2.04 - Trauma and Orthopaedics - The Shoulder

Question 1

What is adhesive capsulitis?

Answer 1

A condition in which the glenohumeral joint capsule becomes contracted and adherent to the humeral head, causing shoulder pain and reduced range of movement in the shoulder.

Question 2

What is the pathophysiology of adhesive capsulitis?

Answer 2

Can be classified as primary or secondary:
- primary adhesive capsulitis: idiopathic
- secondary adhesive capsulitis: associated with rotator cuff tendinopathy, subacromial impingement syndrome, biceps tendonopathy, previous surgery or trauma, joint arthropathy

Adhesive capsulitis is often associated with inflammatory diseases and currently theory suggests it may have an autoimmune element.

Question 3

What are the three stages of adhesive capsulitis?

Answer 3

1. Initial painful stage
2. Freezing stage
3. Thawing stage

There is little evidence to support the segregation of these phases, and the pain is present throughout all stages.

Question 4

What are the clinical features of adhesive capsulitis?

Answer 4

• generalised deep and constant pain (disturbs sleep)
• joint stiffness
• reduction in function
• loss of arm swing
• atrophy of deltoid muscle
• generalised tenderness upon palpation
• limited range of movement, particularly affected external rotation and flexion of the shoulder

NB a full range of motion should prompt consideration of alternative differential diagnoses.

Question 5

What are the differentials for adhesive capsulitis?

Answer 5

• subacromial impingement syndrome (e.g. rotator cuff tendinopathy, subacromial bursitis)
• muscular tear (e.g. rotator cuff tear, long head of biceps tear)
• autoimmune disease (e.g. rheumatoid arthritis, polymyalgia rheumatica)

Question 6

What are the investigations for adhesive capsulitis?

Answer 6

Diagnosis usually made by clinical features alone.

Plain film radiographs are generally unremarkable, but can be used to exclude fracture or acromioclavicular pathology.

MRI can reveal thickening of glenohumeral joint capsule.

Question 7

What disease state is a particular risk factor for adhesive capsulitis?

Answer 7

Condition more common in diabetic patients, therefore anyone presenting with adhesive capsulitis without any risk factors or precipitating events, HbA1c and blood glucose measurements may be useful.

Question 8

What is the management of adhesive capsulitis?

Answer 8

It is a self-limiting condition where recovery occurs over a period of months to years. Initial patient management involves education and reassurance, and physiotherapy. Simple analgesia can be given to manage joint pain.

If symptoms fail to improve or continuously recur, glenohumeral joint corticosteroid injections can be considered.

Surgical intervention may be considered in extreme cases, including:
- joint manipulation under general anaesthetic (MUA)
- arthrogaphic distension
- surgical release of glenohumeral joint capsule

Question 9

What are the complications of adhesive capsulitis?

Answer 9

• small proportion of patients never regain full range of motion
• symptoms may persist
• symptoms may recur in contralateral shoulder

Question 10

What is tendinopathy?

Answer 10

A term used to encompass a variety of pathological changes that occur in tendons due to overuse, resulting in painful, swollen and structurally weaker tendons that are at risk of rupture.

Question 11

What are the risk factors for biceps tendinopathy?

Answer 11

• sports with repetitive flexion movements (e.g. tennis, cricket)
• older individuals (degenerative tendinopathy)

Question 12

What are the pathological changes that occur in tendinopathy?

Answer 12

Tendons become:
- disorganised
- hypervascular
- degenerative

Question 13

What are the clinical features of biceps tendinopathy?

Answer 13

• pain (worse when stressing the tendon)
• weakness
• stiffness
• tenderness over affected tendon
• disuse muscle atrophy

Question 14

Which special tests can be performed to assess for biceps tendinopathy?

Answer 14

• Speed test: patient stands with elbows extended and forearms supinated. They then flex their shoulders against the examiners resistance. Reproducible pain indicated proximal biceps tendinopathy.
• Yergason’s test: patient stands with elbows flexed to 90° and forearm pronated. They active supinate against the examiners resistance. Reproducible pain is indicates distal biceps tendinopathy.

Question 15

What are the main differentials to consider with suspected biceps tendinopathy?

Answer 15

• arthropathy
• radiculopathy
• osteoarthritis
• rotator cuff disease

Question 16

What are the investigations for biceps tendinopathy?

Answer 16

Often clinical diagnosis, with further investigations reserved for cases where there is diagnostic uncertainty.

Blood tests (FBC and CRP) and XRs can be taken as first line investigations, to exclude other differentials.

Specialit imaging is rarely warranted, but ultrasound and MRI can identify thickened tendons.

Question 17

What is the management of biceps tendinopathy?

Answer 17

Nearly all cases are treated conservatively, with the use of analgesia and ice therapy used as first line. Physiotherapy also plays an important role.

