Amanda Bridges - Dislocated Shoulder, Shoulder and Elbow Anatomy

Superficial muscles of the pectoral region

1.pectoralis major (big one in the middle) 2.serratus anterior (underneath pectoralis major) 3.Deltoid (on the shoulder) arrows indicate cephalic vein running through deltopectoral groove

Shoulder joint - Bones

3 constituents : •Scapula, •Humerus, •Clavicle

Nerve supply & Brachial plexus

Axillary nerve Musculocutaneous nerve Radial nerve Ulnar nerve Median nerve Radius Ulna

Biconvolate and Hinge joint Movement

Biconvolate - extension and flexion slight rotation (knee) Hinge - only extension and flexion (elbow)

Anatomy of Elbow - Ligaments, Nerves and Blood supply

Ligaments: - Annular - Lateral: Radial collateral (radial and ulnar lateral collateral bundles) - Medial: Ulnar collateral (anterior and posterior bundle) Nerves: the median, musculocutaneous and radial nerves anteriorly, and the ulnar nerve posteriorly Blood supply: 1. brachial artery splitting to a. radial (2) b. ulnar (3) c. common interosseous (4) - gives rise to · anterior interosseous · posterior interosseous veins: - the cephalic vein (+cephalic vein of the forearm) is a superficial vein - basilic vein (+basilic vein of the forearm) - median cubital vein (with the basilic vein of the forearm turn to the basalic vein) - median antebrachial vein

Anatomy of Shoulder - Ligaments, Nerves and Blood supply

Ligaments: · anterior glenohumeral ligaments (superior/middle/inferior) - humerus to the glenoid fossa · coracoclavicular ligament (trapezoid/ conoid) - clavicle to the coracoid process of the scapula · coracohumeral ligament - base of the coracoid process to the greater tubercle of the humerus · acromioclavicular ligament - acromion and coracoid process of the scapula · transverse humeral ligament - holds the tendon of the long head of the biceps in the intertubercular groove o Between greater and lesser tubercle o Roof of bicipital groove Nerves: Shoulder nerves: axillary, suprascapular and lateral pectoral nerves (all from brachial plexus) Blood supply: · subclavian artery · become axillary artery - shoulder joint blood supply o anterior and posterior circumflex humeral arteries, which are both branches of the axillary artery o Branches of the suprascapular artery · become brachial artery veins: - Brachial vein (->) - Axillary vein (->) - Subclavian vein - Cephalic vein (to the subclavian)

What is an interscalene block and what/where does it block

Regional anesthetic that blocks sensations to shoulder & upper arm. Injected between anterior and middle scalene muscles, affects C5-C7, spread around superior & middle trunks of brachial plexus. Not done for shoulder reductions, high risk procedure for complications.

The commonest conditions - Rotator cuff disorders

Rotator cuff tendinopathy is the commonest cause of shoulder pain Similar picture - impingement from bursitis Often Hx of occupational or sport risk Pain on abduction with thumb down and worse with resistance 'painful arc of abduction' 70-120 degrees

Shoulder joint - Stability

•Highly mobile joint •Relatively unstable -Sacrifices stability for mobility •Glenoid fossa is deepened by the glenoid labrum -The labrum is a fibrocartilaginous ring attached around the rim of the glenoid •The joint capsule is strengthened by ligaments and the tendons of the rotator cuff muscles which fuse with the capsule

Shoulder movements - Summary

•Initiation of abduction: Supraspinatus (C4-C5) •Abduction to 90°: Deltoid (C5-C6) •Abduction beyond 90°: Trapezius (CNXI, C3-C4) •Adduction: Pectoralis minor(C8-T1)/major (C7-T1), latissimus dorsi (C6-C8), teres major (C5-C7) •Flexion: Pectoralis major (C7-T1), coracobrachialis (C6-C7), biceps brachii (C5-C6), anterior fibers of deltoid (C5-C6). •Extension: Latissimus dorsi (C6-C8), teres major (C5-C7), long head of triceps (C5-C6), posterior fibres of deltoid (C5-C6). •Medial (internal) rotation: Subscapularis (C5-C6), latissimus dorsi (C6-C8), teres major (C5-C7), pectoralis major (C7-T1), anterior fibres of deltoid (C5-C6). •Lateral (external) rotation: Infraspinatus (C5-C6) and teres minor (C4-C6), posterior fibres of deltoid (C5-C6) •Circumduction: Pectoralis major (C7-t1), subscapularis (C5-C6), coracobrachialis (C6-C7), biceps brachii (C5-C6), supraspinatus (C4-C5), deltoid (C5-C6), latissimus dorsi (C6-C8), teres major (C5-C7) and minor (C4-C6), infraspinatus (C5-C6), long head of triceps (C5-C6).

Radioulnar Motion

•Supinator, pronator teres with assistance from pronator quadratus distally •Biceps is also a supinator

Shoulder joint - Pathology

•Susceptible to anterior (most common), posterior and inferior dislocations •Axillary nerve at risk of damage (antero-inferior dislocation) •Also possible damage to labrum (Bankart lesion) or head of humerus (Hill-Sachs lesion) may be a factor contributing to recurrent anterior dislocations

Elbow joint - Soft tissue relations

•The elbow joint and the superior radioulnar joint are enclosed by a single fibrous capsule. The capsule is strengthened by ligaments at the sides but is relatively weak in front and behind. •A bursa also exists between the olecranon and the skin •Common site of inflammation (bursitis) Olecanon - the bony part that you fell in the posterior of the elbow (the proximal end of the ulna)

Thickenings of the deep fascia: anterior

1) bicipital aponeurosis (1 in the picture) 2) flexor retinaculum (3 in the picture) 3) palmar aponeurosis (not in the pictur in the middle of the palm)

Pain Management: Pharmacological Agents - Pyramid

1. Paracetamol 2. NSAIDs ± Paracetamol 3. Mild opiate ± NSAIDs 4. Strong Opiate Note: Co-analgesics are also used to treat pain

