Conditions Of The Shoulder And Surgery Flashcards
What are the rotator cuff muscles and their actions?
- supraspinatus: ABduct arm 0-15
- infraspinatus: external rotation of arm
- teres minor: external rotation of arm
- subscapularis: internal rotation of arm
What muscles ABduct the arm?
- supraspinatus: 0-15
- deltoid: 15-90
- trapezius + serratus anterior: +90
Presentation of rotator cuff tears
- shoulder pain
- weakness + pain with movements relating to the action of the torn muscle
- tenderness over greater tuberosity
Investigations of rotator cuff tears
- x ray to rule out fracture
- USS or MRI scan for diagnosis
- Shoulder examination with special tests
What special tests on a shoulder examination indicate a rotator cuff tear?
- internal rotation against resistance - subscapualris
- external rotation against resistance - infraspinatus + teres minor
- empty can test - supraspinatus
Management of rotator cuff tears
- rest + adapted activities
- analgesia
- Physiotherapy
- arthroscopic rotator cuff repair: if surgery is needed
Risk factors of rotator cuff tears
- increasing age
- trauma
- overuse
- repetitive overhead shoulder motions
- obesity
- smoking
- DM
Complications of rotator cuff tears
Adhesive capsulitis/frozen shoulder
What is subacrominal impingement syndrome?
Inflammation + irritation of the rotator cuff tendons as they pass through the subacrominal space
Pathophysiology of subacrominal impingement syndrome
- intrinsic mechanisms (due to tension): muscular weakness, overuse of shoulder, degenerative tendinopathy
- extrinsic mechanisms (due to external compression: anatomical variations of acromion, scapular musculature, glenohumeral instability
Presentation of subacromial impingement syndrome
- progressive pain in anterior superior shoulder
- worsened by abduction
- relieved by rest
- pain in 60-120 of ABduction
What special tests can be done to look for subacromial impingement syndrome?
Neers impingement test
Hawkin’s test
Painful arc
Investigations of subacromial impingement syndrome
- clinical diagnosis
- MRI imaging
Management of subacromial impingement syndrome
- analgesia
- Physiotherapy
- corticosteroid injections into subacrominal space
- surgery if pain persists over 6 months
- surgical repair of muscular tears
- surgical removal of subacromial bursa
- surgical removal of part of the acromion
Why does tendiopathy have a risk of tendon rupture?
Tendons become disorganised, hyper vascular + degenerative
Presentation of biceps tendinopathy
- pain in anteior arm
- worse when stressing tendon
- better with rest + ice
- weakness in flexion of arm + shoulder + supination
- stiffness
Management of biceps tendinopathy
- analgesia
- ice therapy
- Physiotherapy
- USS guided steroid injections
- arthroscopic tendesis or tenotomy
When do biceps tendon ruptures often occur?
Following suddenly forced extension of a flexed elbow
Risk factors of biceps tendon rupture
- biceps tendinopathy
- steroid use
- smoking
- CKD
- fluoroquinolone abx
Presentation of biceps tendon ruptures
- reverse pop eye sign
- sudden onset pain + weakness
- swelling + bruising in antecubital fossa
Imagining for suspected biceps tendon rupture
USS
Management of biceps tendon rupture
- analgesia
- Physiotherapy
- surgery last line
What is frozen shoulder/adhesive capsulitis?
When the glenohumeral joint capsule becomes contracted and adherent to the humeral head
Resulting in shoulder pain and reduced ROM
Demographic of frozen shoulder pain
- women
- 40-70s
- diabetes mellitius
Categories of frozen shoulder pain
- primary: idiopathic
- secondary: occurs in response to trauma, surgery or immobilisation e.g. rotator cuff tendinopathy, impingement syndrome biceps tendinopathy etc.
Pathophysiology of adhesive capsulitis
- Inflammation + fibrosis in the joint capsule lead to adhesions
- this binds the capsule + cause it to tighten around the joint
- restricting movement
Outline the three stages of adhesive capulitis
- freezing/painful stage: shoulder pain, worse at night
- frozen/stiff stage: stiffness on both active + passive movement (ER worst)
- thawing stage: gradual improvement in stiffness until normal
What movement is affected in the freezing stage of adhesive capsulitis?
Stiffness in active + passive movement
Especially external rotation
Presentation of adhesive capsulitis
- generalised deep + constant shoulder pain
- disturbs sleep + worse with movement
- reduced ROM
- tenderness on palpation
- joint stiffness
Imaging of adhesive capsulitis + findings
MRI
Thickening of glenohumeral joint capsule
Management of frozen shoulder
- self limiting 1-3 years
- education + reassurance
- analgesia
- continue to use arm
- physiotherapy
- intra-articular corticosteroid injections
- manipulation under anaesthesia
- arthroscopy
Surgical options for adhesive capsulitis
Manipulation under anaesthesia
Arthroscopy
Management of OA in the shoulder
- NSAIDs
- weight loss
- Physiotherapy
- intra-articular steroid injection
- hemiarthroplasty
- reverse total shoulder replacement
What is a shoulder dislocation?
Where the head of the humerus comes entirely out of the glenoid cavity
What is the most common type of shoulder dislocation?
Mechanism of action
Anterior dislocation
Force applied to extended, ABducted + externally rotated arm
What are posterior shoulder dislocations associated with?
Electric shocks + seizures
What associated damage can occur in shoulder dislocations?