Ultrasound-guided steroid injections can be useful in cases unresponsive to initial conservative management.

Surgical interventions include arthroscopic tenodesis (tendon is severed and reattached) or tenotomy (division of the tendon).

Question 18

What is the prognosis of biceps tendinopathy?

Answer 18

Most cases recover well with no complications, though some may develop recurrent or chronic pain at the affected site.

Chronic cases are at an increased risk of having a biceps tendon rupture.

Question 19

Define:

a) complete biceps tendon rupture

b) partial biceps tendon rupture

Answer 19

a) complete rupture of biceps tendon

b) biceps tendon remains partially intact (tear)

Question 20

What is the typical MOI of biceps tendon ruptture?

Answer 20

Sudden forced extension of a flexed elbow.

Question 21

What are the clinical features of biceps tendon rupture?

Answer 21

• sudden onset pain
• sudden onset weakness
• marked swelling and bruising in ACF

Question 22

In biceps tendon rupture, why are all elbow movements apart from elbow flexion weakened?

Answer 22

Action of brachialis and supinator muscles allows for flexion at the elbow to remain.

Question 23

What are the investigations for suspected biceps tendon rupture?

Answer 23

Most cases can be diagnosed clinically, with confirmation via ultrasound imaging.

If ultrasound imaging is inconclusive, MRI may be suitable.

Question 24

Outline the management of biceps tendon rupture.

Answer 24

Conservative approaches include analgesia, physiotherapy and rest to allow muscle strength and function to restore.

For those who warrant surgical management, an anterior single-incision (in ACF) or dual incision technique (in ACF and posterolateral elbow) will be required. The operation involves forming a bone tunnel in the radius and re-inserting the ruptured tendon end.

Question 25

Why must surgical repair of biceps tendon rupture happen within the first few weeks of injury?

Answer 25

The tendon will retract and scar after a few weeks.

Question 26

What are the main complications of surgical fixation of biceps tendon rupture?

Answer 26

Injury to lateral antebrachial cutaneous nerve, posterior interosseous nerve, or radial nerve.

Question 27

Describe the classifications of rotator cuff tears:

a) acute

b) chronic

Answer 27

a) last <3/12

b) last >3/12

Can also be classified as partial thickness or full thickness tears.

Question 28

Give the rotator cuff muscles and their respective function.

Answer 28

• Supraspinatus: abduction
• Infraspinatus: external rotation
• Teres minor - external rotation
• Subscapularis - internal rotation

Question 29

What is the pathophysiology of rotator cuff tears?

Answer 29

Acute tears commonly occur within tendons with pre-existing degeneration following minimal force, or in younger individuals subjected to larger force.

Chronic tears occur in individuals with degenerative microtears to the tendon, most commonly from overuse and seen in greater incidence with increasing age.

Question 30

What are the risk factors for rotator cuff tears?

Answer 30

• age
• trauma
• overuse
• repetitive overhead shoulder motions (e.g. athletes, painter)
• obesity
• smoking
• diabetes mellitus

Question 31

What are the clinical features of a rotator cuff tear?

Answer 31

• pain over lateral aspect of the shoulder
• inability to abduct the arm above 90°
• tenderness over greater tuberosity
• supraspinatus / infraspinatus atrophy

Question 32

Give the special tests that can help assess for the presence of the specific rotator cuff tears:

a) supraspinatus

b) infraspinatus

c) teres minor

d) subscapularis

Answer 32

a) Jobe’s test (empty can test) - place shoulder in 90° abduction and 30° forward flexion and internally rotate fully, gently push down on the arm. A positive test is present if there is weakness on resistance.

b) Posterior cuff test - position arm at patient’s side, with elbow flexed to 90°; ask the patient to externally rotate their arm against resistance. A positive test is present if there is weakness on resistance.

c) Posterior cuff test - position arm at patient’s side, with elbow flexed to 90°; ask the patient to externally rotate their arm against resistance. A positive test is present if there is weakness on resistance.

d) Gerber’s lift-off test - internally rotate the arm so the dorsal surface of the hand rests on the lower back, then ask the patient to lift their hand away from the back against resistance. A positive test is present if there is weakness on resistance.

Question 33

What are the differential diagnoses for rotator cuff tear?

Answer 33

• shoulder fracture
• glenohumeral subluxation
• brachial plexus injury
• radiculopathy

Question 34

What are the investigations for suspected rotator cuff tear?

Answer 34

Arrange urgent plain-film radiograph to exclude a fracture.

Once fracture has been excluded, ultrasound and MRI can be used to further assess rotator cuff tear.

Question 35

Outline the criteria for and principles of conservative management of a rotator cuff tear.

Answer 35

Conservative management used in patients:
- not limited by pain or loss of function
- present within 2 weeks of injury

Conservative management includes analgesia and physiotherapy.