Pectoral region

1. Pectoralis Major Origin. middle ½ clavicle, sternum, rib 1-5 Insertion. lateral lip of bicipital groove of humerus Action. adduction, medial rotation of arm 2. Pectoralis Minor (pointed in the picture) O. rib 3-5 I. coracoid process of scapula A.draw the scapula down / lift up the ribs 3. Serratus Anterior O. half way of the anterior part of rib 1-8 I. medial border (anterior surface) of the scapula A. pull scapula to chest wall / lift up the ribs

Arterial supply - elbow and forearm

1. brachial artery split to - radial - ulnar 4. common interosseous - from ulnar artery, gives rise to •anterior interosseous •posterior interosseous

Deep muscles of the glenohumeral joint: the 'rotator cuff' muscles - other structures

1.subscapularis 2.tendon of biceps (long head) 3.tendon of supraspinatus 4.coracoacromial ligament 5.acromion 6.coracoid process

Elbow joint - Bones

3 articulations •Humeroradial •Humeroulnar •Proximal radioulnar Humeroulnar joint - hinge joint - flexion and extension Humeroulnar and radioulnar - permit rotation of the forearm (supination, pronation), whatever the angle of the humeroulnar joint

Deep muscles of the glenohumeral joint: the 'rotator cuff' muscles

A group of muscles and their tendons that act to stabilize the shoulder - pulls the head of the humerus into the glenoid fossa Supraspinatus: Medial 2/3 of supraspinatus fossa above scapular spine (origin) Greater tuberosity of humerus and capsule of shoulder joint (insertion) Infraspinatus: Infraspinous fossa of scapula (origin) Greater tuberosity of humerus and capsule of shoulder joint (insertion) Teres minor: Middle half of lateral scapular border (origin) Greater tuberosity of humerus and capsule of shoulder joint (insertion) Subscapularis: Subscapular fossa (origin) Lesser tuberosity of humerus and capsule of shoulder joint (insertion)

Gout treatment - Acute and Chronic

Acute gout treatment Aim for acute treatment: relieve pain and inflammation • NSAIDs: e.g. high dose of naproxen, diclofenac etc. • Colchicine: inhibits leukocyte micro-tubular formation and migration o Must be given early until good pain relief or G.I side effects (nausea, vomiting, diarrhoea, abdominal pain) o t1/2= 30hrs clearance reduced in renal impairment • Steroids may be useful • Do not initiate urate-lowering therapy such as allopurinol (xanthine oxidase inhibitor) or probenecid (uricosuric agent) acutely as they cause mobilization of uric acid stores as serum levels fall & will prolong acute attack o If already prescribe the treatment in continued Chronic gout treatment Aim: control symptoms and prevent renal damage. • Long-term hypouricaemic agents for those with recurrent attacks (>2/year) • Allopurinol o Competitively binds xanthine oxidase (enzyme that make uric acid) o Reduce dose in renal failure o Side effects: headaches, dyspepsia (indigestion), diarrhoea o Rarely fever, renal failure, toxic epidermal necrolysis, allopurinol hypersensitivity • Probenecid o Organic anion transporter (OAT) inhibitor: less uric acid re-absorbed

NSAIDs - Interactions

Affected drug Drug (causing effect) Effect Oral Anticoagulants NSAIDs Increased Risk of G.I bleed Anti-Hypertensives NSAIDs Increased Hypertensive effect (raise hypertension) Diuretics NSAIDs Reduce Diuretic effect (Na+/H2O retention) Lithium Most NSAIDs Increased Lithium levels Methotrexate NSAIDs Increased Methotrexate levels

NSAID Therapeutic Actions

Analgesic effects · Decrease production of prostaglandins that sensitize nociceptors to inflammatory mediators · Headache: reduction in vasodilatory prostaglandins in cerebral vasculature Anti-inflammatory effects · Reduce vasodilation · Indirectly reduce oedema due to decreased vasodilation Anti-pyretic effects · Inhibition of PG synthesis in the hypothalamus (heat-control center) Effects of NSAIDs in the Gut Prostaglandins · Stimulate mucus release · Inhibit gastric acid secretion · Stimulate bicarbonate release · Stimulate blood flow NSAIDs inhibit the protective actions of prostaglandins in the gut via COX-1 inhibition

Muscle compartments of the arm

Anterior (flexor) compartment: Musculocutaneous nerve.(C5-C7) -Biceps brachii -Brachialis -Coracobrachialis Posterior (extensor) compartment: Radial nerve (C5-T1), Axillary nerve (C5-C6) -Triceps brachii (long, lateral and medial head) -Anconeus

The axilla

Apex - also known as the axillary inlet, it is formed by lateral border of the first rib, superior border of scapula, and the posterior border of the clavicle. Lateral wall - formed by intertubercular groove of the humerus. Medial wall - consists of the serratus anterior and the thoracic wall (ribs and intercostal muscles). Anterior wall - contains the pectoralis major and the underlying pectoralis minor and the subclavius muscles. Posterior wall - formed by the subscapularis, teres major and latissimus dorsi. contents •axillary artery and vein •cords of brachial plexus • lymph nodes • fat

Causes of shoulder pain - origens from shoulder and elsewhere

Arising FROM the shoulder • Rotator cuff (tendinopathy, calcific tendonitis, impingement, subacromial bursitis, rotator cuff tears) • Glenohumeral joint (adhesive capsulitis - 'frozen shoulder' - or arthritis, traumatic dislocation) • Acromioclavicular joint • Infection (rare) Arising from elsewhere: • Referred pain (neck, myocardium, diaphragmatic) • Polymyalgia Rheumatica (older patients) • Malignancy (apical lung tumours, metastases) • If in the right shoulder gallstones

Shoulder Joint - Movements

As a ball and socket (golf ball and tee) synovial joint, there is a wide range of movement permitted: · Extension (upper limb backwards in sagittal plane) - posterior deltoid, latissimus dorsi and teres major. · Flexion (upper limb forwards in sagittal plane) - pectoralis major, anterior deltoid and coracobrachialis. Biceps brachii weakly assists in forward flexion. · Abduction (upper limb away from midline in coronal plane): o The first 0-15 degrees of abduction is produced by the supraspinatus. o The middle fibres of the deltoid are responsible for the next 15-90 degrees. o Past 90 degrees, the scapula needs to be rotated to achieve abduction - that is carried out by the trapezius and serratus anterior. · Adduction (upper limb towards midline in coronal plane) - pectoralis major, latissimus dorsi and teres major. · Internal rotation (rotation towards the midline, so that the thumb is pointing medially) - subscapularis, pectoralis major, latissimus dorsi, teres major and anterior deltoid. · External rotation (rotation away from the midline, so that the thumb is pointing laterally) - infraspinatus and teres minor.

