Conditions & treatments covered

The surgical team is led by three highly experienced orthopaedic surgeons, specialising in arthroscopic (keyhole), reconstructive and joint replacement surgery. Whether the shoulder or elbow problem is the result of long term wear and tear, childhood conditions or sudden trauma from occupational or sporting injuries, the Shoulder & Elbow Unit is comprehensively resourced to provide fully informed diagnosis, treatment and rehabilitation. We work alongside a range of other Wellington Hospital specialist units including consultants, anaesthetists, radiologists and physiotherapists.

Rotor Cuff Tendons

Location

There are four flat tendons known as the rotator cuff tendons. Each connect to smaller muscles which pass around the shoulder to then fuse together to encircle the shoulder blade.

Symptoms

Most commonly, rotator cuff problems will cause aching in the top and front of the shoulder, or on the outer side of the upper arm (deltoid area). Pain may be worse if the arm is raised overhead and in severe cases where the rotator cuff is completely torn, the arm cannot be lifted in the forward or outward direction at all. If there is repetitive constriction of the rotator cuff tendon and their lubricating tissue (bursa) when the arm is raised forward, they can become inflamed and swollen. This is called "chronic impingement syndrome".

Diagnosis

Impingement may be caused by genetic problems or trauma. In some people, there is narrowed space between top of the humeral head and the roof of the shoulder blade (or a bone spur on its leading edge), which causes pinching of the rotator cuff tendon, which may break down near its attachment to the humerus and even tear away completely. Apart from impingement, injury in young, active patients may result from sporting activity such as repetitive throwing, overhead racquet sports or swimming, all of these can overstretch the rotator cuff, particularly if inadequate recovery time after exercise is allowed.

Treatment

Physical examination and review of personal medical history will help identify possible causes of rotator cuff problems, but diagnostic imaging is usually required to confirm the focus and extent of damage, for example, an x-ray may show an acromial spur on the shoulder blade causing nerve compression. If the rotator cuff tendons are shown to be injured, impingement tests may then confirm severity and an MRI scan would give a definitive diagnosis.

For minor impingement and tendon pain, rest, physiotherapy and applying ice to the painful area may help reduce inflammation. If imaging shows a bone spur this may be removed arthroscopically (keyhole surgery) along with any minor fraying of the biceps tendon, and scar tissue that may have formed as the tendon tries to repair itself naturally. In cases of complete detachment of the tendon off the bone, arthroscopic surgery may be necessary to stitch the rotator cuff tendon back in place. Recovery will then depend on the type of surgery necessary and the success of any rehabilitation programme.

 

 

Unstable Shoulders

Location

Instability in the shoulder is usually a result of trauma causing the ball joint at the front of the shoulder to partially or fully dislocate, which is then unable to function normally because of damage to the soft tissues around the joint.

Symptoms

Instability can range from a partial dislocation which recovers naturally to a full disclocation, which needs anaesthesia and traction to reduce pain and swelling. In younger patients, there is then a substantially higher chance of recurrent dislocations and joint damage, so early repair surgery is usually recommended for the under-30s.

Diagnosis

Following initial physical examination, x-ray and MRI will be recommended to confirm the extent of damage to the ligaments, capsule and tendons surrounding the shoulder joint.

Treatment

Surgery will aim to repair the damaged capsule and ligaments, usually arthroscopically into the shoulder joint to reattach the torn ligaments. Recovery can usually be achieved within 4-6 months.

Elbow Arthroscopy

Location

The anatomy of the elbow is rather crowded. The single upper and two lower bones of the arm articulate and lie close to the various nerves and blood vessels in the upper and lower arm. Repetitive stress, such as might be caused by weight-lifting and overhead sports, may lead to the formation of small fragments of cartilage or bone to loosen and move around in the elbow joint. Also stress or trauma may cause the formation of elbow joint spurs.

Diagnosis

Following initial physical examination and review of any personal history that may explain elbow pain, MRI scan will classify the location and extent of an elbow lesion. In adolescent males, osteochondritis dissecans is a common condition causing fragmentation and possible separation of a portion of the cartilage of the joint.