- bankart lesion
- hill-sachs lesion
- axillary nerve damage
- fractures
- rotator cuff tears
What are bankart lesions?
Causes
Tears to the anterior portion of the glenoid labrum
Due to repeated anterior subluxations or dislocations of the shoulder
What are Hill-Sachs lesions?
Compression fractures of the posterolateral head of the humerus during an anterior dislocation of the shoulder
What does axillary nerve damage cause?
- weakness in deltoid + teres minor
- loss of sensation in regimental badge area
What could be fractured in a shoulder dislocation?
- humeral head
- greater tuberosity of humerus
- acromion
- clavicle
What nerve is commonly damaged in anterior shoulder dislocations?
Axilllary nerve C5 C6
What is the apprehension test?
- used to assess for shoulder instability
- shoulder ABducted to 90 + elbow flexed to 90
- shoulder is externally rotated
- as the arm approaches 90 of ER, the patient will becomes anxious + apprehensive (but no pain)
Investigations of shoulder dislocations
- X-rays
- magnetic resonance arthrography
- arthroscopy
What is a magnetic resonance arthrography?
When is it used in shoulder dislocations
- MRI of the shoulder with contrast injected to the joint
- used to assess for damage e.g. Bankart + Hill-Sachs lesions + planning for surgery
Acute management of shoulder dislocations
- relocate shoulder as soon as safely possible (closed reduction)
- analgesia + muscle relaxants
- gas + air
- broad arm sling
- post reduction X-ray
- immobilisation
Ongoing management of shoulder dislocations
- Physiotherapy
- shoulder stabilisation surgery (can correct underlying structural problems)
Presentation of shoulder dislocation
- painful shoulder
- acutely reduced mobility
- asymmetry
- loss of shoulder contours (flattened deltoid)
Most common site of shoulder fracture
Mechanism of action for this
Proximal humerus
Elderly patients FOOSH (most common)
High energy trauma injuries in younger patietns
Presentation of shoulder fracture
- pain in upper arm + shoulder
- restricted arm movement
- inability to ABduct arm
- swelling + bruising
Investigations of shoulder fracture
- urgent bloods incl. coag, G+S
- X-ray AP, lateral + axillary views
- CT scan
Classification of shoulder fracture
Neer classification
- characterise proximal humeral fractures based on relation between:
- greater tuberosity
- lesser tuberosity
- articular segment (anatomical neck)
- humeral shaft (surgical neck)
Management of shoulder fractures
- most are conservatively managed
- immobilisation initially with early mobilisation at 2-4 weeks post #
- correctly applied poly sling
- ORIF: if head splitting fracture
- inter medullary nailing: if involving surgical neck
- hemiarthroplasty or reverse shoulder arthroplasty (last line)
Complications of shoulder fracture
- reduced ROM
- avascular necrosis of humeral head
- axillary nerve damage
Blood supply to the humeral head
Anterior + posterior humeral circumflex arteries
Why are scapular fractures very rare?
Lots of protection from surrounding muscles
Management of scapular fractures
- mainly treated non operatively as most are aligned acceptably
- ORIF
Risk factors of humeral shaft fractures
- osteoporosis
- increasing age
- previous fractures
Most common site of humeral shaft fractures
Mechanism
- middle 3rd of humerus
- high energy trauma in younger people
- low energy trauma in older people
Presentation of humeral shaft fracture
- pain
- deformity
- possible damage to radial nerve > reduced in dorsal 1st web space or wrist extension weakness
What is a Holstein-Lewis fracture?
- fracture of the distal 3rd of the humerus causing entrapment of the radial nerve
- loss of sensation in dorsal 1st web space
- wrist drop deformity
Investigations of humeral shaft fracture
- AP + lateral X ray
- CT if severely comminuted
Management of humeral shaft fractures
- realignment
- analgesia
- most are treated conservatively in functional humeral brace
- regular follow up X-rays
- ORIF with plate or intramedullary nailing
Complications of humeral shaft fractures
- radial nerve damage
- non union
- mal union
- varus angulation (in transverse fractures)
Demographic of clavicle fractures -
- adolescents + young adults
- > 60 (osteoporosis)
Classifications of clavicle fractures
Allman classification
- based on the anatomical location of the fracture
- type I: middle 3rd of clavicle
- type II: lateral 3rd of clavicle
- type III: medial 3rd of clavicle
What is a type III clavicle fracture?
What are associated risks and why?
- fracture in the medial 3rd of the clavicle
- mediastinum sits directly behind the medial aspect
- neurovascular compromise
- pneumothorax or haemothorax
Displacement of clavicle fractures -
- medial fragment - superior displacement due to SCM pull
- lateral fragment - inferior displacement due to weight of arm
Presentation of clavicle fracture
- sudden onset localised severe pain
- worse on active movement of arm
- tenderness + deformity at fracture site
- possible tented, tethered, non blanching skin
Investigations of clavicle fracture
X ray AP and modified axial
Management of clavicle fracture site
- sling until pt pain free movement of shoulder
- early movement of shoulder joint
- surgical intervention if open or bilateral fracture
- ORIF if non union 2-3 months post injury
Complications of clavicle fracture site
- Non union
- Neurovascular injury
- puncture injury > haemothorax or pneumothorax
Presentation of acromioclavicular joint injury
- contact sport e.g. rugby or FOOSH
- shoulder pain
- step off deformity
- swelling + bruising