Assessment of shoulder disorders

Assessment of shoulder disorders • Holistic approach • Assess the functional impact • Address occupational issues • Explore psychosocial issues • Ask about general health and co morbidity Assessment of shoulder disorders • History o Onset, recurrence and pain history o Relationship to movement o Nocturnal, or at rest? o Consider neck origin, nerve root pain, bone pain, malignancy and infection i.e. watch out for RED FLAGS (constitutional symptoms like fever, history of malignancy, severe continuous pain, new onset breathlessness etc) o What activities impaired? o Other joints? (arthritis) o Other shoulder? ('frozen shoulder', PMR, arthritis) o Sports? o Past similar history? o Medication tried and side effects • Clinical examination • Imaging (occasionally, and not 'blindly'!)

Anatomy of Elbow - Bones and Muscles

Bones: - Humerus - Radius - Ulna Muscles: Posterior Muscular Component: Radial nerve (C5-T1), Axillary nerve (C5-C6) - Elbow extensors: triceps, anconeus - Triceps: 3 heads o Long: from GH joint to elbow o Medial/Lateral: only cross elbow - Anconeus - Common extensor tendons o Extensor carpi radialis brevis o Extensor digitorum o Extensor digiti minimi o Extensor carpi ulnaris Anterior (flexor) compartment: Musculocutaneous nerve (C5-C7) - Biceps brachii - Brachialis - Coracobrachialis

Anatomy of Shoulder - Bones and Muscles

Bones: · Scapula - acromion, coracoid process, glenoid fossa · Humerus - head part of the shoulder joint · Clavicle Muscles: The rotator cuff muscles: stabilize the shoulder, hold the humerus in place. Do lateral rotation · Supraspinatus: (nerve: Suprascapular nerve) o Medial 2/3 of supraspinatus fossa above scapular spine (origin) o Greater tuberosity of humerus and capsule of shoulder joint (insertion) · Infraspinatus: (nerve: Suprascapular nerve) o Infraspinous fossa of scapula (origin) o Greater tuberosity of humerus and capsule of shoulder joint (insertion) · Teres minor: o Middle half of lateral scapular border (origin) o Greater tuberosity of humerus and capsule of shoulder joint (insertion) · Subscapularis: o Subscapular fossa (origin) o Lesser tuberosity of humerus and capsule of shoulder joint (insertion) Superficial muscles of the pectoral region o Pectoralis major (1) - adduction, medial rotation of arm o Pectoralis Minor - ribs to scapula - draw the scapula down / lift up the ribs o Serratus anterior (2) - pull scapula to chest wall / lift up the ribs o Deltoid (3) - Anterior, intermedius, and posterior- Flexion, abduction, and extension, respectively (nerve - Axillary) - Cephalic vein running through deltopectoral groove - Latissimus Dorsi- medial rotation, adduction, and extension - Trapezius- Flexion/abduction above 90 degrees - Teres major- medial rotation - Coracobrachialis- adducts the shoulder

Brachial plexus - Anatomical relations to the glenohumeral joint, the arm muscles and elbow joint. Which nerves could be injured in a glenohumeral dislocation

Brachial plexus (C5, C6, C7, C8,T1 - 5 roots) → 3 trunks → 6 divisions → 3 cords → 5 branches (musculocutaneous, median, ulnar, axillary and radial nerves) Brachial plexus is a somatic plexus formed by the anterior rami of C5-C8 and most of the anterior rami of T1 Originates in the neck, passes over the first rib, then goes underneath the clavicle and enters the axilla to the glenohumeral joint - roots, trunks, divisions - medial superior - cords - medial - terminal branches - inferior o Axillary nerve wrap around the head of the humerus The arm muscles: Median nerve and ulnar nerve - medial to biceps, anterior to brachialis Musculocutaneous nerve - pierce the coracobrachialis and pass between biceps and brachialis Anterior to Triceps brachii Elbow joint Terminal branches - ulnar and median pass medially, radial laterally Which nerves could be injured in a glenohumeral dislocation? - Axillary nerve most common - Musculocutaneous is the next most likely Every nerve can be affected (but unlikely) - Brachial plexus (axillary, musculocutaneous, radial, ulnar and median nerves)

Arachidonic Acid Pathway

Cell injury -> Ca in cytosol Ca in cytosol + Cytokines (cell signaling) -> conversion of Phospholipase A2 (one of the phospholipids in cell membrane) to Arachidonic acid Arachidonic Acid can be converted to Leukotrienes vis Lipoxygenase or Prostaglandins Via COX (Cyclooxygenase) Leukotrienes: · LTB4 -> attracts Neutrophils · Others -> Bronchoconstriction (asthma) and Arteriole dilation and an increase in venule permeability Prostaglandins: · PGE2 - Fever and Pain · Others - Arteriole dilation and an increase in venule permeability

Clavicle

Clavicula = "little key" convex shape the only long bone that lies horizontally Most clavicular fractures occur between the lateral 1/3 and medial 2/3

The cubital fossa - Content

Contents: brachial artery (devide to ulnar and radial) median nerve radial nerve (lateral, deep branch)

COX-1 Vs COX-2

Cyclooxygenase-1 (COX-1) · Constitutively expressed · Produces prostaglandins that mediate homeostatic functions · Plays an important role in: o Gastric mucosa o Kidney o Platelets o Vascular endothelium Cyclooxygenase-2 (COX-2) · Induced mainly in sites of inflammation by cytokines · Produces prostaglandins that mediate inflammation, pain, and fever (PGE2) · Therapeutic benefits of NSAIDs are attributed to COX-2 inhibition

