4- shoulder pathologies & compressive neuropathies & elbow Flashcards
what are the 4 common shoulder pathologies?
- instability
- cuff disease (impingement & cuff tears)
- frozen shoulder
- arthritis
what ages are typical for which shoulder problem?
20s-30s = instability problem
30s-40s = impingement
40s-50s = frozen shoulder
50s-60s = cuff tear
over 60 = arthritis
*grey hair cuff tear
what movements do the rotator cuffs cause?
- supraspinatus = initiate abduction
- infraspinatus & teres minor = external rotation
- subscapularis = internal rotation
*often they initiate movement but other muscles help the movement
what is typical presentation of instability?
- younger sporty people
- mostly anterior dislocation in contact sport
- can be posterior dislocation (5%) sometimes caused by epileptic fits or electrocution due to muscle spasm
- mostly traumatic
on examination = lose roundness of shoulder, tenderness, muscle spasm
what is management of instability shoulder injury?
anterior dislocation = in normal sling
posterior dislocation = different brace with external rotation position
- also have physio for rotator cuff & scapula strengthening, always try move early with shoulder injuries
- can do surgery too
what investigations done for instability shoulder injuries?
- x-ray = 1st line
- and MRI angiogram to look for capsule fluid leaks etc
*remember there’s more associated injuries to look out for like rotator cuff injury, humerus fracture etc
what is impingement syndrome?
- big like bucket disease that loads of things can be in
= when people have pain originating in subacromial space
- can be intrinsic (tendon or cuff problems) or extrinsic (acromion, coracoacromial ligament, osteophyte)
what is typical presentation of impingement? (type of cuff disease)
= classically pain right over end of shoulder at arm
- painful arc, painful picking up something far away, neck pain & vague pins & needles
what are different causes of impingement syndrome more typical for what age? i.e. 30s more likely X causing impingement
30s = tendonitis or bursitis
30-40s = calcific tendons
40-50s = tendinosis or partial tears
50-60s = cuff tears
70s = cuff arthropathy
what are investigations for impingement?
x-ray for calcification around head
- can then progress to MRI or ultrasound
what is treatment of impingement?
- mainly rest & activity modification,
- pain relief like NSAIDs
- physio
- couple steroid injections
- keyhole operation last resort - less done now, painful rehab & lots of physio
what is typical presentation cuff tear?
“grey hair cuff tear” = 50-60s
- weakness & pain (sometimes other muscles compensate if tear which means won’t present until later)
*weakness important syndrome - test with rotator cuff resistance clin skills
what is investigations done for cuff tear?
x-ray = see migrating head
- ultrasound if good movement, MRI if not good movement
what is treatment for cuff tear?
rest, analgesia, sling
chronic = physio & steroid injection
acute = urgent investigation, early physio and if doesn’t settle then early intervention with surgery (good, long ish recovery but good)
what is typical presentation of frozen shoulder?
- severe pain coming in short period of time, can’t move or lie on shoulder. feels like gripping pain deep inside. pain at night & rest
- lost more than 50% of external rotation
- stiffness
- more in females 40-50s
- associated with diseases such as dupuytren’s
what is frozen shoulder?
= also called adhesive capsulitis. contracture & thickening of coracohumeral ligament (external rotation main issue)
= tightening & decreases joint volume. it’s basically the ligament in capsule getting thicker & firmer & less elastic = bad movement
what are the phases of frozen shoulder?
basically frozen shoulder comes on and lasts for like 3-4 years, easy to think of in 3 phases
- freezing = very very sore, reduced movement
- frozen = acute pain settles, very stiff & barely movement
- thawing = pain reduces and more movement comes back
what is the treatment of frozen shoulder?
- gentle movements
- analgesia
- physio
- steroid injections
- fluoroscopic distension →air or saline forcefully pumped in to expand joint until pops, not painful for patient but they can feel something changes. helps movement
what are the only 3 differential diagnosis if lack of passive external rotation?
- locked posterior dislocation
- severe glenohumeral arthritis
- frozen shoulder
→these all seen on plain x-ray so xray important
what is presentation of glenohumeral osteoarthritis?
- over 60s
- uncommon location
- gradual location
- intermittent exacerbations
- pain at rest & night
- stiffness
- functional difficulties
can see radiographic features of arthritis = joint space narrowing, subchondral sclerosis, subchondral cysts, osteophyte formation
what is risk factors of carpal tunnel syndrome?
- female, often pregnancy or hormonal fluctuations
- hypothyroidism
- obesity
- diabetes
- rheumatoid arthritis
what is common presentation of carpal tunnel syndrome?
- under 30
- pins & needles
- pain (very varied)
- clumsiness
- early morning awake = shake & relieves
- driving, reading & phone use pain
- thenar atrophy, altered sensation, weakness APB
what is cause of carpal tunnel syndrome?
→due to relative reduction of blood supply (intrinsic or extrinsic) causing compression of tunnel, the nerve easily squished (9 tendons & median nerve)
median nerve muscles = LOAF (lumbricals, opponens, abductor pollicis brevis, flexor pollicis brevis)
what are tests for carpal tunnel syndrome?
test abductor pollicis brevis best by thumb up to sky against resistance
= durkins test (compression), tinels test )tapping), phalens (flex wrist for long time and they’ll feel tingling)
