Cortex- Upper limb: Shoulder Flashcards
what is the proper name for the shoulder joint
gleno-humeral
what forms the shoulder joint
humeral head
scapular glenoid
what forms the shoulder girdle
scapular, clavicle, proximal humerous, supporting muscles (inc deltoid and rotator cuff muscles)
where does the clavicle attach to the scapular
to the acromion process
what four muscles make up the rotator cuff
supraspinatus, infraspinatus, terers minor and subscapularis
where do the supraspinatus, infraspinatus and teres minor attach to
the greater tuberosity
what is the role of supraspinatus
initial (first 15 degrees) abduction
what is the role of infraspinatus and teres minor
external rotators
where does subscapularis attach and what is its role
lesser tuberosity
principal internal rotator
what is the role of the rotator cuff
pull humeral head into the glenoid to provide a stable fulcrum for the deltoid to abduct the arm
why can acute or degenerative tears happen to the rotator cuffs
as they are under significant repeated stress
what causes chronic rotator cuff insufficiency and what can it lead to
altered shoulder biomechanics
glenohumeral OA
which joints in shoulder can be affected by OA
glenohumeral and acromiocalvicular joints
what usually causes shoulder pain in younger patients
instability of the joint
what usually causes shoulder pain in middle aged patients
rotator cuff tears and frozen shoulder
what usually causes shoulder pain in elderly patients
OA
what causes a painful arc
impingement syndrome
what is impingement syndrome
where the tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement, producing pain
when in impingement syndrome does the patient typically feel pain during the arc- why
between 60 to 120 degrees of abduction
as an inflamed area of supraspinatus passes through the space during movement producing pain
what can cause impingement syndrome
tendonitis subacromial bursitis
acromioclavicular OA with inferior osteophyte
a hooked acromion rotator cuff tear
describe the pain in impingement syndrome
radiates to the deltoid and upper arm
tenderness may be felt below the lateral edge of the acromion
what test recreates the pain in impingement syndrome
hawkins- kennedy test (internally rotating the flexed shoulder)
what should be excluded from the differential diagnosis list in impingement syndrome by history and exam
cervical radiculopathy
what is the treatment for impingement syndrome
conservative in the first instance, majority settle with NSAIDs, analgesics, physio, (up to three) subacromial injection of steroid
what treatment for cases of impingement syndrome that do not settle with conservative treatment
subacromial decompression surgery- creates more space for the tendon to pass through (can be done openly or via minimally invasive arthroscopic techniques
why can the tendons of the rotator cuffs tear with minimal or no trauma
as a consequence of degenerative changes in the tendons
what is the presentation of a rotator cuff tear
sudden jerk (bus stopping whilst holding onto rail) causing subsequent pan and weakness
patients usually over 40
why do 20% of over 60s have asymptomatic cuff tears
due to tendon degeneration
can rotator cuffs tear in the young
yes, uncommon, but can in significant injury
what muscle is usually involved in rotator cuff tears
surpaspinatus
what muscles can large rotator cuffs tears involve
subscapularis and infraspinatus
what clinical signs might be seen in a rotator cuff tear
weakness of initial abduction (supraspinatus)
weakness of internal rotation (subscapularis)
weakness of external rotation (infraspinatus)
wasting of supraspinatus
how are rotator cuff tears confirmed
ultrasound/ MRI
what is the treatment for rotator cuff injuries
surgery- rotator cuff repair with subacromial decompression
non operative- physio, subacromial injection
what is adhesive capulitis
frozen shoulder
describe adhesive capulitis
progressive pain and stiffness of the shoulder in patients between 40 and 60 which resolves after 18-24 months
what is the presentation and course of adhesive capsulitis
initially pain which will subside after 2-9 months
stiffness increases for 4-12 months
stiffness gradually thaws
normally good recovery of shoulder motion
what in the principal sign of adhesive capsuilits
loss of external rotation
loss of external rotation can also occur in OA, how can you differentiate this from adhesive capsulitis
OA tends to affect older patients
what is the aetiology of adhesive capsulitis
unclear- may occur after surgery or injury
diabetic predisposed
associated with hypercholesterolaemia and dupuytrens
what is the pathology of adhesive capsulitis
the capsule and glenohumeral ligaments become inflamed then thickened and contract
what is the treatment for adhesive tendonitis
physio and analgesics
glenohumeral injections may help in the painful stage
if after painful stage patient cannot tolerate function loss caused by stiffness can undergo manipulation under anaesthetic (which tears capsule) or surgical capsular release (divides the capsule)
what is acute calcific tendonitis
acute onset of severe shoulder pain
characterised by calcium deposition in the supraspinatus tendon
where is the supraspinatus tenson seen on x ray
proximal to the greater tuberosity
what is the treatment for acute calcific tendonitis
self limiting with pain easing as calcification resorbs
pain relief can be achieved with subacromial steroid and local anaethetic infection
what is involved in shoulder instability
painful abnormal translocation movement or subluxation and/ or recurrent dislocation
what are the two types of shoulder instability
traumatic, atraumatic
describe traumatic instability
when patients experience a traumatic anterior dislocation- might stabilse with rest and physio but may no stabilise and develop recurrent dislocations or subluxations often with minimal force
is the redislocation rate higher in traumatic instability in the old or young
young- 80% redislocation rate in under 20s
20% in over 30s
what can stabilise the shoulder when there is reccurent dislocations due to traumatic instability
bankart repair- reattaches the labrum and capsule to the anterior glenoid which was torn in first dislocation
what is atraumatic instability
patients with generalised ligametous laxity (idiopathic, ehlers-danlos, marfans) can have pain from multidirectional (anterior, posterior or inferior) subluxations or dislocations
what are rare causes of shoulder pain
inflammation of the tendon of the long head of biceps (biceps tendonitis) causes anterior shoulder pain
tear in the glenoid labrum
what can cause referred shoulder pain
neck problems, angina pectoris, diaphragmatic irritation (biliary colic, hepatic or subphrenic abscess)