Symptoms

Invariably there is pain around the elbow joint that is aggravated by motion, or restricts normal motion, with possible 'clicking' of the joint and swelling. This depends upon whether the osteochondral fragment remains in situ, is displaced or is loose within the joint cavity. Once detached from the underlying bone, healing isn't possible and the loose cartilage may swell causing restriction of normal joint movement.

Treatment

Although difficult, arthroscopy within the elbow joint to identify and treat an injury or arthritic damage to bones or bone spurs, can be highly successful. The arthroscope (small 'telescope') is inserted into the elbow joint through several very small incisions. Any loose cartilage, bone spurs and other irregularities can be visualised and then removed using an arthroscopic burr. Full recovery may be expected within 3-6 weeks for loose body removal and 8-12 weeks for elbow spur removal.

Shoulder Joint Replacement

Location

The normal action of the upper arm bone (humerus) within the glenoid socket in the shoulder blade (scapula) may be lost or impaired, typically because of diminished cartilage joint space, the bone is flattened or irregular, or there are bone spurs, or bone and cartilage fragments are loose within the joint. In severe cases, for example degenerative joint disease (osteoarthritis), bone-on-bone erosion may result from loss of the shoulder joint's natural lining.

Symptoms

In cases of arthritis (which may also be rheumatoid or post-traumatic) patients will feel a deep ache within the shoulder joint that is aggravated by movement. Sometimes these symptoms may also indicate a combination of severe arthritis and a major non-reparable tear of the rotator cuff tendon, or avascular necrosis in which the head of the humerus bone dies due to lack of blood supply. Patients may also experience grinding, locking up and catching sensations in the joint with loss of motion or weakness in the shoulder. Left untreated, the essential stability and support of surrounding muscles and tendons may also deteriorate.

Diagnosis

In older patients, osteoarthritis may develop over time, possibly aggravated by an earlier shoulder injury. Initial physical examination and review of patient history should identify earlier trauma, particularly if the injury has healed imperfectly. Untreated tears in the rotator cuff may also lead to arthritic damage to bone and cartilage. Avascular necrosis may be diagnosed as a result of severe shoulder fracture, deep sea diving, sickle cell disease, heavy alcohol or steroid use.

Treatment

Shoulder joint replacement surgery may be necessary after non-surgical options such as physiotherapy and medication, are ruled out. Conventional total shoulder replacement will depend upon the condition of humeral bone and the rotator cuff tendons, to ensure sound fixing and retention of the new metal and plastic ball and stem that will be implanted and cemented in place. If the natural socket is still normal, the surgeon may only replace the ball.

In patients with a completely torn rotator cuff, cuff tear arthopathy or a failed previous shoulder replacement, a conventional shoulder replacement may still leave them in pain. In these cases, a reverse total shoulder replacement may be recommended. This reverses the positions of the ball and socket, attaching the ball to the shoulder bone and a plastic socket to the upper arm bone, allowing the deltoid muscle to lift the arm instead of the ineffective torn rotator cuff. Most patients should be able to start performing simple activities such as eating, dressing, bathing within 2 weeks of surgery and driving after a further 4 weeks.

Elbow Joint Replacement

Location

The natural hinging and rotation of the elbow joint is made possible by the muscles being able to move the three bones that meet at the elbow joint smoothly and without friction. The articular cartilage that provides this essential shock absorber and lubricant, once damaged, may lead to progressively painful joint damage. Elbow arthroplasty - joint replacement surgery - replaces the damaged surfaces with a metal and plastic joint.

Symptoms

The most common reason for elbow arthroplasty is arthritis, either through the wear-and-tear of aging (osteoarthritis) or systemic disease such as rheumatoid arthritis, which causes breakdown in the articular cartilage lining the joints. Elbow joint replacement may also be best following elbow fracture in an elderly patient as many will have weakened bones as a result of osteoporosis, making fracture repair and healing very difficult.

