Common Shoulder Conditions

Question 1

What happens during an anterior shoulder dislocation in the subcoracoid location

Answer 1

This is the more common one. Glenoid fossa is shallow and is least supported from the inferior aspect and therefore dislocates at an anterior-inferior angle and ends up displaces anteriorly due to the pull of different muscles

Question 2

What happen during anterior shoulder dislocation in the subglenoid location

Answer 2

Head of humerus may lie displaced anterior-inferior to the glenoid. This is is where head of humerus is seen to be much lower

Question 3

Is which position is the arm held after anterior dislocation

Answer 3

Arm is held in a position of external rotation and slight abduction

Question 4

Ways in which the shoulder can become anteriorly dislocated

Answer 4

When is position of abduction and external rotation (hand behind head) and injury forces shoulder more posteriorly
OR
Direct blow to the posterior shoulder

Question 5

What is a bankart lesion

Answer 5

When the force of the numeral head popping out of the socket causes a part of the glenoid labrum to be torn off. Sometimes a small piece of bone can be torn off together with the labrum

Question 6

What is a hill-Sachs lesion and what is it causes by

Answer 6

When the humeral head is dislocated and the infraspinatas and teres minor muscles mean that the humeral head becomes jammed against glenoid fossa causing a dent

Question 7

When do posterior dislocations occur

Answer 7

Very rare. Happen during violent muscle contractions eg seizure, electrocution or lightening strike. When there is blow to anterior shoulder or when arm is flexed across body and pushed posteriorly

Question 8

How is the posterior dislocated shoulder usually presented

Answer 8

The patients arm will be internallly rotated and addicted. The arm cannot be externally rotated into the anatomical position

Question 9

What is an inferior dislocation and h dos it happen

Answer 9

Found underneath the glenoid fossa. Very traumatic. Happens during forceful traction on arm when its fully extended over the head - grasping over head to break fall for example

Question 10

Injuries associated with inferior shoulder dislocation

Answer 10

60% nerve damage, 80% rotator cuff tears ad can also cause some injury to blood vessels

Question 11

What is recurrent dislocation

Answer 11

Common complication of shoulder dislocation. Happens due to the damage to the stabilising tissues around the shoulder. Risk decreases the older you are when you dislocate your shoulder.
ALSO increases risk of secondary osteoarthritis in that shoulder

Question 12

When does axillary artery damage occur

Answer 12

Damage to axillary artery as its in the same area. More common in old people as they have less elastic vessels. Patient may have haematoma/absent pulses or cool limb (less blood supply)

Question 13

How nerve injuries occur after shoulder dislocation

Answer 13

Particularly the axillary nerve is easily damaged as is it wraps around the neck of the humerus and supplies and deltoi muscle and the skin overlying it. - regimental badge area. Sometimes this can be resolved when the shoulder is put back into position
Sometimes dislocation may cause damage to cords of brachial plexus or musculotaneous nerve (much more unlikely)

Question 14

Discuss what happens when fracture occurs at the same time as a dislocation

Answer 14

Usually only happens when the injury happen in a traumatic way. More common during first time dislocation (because everything is a bit less flexible) or when the person is older. Affects bones; humeral head, greater tubercle, clavicle and acromion.

Question 15

Discuss rotator cuff muscle tears in association with shoulder dislocation

Answer 15

Comply in older people and if its an inferior dislocation.

Question 16

Function of the clavicle

Answer 16

Transmits force form the upper limb to the axial skeleton
Protection of brachial plexus, subclavian vesssels and top of lung .
Allows arm to have freedom of motion by acting as a strut between sternum and glenohumeral joint

Question 17

How do you break your clavicle

Answer 17

Falling onto shoulder or outstretched hand

Question 18

Treatment of clavicle fracture

Answer 18

Use sling 
Need surgical fixation if;
Complete displacement 
Severe displacement causing tenting of the skin = risk of puncture and necrosis 
Open fracture
Neurovascular compromise
Fractures with muscles between. 
Floating shoulder - fracture is clavicle and of glenoid neck

Question 19

What happens to arm posits in a mid-clavicular fracture

Answer 19

Sternocleiodomastoid muscle elevates the medial segment and trapezius cant hold lateral segment plus pulled down by the weight of the arm. Arm is pulled medically by pictorial is major

Question 20

Complications that occur with clavicle fracture

Answer 20

Pneumothorax or injury to surrounding neurovascular structures - eg the suprascapular nerve may be damaged and/or the supracalvicular nerve may also be damaged

Question 21

What is a rotator cuff tear

Answer 21

Tear of one or more of the tendons of the four rotator cuff muscles of the shoulder

Question 22

Which tendons are in the rotator cuff and which are frequently torn

Answer 22

Supraspinatus, infraspinatus, subscapularis, an teres minor. Most commonly torn is the supraspinatus tearing at the site of its insertion into the greater tubercle of the humerus

Question 23

Can acute tears of the rotator cuff occur

Answer 23

Can occur for example following shoulder dislocation but not that common

Question 24

Can/when do chronic tears of rotator cuff occur

Answer 24

Results from extended use in combo with factors e.g poor biomechanics. Common causes;
Age related degeneration - less blood supply to raptor cuff so cant repair injuries as well

Question 25

What is the degenerative-microtrauma model

Answer 25

Micro trauma + age-related degeneration is what causes partial tendon tears which develop into full rotator cuff tears. Inflammatory cells re recruited and oxidative stress leads to tenocyte (tendon cell) apoptosis leading to further damage.

