Clinical Anatomy: Shoulder and Arm

Question 1

Where are clavicle fractures most common? What are potential complications?

Answer 1

Middle 3rd. Distal end displaces inferiorly and anteriorly if not immobilized results in bump deformities.

Question 2

How are clavicle fractures treated?

Answer 2

Immobilized with a figure 8 splint or sling.

Since it cannot be cast the healing period is painful and so regular medication is needed for sleeping.

Question 3

When is orthopaedic surgery indicated with clavicle fractures?

Answer 3

When it is near the AC joint (distal part)

Question 4

Where are dislocations more common?

Answer 4

Hand

Elbow

Shoulder

Question 5

How is a dislocated finger fixed?

Answer 5

Usually it can be stretched out then placed back into the socket

Question 6

How are ligaments often damaged?

Answer 6

When a ligament is repeatedly stretched or stretched beyond its yield point the ligament becomes lax and non-functioning.

Joint lacks support and is prone to recurring injury.

Question 7

How can a lax ligament be fixed?

Answer 7

No exercises can shorten a lax ligament (requires surgery) But stronger muscles can support the joint.

Taping provides a good short-term solution.

Question 8

How is a shoulder dislocation treated?

Answer 8

By careful closed reduction. (pain goes away immediately)

Muscles in the area are then strengthened and taping is used for a while.

Sometimes surgery needs to be done due to ligament laxity which needs to be tightened.

Question 9

When do shoulder labrum tears typically happen?

Answer 9

During dislocations or injuries to the glenoid rim.

Question 10

What causes damage to tissue rim of glenoid?

Answer 10

Falling on outstretched arm

Direct blow to the shoulder

Sudden pull such as when trying to lift a heavy object

Violent overhand reach such as when trying to stop a fall or slide

Question 11

What causes damage to tissue rim of glenoid? (examples)

Answer 11

Falling on outstretched arm

Direct blow to the shoulder

Sudden pull such as when trying to lift a heavy object

Violent overhand reach such as when trying to stop a fall or slide

Question 12

What causes labral tears?

Answer 12

Throwing motion or weight lifting repetitively.

Question 13

What is a bankart lesion?

Answer 13

Tear of rim below middle of glenoid socket also involves the inferior glenohumeral ligament is called bankart lesion

Question 14

What is a SLAP lesion?

Answer 14

SLAP lesion results and is a tear of the rim above the middle of the socket that may involve the biceps tendon

Question 15

How are labral tears repaired surgically?

Answer 15

Arthroscopig surgery, if the injury is confined to the rim itself (no tear of biceps tendon) the shoulder is still stable the torn flap is removed and other problems are fixed.

If tear extends to biceps tendon the tendon is detached the tendon is repaired because at this point the shoulder is unstable.

Question 16

How is the biceps tendon repaired?

Answer 16

Surgeon transfers tendon to safe location using absorbable tacks, screws, or sutures.

Question 17

What are burners and stingers?

Answer 17

Burning or stinging. Usually these injuries are temporary and quickly go away and are caused by minor nerve injuries from stretching suddenly

Question 18

What are the symptoms of nerve injuries?

Answer 18

Pain

Anaesthesia (numbness)

Parasthesia in arm and forearm - depending on which nerve is affected.

Question 19

What is spinal stenosis?

Answer 19

Small intervertebral foramen in the cervical region created with bone degeneration

Question 20

What kind of injuries can cause nerve injury symptoms?

Answer 20

Spinal stenosis

Severe anterior joint dislocations

Question 21

Where are overuse injuries located most often?

Answer 21

Overuse injuries related to work tasks are predominantly located in the upper limb and can affect:

Cervical spine

Brachial plexus

Peripheral nerves

Synovial joints

Tendons and muscles

Majority of injuries are muscular or neurological in nature with symptoms relating to specific area of injury.

Question 22

What causes overuse injuries?

Answer 22

Whether sport or work overuse injuries are caused through some combination of the following factors:

High strain

High repetition

Holding long isometric contractions

Maintaining poor posture

Direct pressure on nerves

Prolonged exposure to discrete or whole body vibrations.

(A worker can’t stop playing for a few weeks until the pain subsides)

Question 23

What are the common outcomes of overuse?

Answer 23

Muscle fatigue

Inflammation of the tendon sheath or tissue

Inflammation of muscle-tendon junction and adjacent tissue

Over time this can result in restricted mobility, injury and even disability.

Question 24

How does the body normally react to stress?

Answer 24

Inflammatory response:

Acute inflammation resulting in swelling, redness, heat and pain.

Vasodilation of the small blood vessels increasing blood supply to the area.

Increasing vascular permeability to protein

Filtration of fluid into tissue

Phagocytosis (removal of damaged tissue)

Tissue repair

Question 25

Why do overuse injuries occur?

Answer 25

People keep reinjuring prior to the repair stage making the inflammation worse (<72 hours after injury)

Question 26

Where do cervical spine injuries appear?

Answer 26

Neck pain can be localized or can radiate into arms and head due to cervical nerve distribution and this presents as pain, parasthesia, anaesthesia, headaches, and dizziness.

Question 27

What causes cervical spine injuries?

Answer 27

Prolonged static postures such as chin pke and excessive cervical lordosis. Static muscle work is required to maintain posture leading to muscle and joint inflammation and nerve irritation

Question 28

What causes rotator cuff injuries?

Answer 28

Their tendons are located in small places and so overuse leads to inflammation and lack of mobility.

Question 29

What are the symptoms of a rotator cuff injury?

Answer 29

Pain with overhead activity

Decreased ability to apply power through the arm

History of shoulder dislocation

Question 30

How are rotator cuff injuries treated?

Answer 30

Rest

Anti-inflammatory medication and physiotherapy

Strengthening rotator cuff muscles and correction of joint biomechanics

If conservative treatment doesn’t work surgery can be done in a procedure called debridement where tendon is trimmed and smoothed.

A complete tear is stitched back to the greater tuberosity of the humerus

Bone spurs may need removal as well.

Question 31

How is shoulder arthritis diagnosed?

Answer 31

Radiographer can see loss of joint space as articular cartilage wears. Loss of ROM grinding and weakness allow the diagnosis to be made. Must be differentiated from frozen shoulder and rotator cuff disease.

Question 32

When is conventional total shoulder arthroplasty done?

Answer 32

On patients with end stage osteoarthritis

With rotator cuff muscles intact or with mild tears but no instability.

Question 33

When is a reverse total shoulder arthroplasty done?

Answer 33

Patients with end stage OA with irrebpairable rotator cuff tears and shoulder instability.

Question 34

What is shoulder impingement syndrome?

Answer 34

Compression of supraspinatus under the subacromial arch as the tendon impinges against acromion resulting in oedema, inflammation, and haemorrhage.

Question 35

What causes shoulder impingement syndrome?

Answer 35

Failure of normal rotator cuff function with overuse

Abnormal acromion shape (limited space)

Age-related degradation

Further damage can be caused by bursitis of subacromial bursa and development of bone spurs.

Question 36

How is shoulder impingement syndrome managed?

Answer 36

Conservative:

Control of pain - injections or NSAIDs

Physiotherapy

Work / technique modification

Surgery:

Resection of acromial variance

Removal of bone spurs

Subacromial decompression

+/- cuff repair