A 38-year-old woman slips on icy sidewalk and falls, hitting the ground with her right elbow. She reports that she is experiencing sever pain in her upper limb. Examination reveals that she cannot extend her hand at the wrist. She has diminished sensation on the lateral portion of the dorsum of her hand. Which of the following is the most likely site of her fracture? A.Scaphoid B.Distal end of the radius C.Medial epicondyle of the humerus D.Midportion of the shaft of the humerus E.Surgical neck of the humerus

D ''Examination reveals that she cannot extend her hand at the wrist. She has diminished sensation on the lateral portion of the dorsum of her hand.''- the clinical findings indicate that the radial nerve has been injured. The radial nerve passes through the arm in close proximity to the midshaft of the humerus. The musculospiral groove of the humerus has the radial nerve and the deep brachial artery lying in it. Fracture of the midshaft of the humerus endangers the radial nerve. Choice A- Scaphoid Scaphoid is the most common fractured carpal bone. The injury typically occurs when the patient falls on the outstretched hand and force is transferred from the hand across the scaphoid to the radius. Nerve injuries do not typically accompany this fracture. Avascular nectosis of the proximal head of the scaphoid is a clinical concern with this type of fracture. Choice-B - Distal end of the radius •Fracture of the distal end of the radius is often called a Colles fracture. This fracture usually occurs by falling on the outstretched hand. Nerve injuries do not typically accompany this fracture, but if a nerve is injured, it is likely to be the median nerve. Choice-C - Medial epicondyle of the humerus •The nerve in close proximity to the medial epicondyle of the humerus is the ulnar nerve. •If the ulnar nerve is injured at this site, the patient would be able to extend at the wrist but would have weakness in flexing the wrist, and the hand would deviate radially upon flexion at the wrist. The patient would have normal sensation on the lateral portion of the dorsum of the hand but diminished sensation on the medial portion of the dorsal and palmar aspect of the hand. Choice-E - Surgical neck of the humerus •Fracture of the surgical neck of the humerus would endanger the axillary nerve, which lies against the surgical neck as it passes through the posterior wall of axilla. The axillary nerve innervates the deltoid muscle. Injury of this nerve would result in weakness in abduction at the sholder and a region of diminished sensation on the skin overlying the deltoid muscle.

Fracture shaft of humerus

Danger to the radial nerve

Selective NSAIDs (Coxibs)

Diagram: Phospholipids (Phospholipase A2) -> Arachidonic Acid è COX-1 inhibit From Platelets - Thromboxane -> Mediator of platelet aggregation è COX-2 inhibit From Vascular endothelium - Prostacyclin -> Inhibition of platelet aggregation E.g. celecoxib · Thought that specific targeting of COX-2 pathway would lead to anti-inflammatory effects only without GI side effects · But: o COX-2 also has a role in platelet function - inhibition of COX-2 leads to more frequent thromboembolic events (inhibit inhibition of platelet aggregation) o COX-2 inhibitors not recommended in patients at higher risk of cardiac events, if used only use short-term

Posterior Muscular Component

Elbow extensors: triceps, anconeus •Triceps: 3 heads -Long: from GH joint to elbow -Medial/Lateral: only cross elbow •Anconeus Common extensor tendons

Shoulder Dislocation

Epidemiology Anterior: Most common (90-96%) Posterior: Uncommon (4-10 %) (apilepsy than dislocation) Inferior (Luxatio Erecta) <1% (Essentially the arm is "locked" in abduction. Often there is an associated greater tuberosity fracture) Superior (extremely rare) Clinical Picture •Loss of the contour of the shoulder may appear as a step (sharp angle) •Anterior bulge of head of humerus may be visible or palpable •A gap can be palpated above the dislocated head of the humerus

Brachioradialis

Extension of the elbow

Shoulder Joint - Factors that contribute to mobility and Stability

Factors that contribute to mobility: · Type of joint - ball and socket joint. · Bony surfaces - shallow glenoid cavity and large humeral head - there is a 1:4 disproportion in surfaces. A commonly used analogy is the golf ball and tee. · Inherent laxity of the joint capsule. Factors that contribute to stability: · Rotator cuff muscles - surround the shoulder joint, attaching to the tuberosities of the humerus, whilst also fusing with the joint capsule. The resting tone of these muscles act to compress the humeral head into the glenoid cavity. · Glenoid labrum - a fibrocartilaginous ridge surrounding the glenoid cavity. It deepens the cavity and creates a seal with the head of humerus, reducing the risk of dislocation. · Ligaments - act to reinforce the joint capsule, and form the coraco-acromial arch. · Biceps tendon - it acts as a minor humeral head depressor, thereby contributing to stability.

Innervation of movement

Flexsion Biceps - Musculo-cutaneous nerve (C5/6) branches Brachioradialis - Radial nerve (C5/6) Extension Triceps - Radial nerve (C7) Radioulnar Motion Supinator - radial nerve Pronator teres - median nerve / Pronator quadratus median nerve - anterior interosseous branch

Rheumatoid arthritis - Treatment

Goals of treatment: • Alleviate pain • Control disease activity • Maintain function • Slow disease progression • Improve/ maintain quality of life Analgesia in Rheumatoid Arthritis Clime up the pyramid • Paracetamol • NSAIDs (including Coxibs) • Paracetamol/NSAID-opioid combinations o (Do not change natural history of disease, used for symptom control only) • Prescribe at lowest effective dose for the shortest time possible

Hill-Sachs and Bankart lesions

Hill-Sachs lesions are a posterolateral humeral head compression fracture, typically secondary to recurrent anterior shoulder dislocations, as the humeral head comes to rest against the anteroinferior part of the glenoid. It is often associated with a Bankart lesion of the glenoid. Bankart lesions injury of the anterior (inferior) glenoid labrum. represent a common complication of anterior shoulder dislocation. They are frequently seen in association with a Hill-Sachs lesion.

