CONDITIONS OF THE SHOULDER Flashcards by Mathis Tchitchiama

Describe Winging of the scapula

-Damage to the long thoracic nerve paralyses the serratus anterior which normally holds the scapula against ribcage.
-Medial border of the scapula is no longer held against the chest wall so protrudes posteriorly.

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What are causes of winged scapula?

-Trauma
-Long thoracic nerve is vunerbale to surgical trauma during mastectomy.
(passes superficial to serratus anterior muscle in the medial wall of the axilla)
-Blunt trauma to the neck/shoulder
-Wearing a heavy backpack (traction injuries)

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What is axillary lymphadenopathy?

-Enlargement of the axillary lymph nodes

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What are some causes of axillary lymphadenopathy?

-Infection of the upper limb
-Infection of pectoral region and breast
-Metastases from breast cancer
-Leukaemia or lymphoma
-Metastases from malignant melanoma

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Describe fractures of the scapula

-Uncommon
-Indication of severe chest trauma
-Seen in high speed road collision, crushing injuries, high impact sport injuries.
-Does not typically need fixation as tone of surrounding muscles holds fragment in place while healing occurs.

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Describe fracture of the surgical neck of the humerus

-frequent site of fracture usually from blunt trauma to the shoulder/FOOSH

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neurovascular structures at risk in surgical neck of humerus fractures?

-Key neurovascular structures at risk= axillary nerve + posterior circumflex artery.

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Damage to axillary nerve in surgical neck of humerus fracture?

-Paralysis of deltoid + teres minor muscles.
-Patient will have difficulty performing abduction of affected limb.
-Loss of sensation in regimental badge area

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Describe shoulder discloation

-Patient’s shoulder visibly deformed + visible swelling/bruising around the shoulder
-Movement of the shoulder will be severly restricted.

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Describe anterior dislocations

-90-95% of dislocations are anterior.
-The arm is held in a position of external rotation and slight abduction.

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Mechanism of injury in anterior shoulder dislocations?

-Direct blow to the posterior shoulder
-Joint is weak at its inferior aspect, head of humerus usually dislocates anterioinferiorly and displaces in an anterior direction due to pull of muscles.
OR
-Head of humerus may lie anterior-inferior to the glenoid

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What is a bankart lesion + how does it occur?

-The force of the humerul head popping out of the socket often causes part of the glenoid labrum to be torn off.
-Small peice of bone may be torn off with labrum

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What is a Hill-Sachs lesion + how does it occur?

-When humeral head is dislocated anteriorly, the tone of infraspinatus + teres minor means the posterior aspect of the humeral head becomes jammed against ant. lip of glenoid fossa.
-This causes a dent (indentation fracture) in the posterolateral humeral head= HSL

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Describe posterior shoulder dislocations

-Far less common (2-4% of cases)
-Usually caused by violent muscle contractions due to:
>Epileptic seizure
>Electrocution
>Lightning strike

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What are some other causes of posterior shoulder dislocations?

-Can also be caused by a blow to the ant. shoulder or when arm is flexed across body and pushed posterioly

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How does patient present with posterior shoulder dislocation?

-Arm internally rotated and adducted
-Flattening/squarring of the shoulder + prominent coracoid process
-The arm cannot be externally rotated into anatatomcial posistion

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Outline the problems in detecting a posterior shoulder dislocation on X-ray?

-Can easily be missed as it looks ‘in joint’
-As the arm is Internally rotated the projection of the humeral head changes to a more round shape
-‘the light bulb sign’

What is the MOI of inferior dislocations?

-rare (0.5%)
-forceful traction on the arm when the arm is fully extended over the head.
-may occur when grapsing an object above the head to break a fall.

Complications of shoulder dislocations (in any directions)

-Reccurent dislocations (due to damage of surrounding stablising tissues)
-Damage to axillary artery
-Damage to axillary nerve which arounds the NOH
-Significant fractures
-Rotator cuff muscle tears (SITS)

Describe calvicle fractures

-accout for 3-5% of all fractures
-Peak age in children + young adults
-80% of fractures occur in middle third of the clavicle (mid clavicular fractures

What is the MOI of clavicular fractures + treatment?

-Fall onto outstreched shoulder or hand
-Treated conservatively using a sling
-May require surgical fixation

What are the indications for surgical fixation in clavicular fractures?