Diagnosis

Following an initial physical examination and review of personal medical history, diagnostic imaging using MRI scan, x-ray or CT scan will aim to confirm the cause of the deterioration in the elbow joint and best course of action. Once surgery has been scheduled, it may be advisable for a physical or occupational therapist to review the patient to establish a baseline of abilities, pain levels and current movement and strength of the elbow. This will help to plan rehabilitation following surgery.

Treatment

The most commonly fitted prosthetic elbow joint replaces the lower end of the humerus with a hinge joint. During surgery an incision is made in the back of the elbow joint to avoid most of the blood vessels and nerves that are on the inside of the elbow. The tendons, ligaments and ulnar nerve are then eased aside to expose the joint. The joint surfaces of the ulna and the radius are then removed, and the marrow space within the ulna hollowed out to receive the metal stem of the ulnar component. The surgeon then repeats the procedure on the humerus and the two bones then prepared for fixing in place of the prosthetic hinge, either with epoxy cement or a fine mesh which anchors bone regrowth.

Upper Limb Sports Injuries

Whether you enjoy sports as part of your life or you live for sport, the body's response to exercise, particularly sustained, high impact exercise, has the potential to harm as well as help your health and well-being. Indeed, many of the injuries described in this website may result from sporting activity.

Common conditions include injuries to tendons, nerves and bones in the upper limbs. For example, nerve disorders such as carpal tunnel syndrome, cumulative trauma disorders such as tendonitis, acute injuries such as fractures, dislocations and lacerations are frequently seen. The Shoulder & Elbow Unit is the focus for a wide range of expert, supportive and integrated specialist units with treatments to help ensure that your relationship with your chosen sports activity is as healthy and sustainable as possible.

The Shoulder & Elbow Unit provides a fast response to minimise damage from traumatic injury, or timely diagnosis and design of a personal rehabilitation programme to avoid future sports injuries and musculo-skeletal problems.

Clavicle (collarbone)

These fractures are extremely common, occuring in babies (often during birth), children and adolescents (as the clavicle is weaker until adulthood), and athletes (because of the risks of being hit or falling), or during many types of accidents and falls.

Symptoms

Shoulder pain, difficulty in moving the arm, swelling and bruising around the break. May result from impact directly to the clavicle or to the outside of the shoulder or even from falling on an outstretched hand. Clavicle fractures in babies may occur during manipulation of the shoulders in the birth canal.

Diagnosis

X-ray examination will show the fracture and physical examination will check whether the nerves and blood supply around the break are intact.

Treatment

Commonly, rest with a sling to brace the shoulder will allow the clavicle to repair itself, usually within 12 weeks. In cases of severe displacement or shortening of the bone, surgery may be required.

Shoulder girdle

This is formed by the shoulder blade (scapula), the acromion and the head of the upper arm (humerus). Scapular body and neck fractures are the most common injuries, but seldom require any specific treatment other than a simple arm sling unless there is severe misalignment of the bones. However, a fractured scapula may be associated with other trauma injuries in the lung and chest area. Fractures involving the cartilage surfaces of the shoulder joint (glenoid) may, however, require surgery when the shoulder joint becomes unstable or if the fragments are far out of alignment.

Upper arm and forearm

Fractures to the upper arm (humerus) and the forearm (ulna and radius) are common and if the break is without complications, such fractures do not need surgery but may heal better with physiotherapy to ensure a full return of normal limb mobility.

Symptoms

Pain, swelling, and stiffness in the limb, with loss of full mobility and instability.

Diagnosis

Fractures may occur following a fall onto an outstretched arm, most commonly in older people with bones weakened by osteoporosis, or often as a result of motor vehicle accidents. Diagnosis may included testing to check for sensory, vascular or motor function impairment, as well as x-ray or MRI scan.

Treatment

Forearm fractures can be classified as either proximal, middle or distal and can affect one or both forearm bones, and may involve disclocation or damage of the elbow joint. Treatment of fractures in children differs from adults as the forearm bones will continue to grow after healing of the fracture (which is termed 'greenstick' fracture in children).

In adults, displaced fractures will need surgery to fix the bones internally or use intramedullary nailing. In children, however, many both-bone fractures of the forearm can be treated without open surgery.