arthritis

Rheumatoid arthritis

epidemiology

· commonly involves shoulder

· 2/3 of patients

· most commonly involves

· acromioclavicular jt

· subacromial bursa

· less commonly involves glenohumeral jt

pathology

Acromioclavicular joint

· erosive arthritis

· joint expands as more severely involved

· leads to

· AC jt capsular destruction and instability

· impingement

Subacromial bursa

· becomes inflamed and thickened

· leads to

· rupture of long head of biceps

· rupture of rotator cuff

· impingement

Glenohumeral joint

· develops marked soft tissue inflammation

· because of lax capsule and folds of synovium

· followed by severe cartilage and bone erosion

clinical

History

· shoulder pain and swelling with flares of RA

· gradually decreasing ROM

· difficulties with

· combing hair

· washing back

· features of

· rotator cuff tendinitis (pain with overhead activity)

· rotator cuff rupture (loss of abduction)

· biceps rupture (deformity in arm)

Examination

· deformity from

· muscle wasting

· medialisation of humerus secondary to bone loss

· tenderness and swelling

· anterolaterally or in axilla

· loss of ROM

· esp. external rotation

· pain on or loss of active abduction from rotator cuff disease

· can localise pain to AC, SC or GH with LA injection testing

radiology

Plain x-ray

· typical changes of rheumatoid arthritis

· features

· severe bony destruction of humeral head and glenoid with medialisation of humerus

· superior migration of humeral head from rotator cuff rupture

treatment

General

· medical treatment

· HCLA injections

Acromioclavicular joint

· excision of outer third of clavicle

Subacromial bursa

· anterior acromioplasty

· excision of inflamed bursa

Glenohumeral joint

· arthroscopic synovectomy

· for early disease with no bone loss

· arthroplasty

· procedure of choice

· arthrodesis

· may be indicated for severe bone loss

· problem is actual or potential involvement of other joints

· excision arthroplasty

· as salvage procedure

Osteoarthritis of glenohumeral joint

epidemiology

· usually age 50-60

aetiology

· most commonly due to

· avascular necrosis

· trauma

· long-standing cuff lesion (cuff arthropathy)

clinical

· global painful restriction of range of movement

radiology

· typical changes of osteoarthritis

· features

· tear-drop osteophytes on inferior humerus and glenoid

· proximal migration of humeral head and subacromial sclerosis with cuff arthropathy

treatment

Nonoperative

· analgesia

· NSAIDs

· physiotherapy

· ROM

· stengthening

Operative

· arthrodesis

· may be considered in young active patient

· arthroplasty

· procedure of choice in older patient

· better pain relief if glenoid replaced

Osteoarthritis of acromioclavicular joint

aetiology

· posttraumatic

· subluxation or dislocation

· intra-articular fracture of distal clavicle

· occupational

· overhead work

· primary

· in older patients

clinical

· pain on overhead activity

· pain localised to superior shoulder

· painful arc at terminal elevation

· features of impingement or rotator cuff tear

· relief of pain with LA injection

radiology

· narrowing of joint space

· osteophytes

treatment

Nonoperative

· HCLA injection

· physiotherapy

Operative

· excision of outer end of clavicle

· 1-1.5 cm