-Complete displacement
-Severe displacemnet causing tenting of the skin, with risk of puncture
-Open fractures
-Neurovascular compromise
-Fractures with interposed muscle
-‘Floating shoulder’

What is ‘floating shoulder’?

-Clavilce fracture with ipsilateral fracture of the glenoid neck (break in clavicle and upper part of the scapula)
-The shoulder pulls out of place and looks like its floating (on imaging)

What will happen to the position of the arm + clavicular fragment in a displaced mid-clavicular fractures?

-Medial segment elevated by sternocleoidomastoid.
-Trapezius muscle is unable to hold lateral segment up so shoulder drops.
-Arm is pulled medially by pec major (adduction).

Describe rotator cuff tears

-Tear of one or more of the tendons of the four rotator cuff muscles (SITS) -Frequently seen in primary care + orthopaedic outpatients. -Management is conservative or operative

What are some causes of rotator cuff tears?

-extended use -poor biomechanics -muscle imbalance. -Age-related degeneration. -Repetitive overhead activity

What is the degenerative-microtrauma model in rotator cuff tears?

-With age blood supply to rotator cuff tendon decreases. -age related tendon degeneration + chronic microtrauma= partial tendon tears -these partial tears result in full rotator cuff tears.

Presentation of rotator cuff tears?

-Anterolateral shoulder pain radiating down the arm. -Pain in shoulder when they lean on their elbow -Pain in shoulder when reaching forwards -Weakness of shoulder abduction

Describe calcific supraspinatus tendinopathy.

-Presence of macroscopic deposits of hydroxyapatite in tendon of supraspinatus. -(Hydroxyapatite= crystalline form of calcium phosphate). -Can be present in any tendon of the rotator cuff (most commonly seen in supraspinatus). -multifactorial causes

Presentation of calcific supraspinatus tendinopathy?

-Acute/chronic pain -Pain aggravated by abducting or flexing arm above the level of the shoulder. -Lying on the shoulder

What are the mechanical symptoms of calcific supraspinatus tendinopathy?

-Stiffness -Snapping sensation -Catching -Reduced range of movement (all present due to presence of a large deposit)

What is the treatment of calcific supraspinatus tendinopathy

-Initially conservative: rest + analgesia -Surgical treatment sometimes required for persistent symptoms.

Describe Adhesive capsulitis (frozen shoulder)

-Painful and disabling disorder in which the capsule of the glenohumeral joint becomes inflammed + stiff -Restrics movement and causes chronic pain

What are risk factors for Adhesive capsulitis (frozen shoulder)?

-Female -Epilepsy with tonic seizures -Diabetes mellitus -Shoulder trauma -CT disease -Thyroid disease -CV disease

What are signs + symptoms of Adhesive capsulitis (frozen shoulder)?

-Severe pain causing sleep deprivation for prolonged periods -Effect on daily life + work -Some develop depression as a result

What is the treatment for Adhesive capsulitis (frozen shoulder)?

-Physiotherapy -Analgesia -Anti inflammatory medication -Typically resolve with time

What is a surgical treatment option for Adhesive capsulitis (frozen shoulder)?

-Patients undergo manipulation under anaesthesia which breaks up the adhesions and scar tissue in the joint. -Helps restore range of motion -Intensive post-op physiotherpay helps maintain gained fucntion.

Describe OA of the shoulder

-Usually affect people >50yrs -commonly affects the acromioclavicular joint -treatment laddder is similar to OA in other joints: >activity modifciation >NSAIDs >analgesia

What are some surgical treatment options for OA of the shoudler?

-Total shoulder replacement -Arthroscopy (keyhole surgery) to remove loose peices of damaged cartilage.

What is Impingement syndrome (shoulder)?

-Supraspinatus tendon impinges on the coraco-acromial arch leading to irritation and inflammation. -Treatment= treat the underlying cause

What causes impingement syndrome (shoulder)?

-Anything that reduces the space between the head of the humerus in the coraco-acromial arch. -e.g. thickening of coracoacromial ligament, inflammation of supraspinatus tendon

When will pain be felt in impingement syndrome (shoulder)?

-When shoulder is abducted/flexed -Shoulder overhead movement -Lying on affected shoulder -Painful arc between 60 and 120 degree abduction of the shoulder. -grinding + popping sensation