Question 36

Outline the criteria for and principles of surgical management of a rotator cuff tear.

Answer 36

Surgical management used in patients:
- presenting >2 weeks of injury
- remaining symptomatic after conservative management
- large tears

Repairs can be done arthroscopically or via open approach. Prognosis of surgical repair is very good, but worse outcomes in the elderly, those with massive tears, and current smokers.

Question 37

What is the main complication of rotator cuff tear?

Answer 37

Adhesive capsulitis, leading to stiffness of the glenohumeral joint.

Question 38

What is subacromial impingement syndrome (SAIS)?

Answer 38

The inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion within the shoulder.

Question 39

What runs within the subacromial space?

Answer 39

• rotator cuff tendons
• long head of biceps tendon
• caraco-acromial ligament

All surrounded by the subacromial bursa, helping to reduce friction between these structures.

Question 40

Give the intrinsic mechanisms of SAIS.

Answer 40

Involve pathologies of the rotator cuff tendons due to tension, including:

• muscular weakness (imbalances resulting in the humerus shifting proximally towards the body)
• overuse of the shoulder (repeitive microtrauma)
• degenerative tendinopathy (degenerative changes leading to tearing of rotator cuff)

Question 41

Give the extrinsic mechanisms of SAIS.

Answer 41

Involve pathologies of the rotator cuff tendons due to external compression, including:

• anatomical factors (anatomical variations in the shape and gradient of the acromion)
• scapular musculature (reduction in scapular muscular function results in reduction in size of subacromial space)

Question 42

What are the clinical features of SAIS?

Answer 42

• progressive pain in anterior superior shoulder
• exacerbated by abduction (painful arc)
• weakness and stiffness

Question 43

What are the special tests for SAIS?

Answer 43

• Neers impingement test: arm is placed by the patient’s side, fully internally rotated and passively flexed, and is positive if there is pain in the anterolateral aspect of the shoulder.
• Hawkins test: shoulder and elbows are flexed to 90°, with the examiner then stabilising the humerus and passively internally rotates the arm; the test is positive if pain is in the anterolateral aspect of the shoulder.

Question 44

What are the differential diagnoses for SAIS?

Answer 44

• muscular tear
• neurological pain
• adhesive capsulitis
• acromioclavicular arthritis

Question 45

What are the investigations for suspected SAIS?

Answer 45

Diagnosis usually clinical, confirmed via additional imaging.

MRI of the affected shoulder is the mainstay of imaging for SAIS.

Question 46

Outline the management of SAIS.

Answer 46

Conservative management includes analgesia (NSAIDs), physiotherapy, and corticosteroid injections in the subacromial space.

If SAIS persists >6/12 despite conservative management, surgical intervention is recommended:
- surgical repair of muscular tears
- surgical removal of subacromial bursa
- surgical removal of a section of teh acromion

Question 47

What are the complications of SAIS?

Answer 47

• rotator cuff degeneration
• adhesive capsulitis
• cuff tear arthropathy
• complex regional pain syndrome

If diagnosed and assessed early, SAIS resolves with conservative management in up to 90% of patients.

Question 48

How are clavicular fractures classified?

Answer 48

By the Allman classification system, determined by the anatomical location of the fracture along the clavicle:

Type 1 - fracture in middle third of clavicle (~75%)
Type 2 - fracture in lateral third of clavicle (~20%)
Type 3 - fracture in medical third of clavicle (~5%)

Question 49

What are the complications of Type 3 clavicular fracture.

Answer 49

Fracture of medial third of the clavicle, of which the mediastinum sits directly behind.

Therefore, associated with neurovascular compromise, pneumothorax, or haemothorax.

Question 50

What is the pathophysiology of clavicular fractures?

Answer 50

• direct trauma
• fall onto the shoulder

Question 51

How does the clavicle displace when fractures?

Answer 51

• medial fragment displaced superiorly, due to pull of SCM
• lateral fragment displaced inferiorly, due to weight of arm

Question 52

What are the clinical features of a clavicular fracture?

Answer 52

• acute localised severe pain
• worse on active movement of arm
• following trauma

Due to the subcutaneous location of clavicle, it is important to specifically look for open injuries or threatened skin (tenting, tethering, white, non-blanching).

Ensure to check the neurovascular status of the upper limb, given the risk of brachial plexus injury following clavicular fracture.

Question 53

What are the investigations for suspected clavicular fracture?

Answer 53

Plain film AP radiograph of the affected clavicle.

CT rarely indicated, but sometimes needed to assess medial clavicle injuries.

Question 54

How are clavicular fractures managed?

Answer 54

Most can be treated conservatively, with initial treatment with a sling. Early movement of the shoulder is recommended, to prevent the development of adhesive capsulitis. The sling is generally kept on until the patient regains pain-free movement of the shoulder.