Question 26

Risk factors for rotator cuff tear

Answer 26

Repetitive over the head lifting e.g tennis or painters

Question 27

Symptoms of rotator cuff tears

Answer 27

Often asymptomatic but most commonly presented as anterolateral shoulder pain radiating down arm. Patients also experience pain when;
Lean on elbows and push down - pushes head of humerus up and decreases space between humeral head ad coracoacromial arch
When reaching forward (shoulder flexion)
ALSO have weakness of shoulder abduction - usually only found on physical examination

Question 28

What is impingement syndrome

Answer 28

When supraspinatus tendon impinges (rubs or catches) on the coraco-acromial arch leading to irritation and inflammation. May be caused by thickening of coracoacromial ligament, inflammation of supraspinatus lineament or subacromial ostephytes. Then when shoulder i abducted or flexed this space narrows further causing pain, weakness and reduced range of motion .

Question 29

When does impingement syndrome cause the most pain

Answer 29

Shoulder overhead movement - abduction of shoulder e.g brushing hair

Question 30

Treatment of impingement syndrome

Answer 30

Treat underlying cause

Question 31

What is a calcific supraspinatus tendiopathy

Answer 31

It’s hydroxyapatite (calcium phosphate crystals) in the tendon of the supraspinatus. Can also occur in other rotator cuff tendons but less common.

Question 32

How does calcific supraspinatus tendinopathy preset

Answer 32

Acute/chronic pain aggravated by abducting or flexing the arm above shoulder level. Mechanical symptoms e.g stiffness, catching, reduced range of movement occur due to presence of large deposit

Question 33

Why does calcific tendinopathy occur

Answer 33

Multifactoral.
1 theory = regional hypoxia leads to tendocytes being transformed to chondrocytes and laying down cartilage and calcium.
Another theory = ectopic bone formation from metplasia of meshenchymal stem cells in tendons into osteogenic cells

Question 34

What is seen on an X-ray of calcific tendinopathy

Answer 34

Calcific deposits seen on X-ray. They are crystalline in their resting phase and are eventually reabsorbed by phagocytes - look like tooth paste e.g cloudy- this is what causes the most pain

Question 35

Treatment for calcific tendinopathy

Answer 35

Rest and analgesia. Surgery sometimes required for persistent symptoms

Question 36

What is adhesive capsulitis (frozen shoulder)

Answer 36

Gelnohumeral joint becomes inflamed and stiff greatly reducing movement and causing chronic pain which is worse at night and exarcerbated by movement and cold weather

Question 37

Cause/risk factors of frozen shoulder

Answer 37

Unknown cause. Some say it’s autoimmune.
Risk factors; 
Female 
Epilepsy (seizures with lots of muscle contraction)
Diabetes (glucose molecule bind to capsular collagen) 
Shoulder trauma 
Connective tissue disease
Thyroid disease
CVS disease
Chronic lung disease
Breast cancer
Polymyalgia rheumatica (inflammatory muscle condition)
Parkinson’s disease
Long periods of inactivity

Question 38

Treatment for frozen shoulder

Answer 38

Physiotherapist and anti inflammatory medication. Some go under anaesthesia to get adhesions broken up to restore range of motion. Postoperative physiotherapy helps to maintain the movement gained
Usually resolves with time and patients regain 90% of movement but may return in other shoulder.

Question 39

Treatment of osteoarthritis of the shoulder

Answer 39

1. activity modification, analgesia and antiinflammatories.
2. Steroid injections to reduce swelling and alleviate shoulder stiffness and pain and hyalauronic acid injections to increase lubrication.
3. Atheroscopy - (keyhole sugary) to remove loose cartelise and some patients then get total shoulder replacement

Question 40

Places in the shoulder often affected by osteoarthritis

Answer 40

Acromiocalvicular joint

Glenhumeral joint

Question 41

Effects of biceps tendon rupture

Answer 41

Patient usually hears something snap in the shoulder whilst lifting.
Flexion of elbow produces lump in lower arm = Popeye sign
Patient wont notice much weakness due to activation of other muscles and management is usually conservative.

Question 42

Effects of fracture of surgical neck of humerus

Answer 42

Blunt trauma or falling on outstretched hand causes it.
Axillary neve and posterior circumflex artery at risk.
Axillary nerve damage = paralysis of deltoid and teres minor and will therefore have difficulty performing abduction. In regimental badge area skin is also affected

Question 43

Effects of fracture of the scapula

Answer 43

Very uncommon usually due to severe trauma. Doesn’t need fixation as surrounding muscles hold the fragments into place whilst healing occurs