Cortex- Upper limb: Shoulder

Question 1

what is the proper name for the shoulder joint

Answer 1

gleno-humeral

Question 2

what forms the shoulder joint

Answer 2

humeral head

scapular glenoid

Question 3

what forms the shoulder girdle

Answer 3

scapular, clavicle, proximal humerous, supporting muscles (inc deltoid and rotator cuff muscles)

Question 4

where does the clavicle attach to the scapular

Answer 4

to the acromion process

Question 5

what four muscles make up the rotator cuff

Answer 5

supraspinatus, infraspinatus, terers minor and subscapularis

Question 6

where do the supraspinatus, infraspinatus and teres minor attach to

Answer 6

the greater tuberosity

Question 7

what is the role of supraspinatus

Answer 7

initial (first 15 degrees) abduction

Question 8

what is the role of infraspinatus and teres minor

Answer 8

external rotators

Question 9

where does subscapularis attach and what is its role

Answer 9

lesser tuberosity

principal internal rotator

Question 10

what is the role of the rotator cuff

Answer 10

pull humeral head into the glenoid to provide a stable fulcrum for the deltoid to abduct the arm

Question 11

why can acute or degenerative tears happen to the rotator cuffs

Answer 11

as they are under significant repeated stress

Question 12

what causes chronic rotator cuff insufficiency and what can it lead to

Answer 12

altered shoulder biomechanics

glenohumeral OA

Question 13

which joints in shoulder can be affected by OA

Answer 13

glenohumeral and acromiocalvicular joints

Question 14

what usually causes shoulder pain in younger patients

Answer 14

instability of the joint

Question 15

what usually causes shoulder pain in middle aged patients

Answer 15

rotator cuff tears and frozen shoulder

Question 16

what usually causes shoulder pain in elderly patients

Answer 16

OA

Question 17

what causes a painful arc

Answer 17

impingement syndrome

Question 18

what is impingement syndrome

Answer 18

where the tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement, producing pain

Question 19

when in impingement syndrome does the patient typically feel pain during the arc- why

Answer 19

between 60 to 120 degrees of abduction

as an inflamed area of supraspinatus passes through the space during movement producing pain

Question 20

what can cause impingement syndrome

Answer 20

tendonitis subacromial bursitis

acromioclavicular OA with inferior osteophyte

a hooked acromion rotator cuff tear

Question 21

describe the pain in impingement syndrome

Answer 21

radiates to the deltoid and upper arm

tenderness may be felt below the lateral edge of the acromion

Question 22

what test recreates the pain in impingement syndrome

Answer 22

hawkins- kennedy test (internally rotating the flexed shoulder)

Question 23

what should be excluded from the differential diagnosis list in impingement syndrome by history and exam

Answer 23

cervical radiculopathy

Question 24

what is the treatment for impingement syndrome

Answer 24

conservative in the first instance, majority settle with NSAIDs, analgesics, physio, (up to three) subacromial injection of steroid

Question 25

what treatment for cases of impingement syndrome that do not settle with conservative treatment

Answer 25

subacromial decompression surgery- creates more space for the tendon to pass through (can be done openly or via minimally invasive arthroscopic techniques

Question 26

why can the tendons of the rotator cuffs tear with minimal or no trauma

Answer 26

as a consequence of degenerative changes in the tendons

Question 27

what is the presentation of a rotator cuff tear

Answer 27

sudden jerk (bus stopping whilst holding onto rail) causing subsequent pan and weakness patients usually over 40

Question 28

why do 20% of over 60s have asymptomatic cuff tears

Answer 28

due to tendon degeneration

Question 29

can rotator cuffs tear in the young

Answer 29

yes, uncommon, but can in significant injury

Question 30

what muscle is usually involved in rotator cuff tears

Answer 30

surpaspinatus

Question 31

what muscles can large rotator cuffs tears involve

Answer 31

subscapularis and infraspinatus

Question 32

what clinical signs might be seen in a rotator cuff tear

Answer 32

weakness of initial abduction (supraspinatus) weakness of internal rotation (subscapularis) weakness of external rotation (infraspinatus) wasting of supraspinatus

Question 33

how are rotator cuff tears confirmed

Answer 33

ultrasound/ MRI

Question 34

what is the treatment for rotator cuff injuries

Answer 34

surgery- rotator cuff repair with subacromial decompression non operative- physio, subacromial injection

Question 35

what is adhesive capulitis

Answer 35

frozen shoulder

Question 36

describe adhesive capulitis

Answer 36

progressive pain and stiffness of the shoulder in patients between 40 and 60 which resolves after 18-24 months

Question 37

what is the presentation and course of adhesive capsulitis

Answer 37

initially pain which will subside after 2-9 months stiffness increases for 4-12 months stiffness gradually thaws normally good recovery of shoulder motion

Question 38

what in the principal sign of adhesive capsuilits

Answer 38

loss of external rotation

Question 39

loss of external rotation can also occur in OA, how can you differentiate this from adhesive capsulitis

Answer 39

OA tends to affect older patients

Question 40

what is the aetiology of adhesive capsulitis

Answer 40

unclear- may occur after surgery or injury diabetic predisposed associated with hypercholesterolaemia and dupuytrens

Question 41

what is the pathology of adhesive capsulitis

Answer 41

the capsule and glenohumeral ligaments become inflamed then thickened and contract

Question 42

what is the treatment for adhesive tendonitis

Answer 42

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)

Question 43

what is acute calcific tendonitis

Answer 43

acute onset of severe shoulder pain | characterised by calcium deposition in the supraspinatus tendon

Question 44

where is the supraspinatus tenson seen on x ray

Answer 44

proximal to the greater tuberosity

Question 45

what is the treatment for acute calcific tendonitis

Answer 45

self limiting with pain easing as calcification resorbs pain relief can be achieved with subacromial steroid and local anaethetic infection

Question 46

what is involved in shoulder instability

Answer 46

painful abnormal translocation movement or subluxation and/ or recurrent dislocation

Question 47

what are the two types of shoulder instability

Answer 47

traumatic, atraumatic

Question 48

describe traumatic instability

Answer 48

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

Question 49

is the redislocation rate higher in traumatic instability in the old or young

Answer 49

young- 80% redislocation rate in under 20s | 20% in over 30s

Question 50

what can stabilise the shoulder when there is reccurent dislocations due to traumatic instability

Answer 50

bankart repair- reattaches the labrum and capsule to the anterior glenoid which was torn in first dislocation

Question 51

what is atraumatic instability

Answer 51

patients with generalised ligametous laxity (idiopathic, ehlers-danlos, marfans) can have pain from multidirectional (anterior, posterior or inferior) subluxations or dislocations

Question 52

what are rare causes of shoulder pain

Answer 52

inflammation of the tendon of the long head of biceps (biceps tendonitis) causes anterior shoulder pain tear in the glenoid labrum

Question 53

what can cause referred shoulder pain

Answer 53

neck problems, angina pectoris, diaphragmatic irritation (biliary colic, hepatic or subphrenic abscess)