How could you test the actions of supraspinatus? Infraspinatus? (rotor cuff muscles)

How could you test the actions of supraspinatus? Infraspinatus? Supraspinatus initiates abduction of the arm. Weakness and/or pain in resisting abduction of 20o indicates problem with supraspinatus. Infraspinatus is the only efficient external rotator of the shoulder. Weakness and/or pain resisting external rotation indicates problem with infraspinatus.

Rotator cuff disorders - impingement

Impingement from bursitis o Most common o Recurrent episodes - 'catching', o Middle age + o Pathophysiology § Narrowing of sub-acromial space § Acromial morphology § Swollen bursa pressure the tendon § Swollen tendon Types of Impingement EXTERNAL (tendon on gr tuberosity, or acromion) § Primary (AC joint or Gt tuberosity abnormalities) § Secondary (Poor scapula stability, weakened rotator cuff, anterior instability) INTERNAL (inside the GH joint) § Overhead athlete - late cocking phase

Midazolan

Indication: - Intravenous - Indicated for promoting preoperative sedation, anxiolysis, anesthesia induction, or amnesia.12 - Intramuscular - Indicated for the treatment of status epilepticus in adults MOA - Benzodiazepines increase the activity of GABA, thereby producing a sedating effect, relaxing skeletal muscles, and inducing sleep, anesthesia, and amnesia. Side effect - Respiratory and cardiac depression, dependance may occure Signs of overdose include sedation, somnolence, confusion, impaired coordination, diminished reflexes, coma, and deleterious effects on vital signs. Serious cardiorespiratory adverse reactions have occurred, sometimes ending in death or permanent neurologic effects

Shoulder Joint - Ligaments, more detail

Ligaments - stabilize the bony structures. Glenohumeral ligaments (superior, middle and inferior) - the joint capsule is formed by this group of ligaments connecting the humerus to the glenoid fossa. They are the main source of stability for the shoulder, holding it in place and preventing it from dislocating anteriorly. They act to stabilise the anterior aspect of the joint. Coracohumeral ligament - attaches the base of the coracoid process to the greater tubercle of the humerus. It supports the superior part of the joint capsule. Transverse humeral ligament - spans the distance between the two tubercles of the humerus. It holds the tendon of the long head of the biceps in the intertubercular groove. Coraco-clavicular ligament - composed of the trapezoid and conoid ligaments and runs from the clavicle to the coracoid process of the scapula. They work alongside the acromioclavicular ligament to maintain the alignment of the clavicle in relation to the scapula. They have significant strength but large forces (e.g. after a high energy fall) can rupture these ligaments as part of an acromio-clavicular joint (ACJ) injury. In severe ACJ injury, the coraco-clavicular ligaments may require surgical repair. the acoracoacromial ligament - Running between the acromion and coracoid process of the scapula it forms the coraco-acromial arch. This structure overlies the shoulder joint, preventing superior displacement of the humeral head.

Inflammation - Mechanism, Signs

Mechanism: Brief Vasoconstriction - to prevent bleeding A. Vasodilation - to increase blood flow · Due to histamine, serotonin release from injured cells · Results in influx of white blood cells, oxygen, nutrients B. Increased vascular permeability - increased permeability for plasma proteins and leukocytes to leave the circulation and accumulate in the extravascular fluid (exudate) · Due to contraction of endothelial cells · Results in leakage of fluid and cells in injured tissue C. Hemoconcentration and stasis - loss of fluid leads to higher concentration of RBC D. Leukocyte Emigration - rolling on the endothelial cells by binding to proteins close to the site of the stimulus (know by chemotaxis), pass the epithelium (transmigration) to the connective tissue · Adhesion, Transmigration, Chemotaxis, Aggregation E. Pathogen Destruction - Phagocytosis - actin cytoskeleton rearrangement that leads to membrane remodeling that 'swallows' the microbe, later combine with lysosomes to brake down and kill the bacteria Cardinal Signs of Acute Inflammation: local · Redness · Swelling · Heat · Pain · loss of function the first 3 are caused by increased blood flow and edema. Leads to: · Fluid exudate · Cellular exudate Systemic : fever, chills, Myalgia (muscle pain), Malaise (feel general discomfort, uneasiness or pain), Sepsis (out of balance response to inflammation) Summary of key mediators Vasodilation · Histamine, serotonin Inflammatory cytokines - Leukocyte Adhesion · IL-1, TNF-a Chemoattractants (chemotaxis) · IL-8, Complement (C5a), prostaglandins, leukotrienes

NSAIDs used in clinical practice

Nonselective Ibuprofen • Naproxen • Diclofenac • Indomethacin • Ketorolac Selective COX-2 • Celecoxib • Etoricoxib

Classification of NSAIDs

Nonselective COX inhibitors - inhibit COX-1 and COX-2 - ibuprofen, naproxen Selective COX-2 inhibitors - inhibit only COX-2 - Celecoxib · COX-1 (constitutive) - establish the following: o GI cytoprotecting o Platelet aggregation o Renal electrolyte homeostasis o Renal blood flow maintenance · COX-2 (constitutive) o Renal electrolyte homeostasis o Renal blood flow maintenance · COX-2 (inducible) o Pain o Fever o Inflammation

Coracobrachialis

Origin •Coracoid process of scapula Insertion •Medial humerus Artery •Brachial artery Nerve •Musculocutaneous nerve (C5, C6, and C7) Actions •Adducts humerus , flexes the arm at glenohumeral joint

Triceps brachii

Origin •Long head: infraglenoid tubercle of scapula •Lateral head : above the radial sulcus •Medial head : below the radial sulcus Insertion •Olecranon process of ulna Artery : Deep brachial artery Nerve : Radial nerve (mainly) and Axillary nerve (supplies some branches to long head) Actions •Extends forearm, long head extends & adducts arm, extends shoulder Antagonist •Biceps brachii muscle