Some clavicular fractures require surgical intervention, which include fixation with a pin or metal plate.

Question 55

Give the indications for surgical fixation of a clavicular fracture.

Answer 55

• complete displacement
• skin threatened (ie. tented)
• open fracture
• neurovascular compromise
• floating shoulder (clavicular fracture + ipsilateral glenoid neck fracture)

Question 56

What is the main complication of a humeral shaft fracture?

Answer 56

Radial nerve lesion, as it runs along the spiral groove of the humerus.

Question 57

What are the risk factors for humeral shaft fractures?

Answer 57

• osteoporosis
• increasing age
• previous fractures

Question 58

What are the clinical features of a humeral shaft fracture, including involvement of the radial nerve?

Answer 58

• pain
• deformity

If the radial nerve is compromised, there will be reduced sensation over the dorsal 1st webspace and weakness in wrist extension.

Question 59

What is the Holstein-Lewis fracture?

Answer 59

A fracture of the distal third of the humerus resulting in entrapment of the radial nerve.

This results in loss of sensation in the radial distribution and a wrist-drop deformity - urgent surgical management is indicated.

Question 60

What are the investigations for a humeral shaft fracture?

Answer 60

AP X-ray of humerus.

Question 61

What is the management of humeral shaft fractures?

Answer 61

Mainstay of management is realignment of the limb, followed by functional humeral brace.

Surgical fixation often includes open reduction and internal fixation (ORIF) with a plate. Intra-medullary nailing may be indicated in the presence of pathological fractures or severely osteoporotic bones.

Question 62

What are the complications of humeral shaft fractures?

Answer 62

Progonosis is generally good. Complications include:
- varus angulation
- radial nerve injury (most common in Hostein-Lewis #)

Question 63

Give the most common site of shoulder fracture.

Answer 63

Proximal humerus (~5% all fractures)

Question 64

What is the aetiology of a proximal humerus fracture?

Answer 64

Low-energy injuries occurring in elderly patients falling onto an outstretched hand from standing.

Less common in younger patients, but usually the result of a high-energy traumatic injury.

Question 65

What are the risk factors for a proximal humerus fracture?

Answer 65

• osteoporosis
• female sex
• early menopause
• prolonged steroid use
• recurrent falls
• frailty

Question 66

What are the clinical features of a proximal humerus fracture?

Answer 66

• pain in upper arm and shoulder
• restricted arm movement
• inability to abduct arm
• significant swelling and bruising

Important to check neurovascular status of arm.

Question 67

Which nerve is commonly injured in a proximal humerus fracture, and how does this clinically manifest?

Answer 67

Axillary nerve commonly injured, causing a loss of sensation in the lateral shoulder (“Regimental Bade Area”) and loss of power of the deltoid muscle.

Question 68

What investigations are indicated for a proximal humeral fracture?

Answer 68

• urgent bloods (incl. coagulation and Group & Save)
• plain film radiographs AP
• CT for preoperative planning

If pathological fracture suspected, serum calcium and myeloma screen indicated.

Question 69

How are proximal humerus fractures managed?

Answer 69

Fractures that are minimally displaced without neurovascular compromise are managed conservatively, targeted at early immobilisation (using polysling) followed by earrly mobilisation after 2/52.

Surgical management includes open reduction internal fixation (ORIF) or intermedullary nailing, and is indicated when the fracture is open, displaced or causes neurovascular compromise.

Question 70

What is the main complication of a proximal humerus fracture?

Answer 70

Damage to the circumflex arteries supplying the humeral head, causing avascular necrosis.

Question 71

What is the usual cause of scapular fractures?

Answer 71

Very rare and associated with high-energy trauma.

As a result, have an associated mortality rate of 5% due to concurrent severe injuries.

Question 72

What is the common mechanism of injury for an anterior shoulder dislocation?

Answer 72

FOOSH backwards or by forced abduction and external rotation of the shoulder.

Question 73

What are the clinical features of anterior shoulder dislocation?

Answer 73

• severe pain
• visibly deformed shoulder joint

OE shoulder will appear abducted and externally rotated.

Question 74

What is the common mechanism of injury for a posterior shoulder dislocation?

Answer 74

Internal rotation of the abducted arm (e.g. epileptic fit or electric shock).

Question 75

How are shoulder dislocations managed?

Answer 75

MUA and reduction.

Kocher’s method used to reduce elbow dislocation.

Question 76

What are the common complications of shoulder dislocation?

Answer 76

• rotator cuff tear
• nerve injury (axillary nerve)
• axillary artery injury
• fracture dislocation
• recurrent dislocations*

*ligaments, cartilage and muscles are damaged and become more lax, making repeat dislocation more likely.