoms persist, surgery can be performed; options include simple nerve decompression (most cases), partial medial epicondylectomy and/or anterior transposition of  the nerve. Transposition is necessary in cases of  valgus deformity or if  the nerve is unstable after decompression.
Figure 38.35
Radiographs showing loose bodies in the elbow (arrow).
Figure 38.36
Loose bodies removed arthroscopically from the patient
in
Figure 38.35
.
Figure 38.37
Olecranon bursitis.
Figure 38.38
Large chronic olecranon bursa with dense calci
/f_i
c deposit.
(a)
Ulnar nerve
MCL
FCU muscle belly
Fibrous arch of FCU
(b)
Figure 38.39
(a)
Anatomy of the cubital tunnel site for ulnar nerve
compression, with
(b)
a view of arthroscopic ulnar nerve decompres
sion. FCU,
/f_l
exor carpi ulnaris; MCL, medial collateral ligament.
Summary box 38.10 Other common elbow problems /uni25CF /uni25CF /uni25CF
Figure 38.40
Intrinsic muscle wasting on the left due to ulnar neu
ropathy.
Loose bodies cause locking and can be removed
arthroscopically
If the ulnar nerve is compressed, weakness and wasting will
be seen in the hands
Simple decompression is usually successful
Ulnar nerve compression
Compression of the ulnar nerve most commonly occurs in the cubital tunnel (behind the medial epicondyle) within the arcade of Struthers. It may become compressed by the medial intermuscular septum as the nerve passes into the posterior compartment of  the distal humerus. Distally it may also become compressed as the nerve passes between the heads of the flexor carpi ulnaris ( Figure 38.39 ). History and examination Patients describe tingling/numbness in the little and ring fingers. A positive Tinel’s sign is usually present at the compres - sion site, with wasting and weakness of  the intrinsic muscles of  the hand ( Figure 38.40 ). Froment’s sign may be positive if there is weakness of  the adductor pollicis ( Figure 38.41 ). Nerve conduction studies have an unpredictable diagnostic value in the early stages. Radiographs may confirm medial osteophytes or loose bodies if  compression is secondary to arthritis. Jules Froment , 1878–1946, Professor of  Clinical Medicine, Lyons, France. Treatment Splints preventing elbow flexion at night may be useful if only night symptoms are a problem for the patient. If  symptoms persist, surgery can be performed; options include simple nerve decompression (most cases), partial medial epicondylectomy and/or anterior transposition of  the nerve. Transposition is necessary in cases of  valgus deformity or if  the nerve is unstable after decompression.
Figure 38.35
Radiographs showing loose bodies in the elbow (arrow).
Figure 38.36
Loose bodies removed arthroscopically from the patient
in
Figure 38.35
.
Figure 38.37
Olecranon bursitis.
Figure 38.38
Large chronic olecranon bursa with dense calci
/f_i
c deposit.
(a)
Ulnar nerve
MCL
FCU muscle belly
Fibrous arch of FCU
(b)
Figure 38.39
(a)
Anatomy of the cubital tunnel site for ulnar nerve
compression, with
(b)
a view of arthroscopic ulnar nerve decompres
sion. FCU,
/f_l
exor carpi ulnaris; MCL, medial collateral ligament.
Summary box 38.10 Other common elbow problems /uni25CF /uni25CF /uni25CF
Figure 38.40
Intrinsic muscle wasting on the left due to ulnar neu
ropathy.
Loose bodies cause locking and can be removed
arthroscopically
If the ulnar nerve is compressed, weakness and wasting will
be seen in the hands
Simple decompression is usually successful