Biceps

Origin •Short head: coracoid process of the scapula. •Long head: supraglenoid tubercle Insertion •Radial tuberosity and bicipital aponeurosis into deep fascia on medial part of forearm Artery : Brachial artery Nerve : Musculocutaneous nerve (C5-C7) Actions •Flexes elbow •flexes and abducts shoulder •supinates radioulnar joint in the forearm

Brachialis

Origin •anterior surface of the humerus, particularly the distal half Insertion •coronoid process and the tuberosity of the ulna Artery •radial recurrent artery Nerve •musculocutaneous nerve (C5, C6) Actions •flexion at elbow joint

Osteoarthritis - General charectaristics and Treatment

Osteoarthritis • Age or injury-related cartilage damage • Leads to joint damage • Presents with pain and swelling • Cellular mechanisms of disease poorly understood Therapeutic goals are reduction of pain and symptom control Osteoarthritis - Treatment • Patient education • Physiotherapy, exercise, avoid weight gain + loose weight • Simple analgesia (paracetamol, NSAIDS) • Joint injection • Joint replacement • NB: Patients with OA are often elderly therefore need to be careful to avoid drug interactions

NSAIDs

Reduce pain, fever and inflammation They are main drugs used in: - Acute pain e.g. trauma, surgery, gout - Chronic pain e.g. associated with progressive or persistent disease (RA or OA) Other conditions: · other arthritic conditions (e.g. psoriatic arthritis) · headache and migraine · muscle, joint and back ach · menstrual pain · fever · toothache One third of all general practice consultations are for musculo-skeletal complaints These drugs are associated with side effects - GI side effects are estimated to cause 1200 deaths per year

Basic Structure of the Shoulder joint

Shoulder: articulation of the head of the humerus with the glenoid cavity (or fossa) of the scapula. - also known as the glenohumeral joint. The joint is covered with hyaline cartilage. head of the humerus is much larger than the glenoid fossa, giving the joint a wide range of movement at the cost of inherent instability. To reduce the disproportion in surfaces, the glenoid fossa is deepened by a fibrocartilage rim, called the glenoid labrum.

Examination of shoulder (clinical)

Summary of examination • Inspect (remember neck, deformity, muscle wasting, front and back) • Lymph nodes? (neck, axillae) • Palpate joints for swelling warmth and crepitus (AC, SC, GH) • Active movements • Passive movements • Resisted movements - provocation tests • Neck, axillae, neurological List for quick screening Examination • Inspect • Palpate joint lines (GH, AC, SC) • Slowly abduct shoulder and note when pain exists • Observe when pain starts and when finishes in the abduction arc • Ext. rotation à tests GH joint • Painful arc à implies rotator cuff problem • Empty can test or abduct with thumb to floor à subacromial impingement (also other special tests) • Trauma - severe pain à drop arm test • Remember neck, axillae, neuro, general physical and other joints as necessary.

Elbow joint - Ligaments

The articular capsule is thickented to form 3 ligaments Annular (A) •Lateral : (white in the picture) -Radial collateral (radial and ulnar lateral collateral bundles) •Medial : -Ulnar collateral (anterior and posterior bundle)

The Cubital fossa - Borders

The cubital fossa is triangular in shape, and thus has three borders: Lateral border - medial border of the brachioradialis muscle. Medial border - lateral border of the pronator teres muscle. Superior border - hypothetical line between the epicondyles of the humerus. The floor of the cubital fossa is formed proximally by the brachialis, and distally by the supinator muscle. The roof consists of skin and fascia, and is reinforced by the bicipital aponeurosis. Within the roof runs the median cubital vein, which can be accessed for venepuncture (tacking blood)

Deltoid

The deltoid originates in three distinct sets of fibers, often referred to as "heads": •The anterior or clavicular fibers arise from most of the anterior border and upper surface of the lateral third of the clavicle. -The anterior origin lies adjacent to the lateral fibers of the pectoralis major muscle as do the end tendons of both muscles. -These muscle fibers are separated by the deltopectoral groove •Lateral or acromial fibers arise from the superior surface of the acromion process of the scapula •Posterior or spinal fibers arise from the lower lip of the posterior border of the spine of the scapula •Aid with flexion, abduction and extension of the shoulder respectively

Shoulder joint - Joint Capsule and Bursae

The joint capsule is a fibrous sheath which encloses the structures of the joint. It extends from the anatomical neck of the humerus to the border or 'rim' of the glenoid fossa. The joint capsule is lax, permitting greater mobility (particularly abduction). The synovial membrane lines the inner surface of the joint capsule, and produces synovial fluid to reduce friction between the articular surfaces. To reduce friction in the shoulder joint, several synovial bursae are present. A bursa is a synovial fluid filled sac, which acts as a cushion between tendons and other joint structures. The bursae that are important clinically are: Subacromial - located deep to the deltoid and acromion, and superficial to the supraspinatus tendon and joint capsule. The subacromial bursa reduces friction beneath the deltoid, promoting free motion of the rotator cuff tendons. Subacromial bursitis (i.e. inflammation of the bursa) can be a cause of shoulder pain. Subscapular - located between the subscapularis tendon and the scapula. It reduces wear and tear on the tendon during movement at the shoulder joint.

Elbow Joint - Ligaments

The joint capsule of the elbow is strengthened by ligaments medially and laterally. The radial collateral ligament is found on the lateral side of the joint, extending from the lateral epicondyle, and blending with the annular ligament of the radius (a ligament from the proximal radioulnar joint). The ulnar collateral ligament originates from the medial epicondyle and attaches to the coronoid process and olecranon of the ulna. Annular ligament - hold the Proximal radioulnar joint

Elbow Joint - Brusaes

There are many bursae in the elbow, but only a few have clinical importance: · Intratendinous - located within the tendon of the triceps brachii. · Subtendinous - between the olecranon and the tendon of the triceps brachii, reducing friction between the two structures during extension and flexion of the arm. · Subcutaneous (olecranon) bursa - between the olecranon and the overlying connective tissue (implicated in olecranon bursitis).

