3: Shoulder pathologies and upper limb nerve entrapment Flashcards
What are five common shoulder pathologies?
Instability
Cuff impingement
Cuff tear
Frozen shoulder
Arthritis
What shoulder pathology do patients tend to get in their 20-30s?
Instability
What shoulder pathology do patients tend to get in their 30-40s?
Impingement
What shoulder pathology do patients tend to get in their 60s onwards?
Arthritis
The shoulder joint is the most ___ joint in the body.
mobile
Is the shoulder joint stable?
In terms of bones, no
But muscles provide a lot of stability
Which four joints make up the shoulder girdle?
Sternoclavicular
Acromioclavicular
Scapulothoracic (not a real joint)
Glenohumeral
What is a static stabiliser of the shoulder found in the glenoid fossa?
Labrum
What are the four rotator cuff muscles?
What movements are they responsible for?
Supraspinatus - first 15 degrees of abduction
Infraspinatus - external rotation
Teres minor - adduction and internal rotation
Subscapularis - adduction and internal rotation
What are the four extrinsic muscles of the shoulder?
Deltoid
Trapezium
Pec major
Latissimus dorsi
What are the six movements performed at the shoulder?
Flexion / extension
Internal / external rotation
Abduction / adduction
What type of patient tends to get shoulder instability?
Teenagers - 30s
Sporty
What is the usual mechanism of shoulder instability?
Trauma causing subluxation / dislocation
(Anterior / posterior) dislocations are the most common.
Anterior
What are some unusual causes of posterior dislocation?
Seizures
Electrocution
What is a sign of dislocation on X-ray?
Increased space between humeral head and glenoid
What is a long-term consequence of shoulder instability?
Recurrent subluxations/dislocations
Shoulder instability can be caused by ligamentous laxity - in which diseases is this seen?
Ehlers-Danlos syndrome
Marfan’s syndrome
Which sign of shoulder instability may be seen on examination?
What is this caused by?
Sulcus sign
Inferior instability of shoulder joint
think posterior dislocation (not common)
How is an acute shoulder dislocation treated?
Analgesia
Oxygen
Sedation
REDUCTION BY MANIPULATION
What methods can be used to reduce a shoulder dislocation?
Kocher method
Hippocratic method
How is a shoulder dislocation treated post-reduction?
Sling
Analgesia
Movement - physiotherapy
What imaging is used to visualise shoulder dislocations?
X-rays (AP)
If a patient is having recurrent shoulder dislocation, what imaging method is used to investigate?
MRI
What is a Bankart lesion?
Why is MRI used to identify it?
Tear in labrum which shoulder can dislocate into repeatedly
Soft tissue lesion - labral tear
What is a Hill Sachs lesion?
Fracture in humeral head which may predispose to recurrent dislocation
All patients with shoulder instability receive ___.
physiotherapy
Is shoulder instability operated on?
No
The risk of recurrent shoulder dislocation (increases / decreases) with age.
decreases
How long should patients wait before they get back to contact sports following a shoulder dislocation?
6 months
Impingement syndrome pain originates from the ___ ___.
subacromial space
Impingement can be either ___ or ___.
intrinsic - problem with rotator cuff muscles themselves
extrinsic - pressure from elsewhere
What are some possible rotator cuff pathologies causing impingement syndrome?
Tendonitis (+/- calcinosis)
Bursitis
Cuff tear
Many cuff tears are ___.
asymptomatic
Inability to REACH/STRETCH to pick up things is a typical presentation of what?
Impingement syndrome
Polymyositis
Painful arc syndrome is a type of rotator cuff ___.
impingement
What test can be used to diagnose impingement?
Hawkins-Kennedy test
Painful arc on abduction
What is seen on X-ray of a patient with impingement syndrome?
Calcification of humeral head, subacromial space
What other scans can be used in patients with impingement?
Ultrasound
MRI
both show soft tissue swelling, fluid, muscle damage
How is impingement syndrome treated?
Rest
Analgesia
Physiotherapy
2x steroid injections in subacromial space
What is removed in decompression surgery for shoulder impingement?
Subacromial bursae
Bits of acromion
CA ligament
What is a major symptom following shoulder surgery for impingement?
Pain
Gray hair = ___ ___.
cuff tear
Who tends to get rotator cuff tears?
Older patients (50s-60s)
Most rotator cuff tears are (acute / chronic).
chronic
People with rotator cuff tears complain of ___ and ___.
weakness
pain
What may be seen on examination of someone with a rotator cuff tear?
Muscle wasting
Weakness (reduced passive movement, normal active movement)
What is reduced in the X-ray of someone with a rotator cuff tear?
Subacromial space
What bony landmark of the humerus is reduced in patients with rotator cuff tears?
Greater tuberosity
Apart from X-ray, what imaging can be used to view rotator cuff tears?
MRI
How are rotator cuff tears treated?
Rest
Analgesia
Sling
PHYSIOOOOO
surgery if required
Why are acute rotator cuff tears treated more urgently than chronic ones?
Shoulder function may be preserved with treatment
Is there any difference in outcome between keyhole and open shoulder surgery?
No
How long do people with rotator cuff injuries spend recovering compared to those with impingement?
Longer
What is the likelihood of a repaired rotator cuff muscle re-tearing?
30-40%
Who tends to get frozen shoulders?
Females aged 40-50
What conditions are associated with frozen shoulder?
Diabetes
Endocrine disease
Lipid disease
Dupuytren’s
What contracts and thickens in frozen shoulder?
Gleno-humeral ligament
reduces joint space, eventually causing synovitis
What is the natural progression of frozen shoulder?
Freezing (0-6 months, pain disrupting sleep and daily life)
Frozen (less pain, moreso stiffness)
Thawing (movement returns)
How long does frozen shoulder take to resolve?
3-4 years
What MUST be obtained before you can diagnose a patient with frozen shoulder?
Why?
X-ray
OA and locked posterior dislocation also limit external rotation
Apart from the generic rest, analgesia, physio treatment, what non-operative treatment is available for frozen shoulder?
Fluroscopic something
popping capsule with air
Frozen shoulder has a (sudden / gradual) onset.
sudden
The likely shoulder pathology in those over 60 is…
arthritis
What kinds of arthritis can affect the shoulder?
OA
RA
Post-traumatic arthritis
Glenohumeral joint arthritis sets in (acutely / chronically) and causes what kind of pain?
chronic
Pain at rest and at night
Arthritic GH joints will also be ___.
stiff
What are the four signs of GH joint OA on X-ray?
Loss of joint space
Osteophytes
Sclerosis
Subchondral cysts
How is GH joint RA treated?
Analgesia
Physiotherapy
Steroid injections
+/- DMARDS, Biologics
What is the operative route for treating GH joint arthritis?
Total shoulder replacement or arthroplasty e.g resurfacing, partial replacement
In which neuropathy is the
a) median nerve
b) ulnar nerve
compressed?
a) Carpal tunnel
b) Cubital tunnel
Carpal tunnel syndrome is more common in (men / women).
women
What are some conditions associated with carpal tunnel syndrome?
Pregnancy
Diabetes
Hypothyroidism
RA