Cortex - Adult orthopaedics spine and upper limb 2 (shoulder)

Question 1

What is the shoulder (or glenohumeral) joint dependant on the surrounding muscles (e.g. rotator cuff muscles) for ?

Answer 1

For stability as there is a lack of inherint bony stability

Question 2

Look over where the rotator cuff muscles are in terms of the shoulder joint

Answer 2

Think SITS for remembering rotator cuf muscles

Question 3

Match the 3 main ways in which the shoulder can be affected to the age group this usually applies to:

1. Instability causing shoulder pain
2. Rotator cuff tears and frozen shoulders
3. Glenohumeral OA

Elderly, Younger adults, Middle aged

Answer 3

1. Younger adults
2. Middle aged
3. Elderly

Question 4

What is Impingement synrome (painful arc)?

Answer 4

A syndrome where the tendons of the rotator cuff muscles (predominantly supraspinatus) are compressed in the tight subacrominal space during movement producing pain

Question 5

During what range of abduction does impingement typically produce pain ?

Answer 5

60-120 degrees

Question 6

What are the causes of impingement syndrome ?

Answer 6

• Tendonitis Subacromial bursitis
• Acromioclavicular OA with inferior osteophyte
• A hooked acromion Rotator cuff tear

Question 7

In patients with impingement syndrome on clinical examination what may you find ?

Answer 7

Tenderness below lateral edge of acromion

Hawkins kennedy test positive (recreates the patients pain) - internally rotating the flexed shoulder

Question 8

What is the treatment of impingement syndrome ?

Answer 8

• 1st line - conservative with NSAIDs, analgesics, physiotherapy and subacromial injection of steroid.
• 2nd line - subacromial decompression surgery (makes more room for the tendon to pass through)

Question 9

How can rotator cuff tears arise ?

Answer 9

• Usually due to degeneration of the tendons causing them to occur with minimal or no trauma e.g. holding a rail on a bus which suddenly stops (more common in >40)
• Also rarley may be due to trauma in young patients e.g. shoulder dislocation

Question 10

Which rotator cuff muscle is most commonly affected ?

Answer 10

suprapinatus

Question 11

What are the different extents of rotator cuff tears that you can have ?

Answer 11

Can be full or partial thickness

Can affect more than one muscle

Question 12

What are some of the signs of rotator cuff tears ?

Answer 12

• Weakness of initiation of abduction (supraspinatus)
• Internal rotation (subscapularis)
• or external rotation (infraspinatus)

And wasting of supraspinatus may be seen

Question 13

How are rotator cuff tears confirmed ?

Answer 13

MRI or US

Question 14

What is the treatment of rotator cuff tears ?

Answer 14

• Surgical or non-operative (physio)
• Surgical for active young people
• Polysling may be used to support shoulder

Non-operative for older patients (as more likely to have diseased tendons causing it in the first place making the surgery more likely to fail)

Question 15

What is adhesive capsulitis (frozen shoulder) charactersied by ?

Answer 15

Progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after around 18‐24 months

Question 16

What is the principle clinical sign of adhesive capsulitis (frozen shoulder)?

Answer 16

Loss of external rotation (along with restriction of other movements)

Question 17

What are some of the conditions is adhesive capsulitis associated with ?

Answer 17

• Diabetics particularly prone
• Shoulder surgery

Question 18

What is the treatment of adhesive capsulitis ?

Answer 18

1st line - physio plus NSAID’s

Then letting it settle naturally

Question 19

What is Acute calcific tendonitis?

Answer 19

A condition which results in onset of acute severe shoulder pain due to calcium deposition in the supraspinatus tendon

Question 20

What is acute calcific tendonitis characterised by ?

Answer 20

• The calcium deposition in the supraspinatus tendon is seen on X-ray just proximal to the greater tuberosity
• Presents similar to impingement syndrome

Question 21

How is acute calcific tendonitis treated ?

Answer 21

Condition is self-limiting so treated symptomatically

Great relief of pain is achieved with subacromial steroid and local anaethetic injection

Question 22

What are the two main sub-types of shoulder instability ?

Answer 22

Traumatic instability and atraumatic instability

Question 23

What happens in traumatic instability of the shoulder ?

Answer 23

Patient experiences a traumatic anterior dislocation which after reduction may settle and stablise with rest and physio

Question 24

What determines the likelihood of further dislocations following a traumatic dislocation of the shoulder ?

Answer 24

Age!

Patients < 20 with first dislocation have a 80% chance of re-dislcoating

Patients >30 have a 20% chance of re-dislocating

Question 25

For patients who have experienced recurrent dislocations following a traumatic shoulder dislocation what treatment can be done ?

Answer 25

**A bankart repair** - to stabilise the shoulder by reattaching the labrum and capsule to the anterior glenoid which was torn off in the first dislocation.

Question 26

How does atruamtic shoulder dislocations present ?

Answer 26

In patients with generalized ligamentous laxity (idiopathic, Ehlers‐Danlos, Marfan’s) they can have pain from recurrent multidirectional (anterior, posterior or inferior) subluxations or dislocations. Treatment is difficult as soft tissue procedures may not work (remember marfans etc affects soft tissues)

Question 27

What are some other causes of pain in the shoulder (not originating in the shoulder and not even MSK related)

Answer 27

E.g. angina, diapragmatic irritation ((biliary colic, hepatic or subphrenic abscess) etc so beware