Gout

Uric acid synthesis: Hypoxanthine + Guanine with Xanthine Oxidase -> Xanthine with Xanthine Oxidase -> Uric acid • Gout is characterized by hyperuricemia and deposition of urate crystals in tissues/joints • Due to imbalance between production and elimination of uric acid • Urate crystals in the joint trigger an acute inflammatory response • Hyperuricaemia associated with obesity, diabetes, hypertension, coronary artery disease, renal insufficiency, and increased triglycerides

Brachial plexus

a network (plexus) of nerves (formed by the anterior rami of the lower four cervical nerves and first thoracic nerve (C5, C6, C7, C8, and T1) Remember 5:3:6:3:5 for understanding brachial plexus. 5 Roots: 3 Trunks: 6 Divisions: 3 Cords: 5 Branches

Scapula

acromion coracoid process glenoid fossa supraglenoid tubercle infraglenoid tubercle scapular notch

Shoulder joint - Ligaments names

anterior glenohumeral ligaments (superior/middle/inferior) coracoclavicular ligament (trapezoid (closer to joint) / conoid) coracohumeral ligament acromioclavicular ligament transverse humeral ligament -Between greater and lesser tubercle -Roof of bicipital groove

Arterial supply - axilla and arm

aortic arch [brachiocephalic trunk (R)] subclavian artery axillary artery brachial artery Axillary Artery and Vein -> Brachial Artery and Vein

Elbow Joint - Basic structure

articulations: · Humeroulnar - Trochlear notch of the ulna and the trochlea of the humerus · Humeroradial - Head of the radius and the capitulum of the humerus · Proximal radioulnar joint: pivot joint, located near the elbow and is an articulation between the head of the radius, and the radial notch of the ulna. responsible for pronation and supination of the forearm. (most researchers don't consider it as part of the elbow) same articular capsule as the elbow joint. o One of two articulations between the radius and the ulna in the forearm: near the elbow (Proximal radioulnar joint) or near the wrist (Distal radioulnar joint) o held in place by the annular radial ligament, which forms a 'collar' around the joint. o Pronation (palm up): Produced by the pronator quadratus and pronator teres. o Supination (palm down): Produced by the supinator and biceps brachii. - Movement is made by the Proximal and distal radioulnar joint Humeroulnar joint - hinge joint - flexion and extension Humeroulnar and radioulnar - permit rotation of the forearm (supination, pronation), whatever the angle of the humeroulnar joint

Sternoclavicular joint

clavicular and sternom Permits anterior, posterior, and vertical movement of clavicle, limited rotation. Which is more dangerous, anterior or posterior dislocation of the sc joint and why? the posteriorly displaced clavicle can cause damage to vital vascular and respiratory structures such as the aortic arch, the carotid and subclavian arteries, and the trachea.

Thickenings of the deep fascia: posterior

extensor retinaculum (the posterior of flexor retinaculum)

2 shoulder joint

glenohumeral joint and acromioclavicular joint (in the picture)

Coracobrachialis (just to differentiat between it and Brachioradialis)

part of anterior compatrment of the elbow

Sublocation

partial dislocation

Arterial supply - wrist and hand

superficial and deep palmar arches give rise to digital branches if need to damage ulnar or redial artery ulnar is more important (supply more blood) will keep it if we need to chose Allans test - detects abnormal circulation The patient is asked to clench both fists tightly for 1 minute at the same time. Pressure is applied over both radial arteries simultaneously so as to occlude them. The patient then opens the fingers of both hands rapidly, and the examiner compares the colour of both. The initial pallor should be replaced quickly by rubor. The test may be repeated, this time occluding the ulnar arteries.

Elbow - Veins

the cephalic vein (+cephalic vein of the forearm) is a superficial vein basilic vein (+basilic vein of the forearm) median cubital vein (with the basilic vein of the forearm turn to the basalic vein) median antebrachial vein Median cubital vein often used to obtain blood sample Separated by the cubital fossa contents by the bicipital aponeurosis

Superficial back muscles

trapezius latissimus dorsi •Levator Scapulae: 1st-4th cervical vertebrae (elevates the scapula and rotates its inferior angle medially) •Rhomboids: 2nd-5th thoracic vertebrae (elevate the medial border of the scapula medially and upward, hold the scapula (and thus the upper limb) onto the ribcage)

Examination of Impingement

§ Loss of normal movement pattern § Painful arc (abduction usually from 90 degrees) § Resisted abduction (Jobe's test, with hand rotated internally and flexed 90 degrees cannot push down on examiner hand - supraspinatus pathology) § Impingement • Empty can test (Jobe's test - resistance to abduction in full pronation will induce symptoms) • End range forward flexion (full ampty test can - Neer test - arm by side pronate and then forward flex) • Flexion then Internal rotation (Hawkins) - hand in r shape if internal rotation painfull - positive

Rotator cuff disorders - Tendinopathy

§ Rotator cuff tear (i.e. a partial or complete tear of one of the muscles of the rotator cuff) may happen with trauma in the young, without trauma or without pain in the elderly, more sudden onset § A partial tear may give a similar picture to rotator cuff tendinopathy § Complete tear -> 'drop arm test' § MRI studies on asymptomatic patients show tears often § People can function with torn cuff muscles (i.e. surgery not always necessary) § Remember not to blame the tear just because it was seen on the MRI of a person with shoulder pain

Elbow Joint - Neurovasculature

· The arterial supply to the elbow joint is from the cubital anastomosis, which includes recurrent and collateral branches from the brachial and deep brachial arteries. · Its nerve supply is provided by the median, musculocutaneous and radial nerves anteriorly, and the ulnar nerve posteriorly

Shoulder Joint - Neurovasculature

· The shoulder joint is supplied by the anterior and posterior circumflex humeral arteries, which are both branches of the axillary artery. Branches of the suprascapular artery, a branch of the thyrocervical trunk, also contribute. · Innervation is provided by the axillary, suprascapular and lateral pectoral nerves.

Paracetamol

• Also known as Acetaminophen • First-line analgesic • Fewer side-effects than NSAIDs • Anti-pyretic with weak anti-inflammatory properties • No effects on platelet function • Primary mode of action is by COX inhibition • Selective but weak COX-2 inhibitor (Not COX-1) • Inhibits isoform COX-3 o Splice variant of COX-1? o Present in CNS • Part of its analgesic effect: activation of the descending serotonergic pain-inhibiting pathways

Shoulder Functional Anatomy (little bit)

• Ball & socket joint with most movement of any joint. • Static constraints (labrum &ligaments) • Dynamic constraints (rotator cuff muscles) • Scapulohumeral rhythm o integrated movement of § Glenohumeral joint § "Scapulothoracic surfaces" § Acromioclavicular joint § Sternoclavicular joint Bones • Key bony landmarks o Manubrium o Clavicle o Coracoid process o Acromion process o Glenoid fossa o Lateral border o Inferior angle o Medial border o Superior angle o Spine of the scapula Bursas: Subacromial bursa, subcoracoid bursa and subscapular bursa Rotator cuff - Supraspinatus, infraspinatus, subscapularis and teres minor Shoulder Girdle Muscles • 5 muscles primarily involved in shoulder girdle movements (scapula total movements) o Trapezius - upper, middle, lower o Rhomboid - deep o Levator scapulae o Serratus anterior o Pectoralis minor - deep

Shoulder disorders - Characteristics

• Cause pain • Limit ability to carry out routine activities • Disrupt sleep • Up to 25% in the general population • 3rd commonest musculoskeletal complaint to GPs (after back and neck pain) • Most cases recover within 3 months • But they may recur or become chronic • Often mixed cause (GH, plus AC joint, tendons etc) • Differentiating accurately not that useful in primary care • Important to exclude serious conditions (e.g. infection or malignancy - which are rare!) • Take a practical approach to management • Know when to refer to physiotherapy, when to offer injection, when to refer to rheumatology or orthopaedics

Shoulder disorders - Risk factors

• Incidence and functional impact increase with age • Lifting heavy loads • Repetitive movements • Awkward working positions • 'Frozen shoulder' is associated with diabetes, immobility (post stroke, post op, post MI) • Psychosocial factors influence disability, recovery, return to work etc.

Rheumatoid arthritis

• Progressive systemic inflammatory disease • Symmetric synovitis • Joint erosions • Multi-system extra-articular manifestations • Main symptoms are: pain, swelling, stiffness • 1% of adult population, most common polyarthropathy in UK • 40% stop working within 5 years of diagnosis

NSAIDs - Toxicities

• Significant GI disturbance: (consider the use of misoprostol) • Bronchospasm → in 'aspirin-sensitive' asthmatics • Allergy: common, possible cross-hypersensitivity with aspirin • Risk of renal damage, especially in patients with preexisting renal disease (via ↓ formation of PGE2 and PGI2, which normally maintain GFR and RBF).

Deep muscles of the glenohumeral joint: the 'rotator cuff' muscles - Role

• converge on to the head of the humerus • fuse with the capsule of the glenohumeral joint • acting together stabilise the glenohumeral joint • individually: •elevate (supraspinatus) •medially rotate (subscapularis) •laterally rotate (infraspinatus + teres minor)

Axillary Nerve Injury

•Also called circumflex nerve •It is a branch from posterior cord of Brachial plexus •It hooks close round neck of humerus from posterior to anterior •It pierces the deep surface of deltoid and supply it and the part of skin over it

Cross section of the arm

•Anterior / Posterior or Flexor / Extensor compartments that can be further divided into four compartments (see above)

Winged scapula

•Damage of the long thoracic nerve (serratus anterior muscle) - most common •Causes medial winging •Secondary to serratus anterior palsy, a winged scapula is also caused by trapezius and rhomboid palsy involving the accessory nerve and the dorsal scapular nerve, respectively •Rare •Lateral winging

Medial and lateral epicondyle

•Flexor - extensor tendon attachment points •Clinical correlations? muscle and ligament attachment The medial epicondyle (in the picture) of the humerus is an epicondyle of the humerus bone of the upper arm in humans. It is larger and more prominent than the lateral epicondyle and is directed slightly more posteriorly in the anatomical position. The medial epicondyle gives attachment to the ulnar collateral ligament of elbow joint, to the pronator teres, and to a common tendon of origin (the common flexor tendon) of some of the flexor muscles of the forearm: the flexor carpi radialis, the flexor carpi ulnaris, the flexor digitorum superficialis, and the palmaris longus. The medial epicondyle is located on the distal end of the humerus. The lateral epicondyle of the humerus is a large, tuberculated eminence, curved a little forward, and giving attachment to the radial collateral ligament of the elbow joint, and to a tendon common to the origin of the supinator and some of the extensor muscles. Specifically, these extensor muscles include the anconeus muscle, the supinator, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris.

Ulnar and radial nerve

•The ulnar nerve runs in a groove on the posterior aspect of the medial epicondyle (cubital tunnel). •The radial nerve emerges into the cubital fossa between the brachialis and the brachioradialis muscle.

Glenohumeral ligaments (GHL)

•Three ligaments on the anterior side of the glenohumeral joint •Reinforcing the anterior glenohumeral joint capsule, the superior, middle, and inferior glenohumeral ligaments play different roles in the stability of the head of the humerus depending on arm position and degree of rotation

Rotator cuff injuries

•Trauma may tear or rupture one or more of the tendons of the muscles forming the rotator cuff. •Acute tears may occur when the arm is violently pushed into abduction. •Rotator cuff tears also follow dislocation of the shoulder. •The supraspinatus tendon is the most commonly torn part of the rotator cuff, likely because it is relatively avascular.

Shoulder joint - Blood Supply

•anterior and posterior circumflex humeral arteries •Note the important anastomosis round the scapula that connects the proximal part of the subclavian to the distal part of the axillary artery. •This ensures blood supply to the upper limb is uninterrupted whatever the position of the limb and also protects the blood supply against vascular lesions of the axillary artery.

Humerus

•head, anatomical neck (right after the joint end) and surgical neck •greater and lesser tubercle/ tuberosity •superior, middle and inferior facets of the greater tubercle •intertubercular sulcus (bicipital groove) •spiral groove •deltoid tuberosity