L4 - Intro to shoulder surgery Flashcards
SHOULDER PAIN
i) how common is it in GP consultations for MSK problems?
ii) what % of adults visit GP each year with shoulder pain?
iii) what % of adults self report shoulder pain?
iv) what is usually needed to confirm it?
i) 3rd most common MSK consultation in GP practise
ii) 1% adults visit GP with shoulder pain
iii) 25% adults self report shoulder pain
iv) usually need imaging to confirm
SHOULDER SYMPTOMS
i) what the the shoulder required for? (3)
ii) give four common shoulder symptoms reported
iii) is it an stable or unstable joint? what does this allow?
i) power, high range of movement and throwing
ii) stiffness, pain, weakness, instability
iii) unstable joint which allows large range of movement
GLENOHUMERAL JOINT STABILITY
i) what characterstic of the rotator cuff muscles allows stability?
ii) what ligamentous structure is found in the GH joint? what does this allow?
iii) label the diagram and give action of each muscle
iv) where do the rotator cuff muscles insert? in what order?
v) what is the rotator cuff cable?
i) dynamic rotator cuff muscles
ii) capsule and labrum - allows static stabilisation
iii) A - supraspinatous - elevates and abducts arm
B - subscapularis - internal rotator
C - teres minor - external rotator
D - infraspinatous - elevates arm and externally rotates
iv) RC insert into a common tendon on the humeral head
- supraspin, infraspin, teres minor then sub scap on other side
v) muscles and tendons link and allow force transmission together
ROTATOR CUFF BIOMECHANICS
i) what does the compressive force allow?
ii) if the RC isnt working properly - which muscles are implicated? what happens?
iii) what is the ultimate aim of the RC muscles? what does it provide to allow arm movement?
iv) name four power muscles in the arm
i) compressive force allows compress of the humeral head to the glenoid
ii) RC isnt working - power muscles will cause an instability force on the humeral head and head will slide out of position in relation to the glenoid
iii) RC muscles act to stabilise the GHJ
- also act to provide a fulcrum (fixed point) for power muscles to move the arm
iv) power muscles = deltoid, pec major, trapezius, lat dorsi, teres major
RISK FACTORS FOR SHOULDER PAIN
i) name two type of injuries related to shoulder pain
ii) name two conditions related
i) sports related injuries and traumatic injury eg disloc/fracture
ii) degen conditions eg OA or work related conditions due to manual jobs
CAUSES OF SHOULDER PAIN
i) which space is implicated when there are rotator cuff problems?
ii) give three RC disorders that cause sub acrominal problems
iii) in sub acromial impingment - where is pain felt? what actions induce pain (2)
iv) give an intrinsic and extrinsic cause of subacromial impingement?
i) sub acromial space
ii) acromial joint arthritis, rotator cuff tear and calcific tendonistis, sub acrom impingement
iii) in SA impinge - feel pain over deltoid
- pain on abduction and rotation of arm
iv) intrinsic cause - tendinopathy/cuff weakness (disease of tendon where microstruc are affected)
extrinsic cause - bony spurs that have grown over time and dig into the tendon
TREATMENT OF ACROMIAL IMPINGEMENT
i) what is first line treatment? whay may this involve?
ii) what is deemed essential for recovery? give three things this can help to treat
iii) in what situation may surgical intervention be necessary? (2)
iv) name two surgical approaches that may be used? what technique is normally used?
i) first line is non surgical > activity modification
ii) physio is deemed essential for recovery
- can help treat tendonopathy, strengthen muscles to restabilise rotator cuffs and centre head against glenoid
iii) may need sx intervention if there are bony spurs or bursitis
iv) sub acromial decompress or debridement of bony and soft tiss impinging areas
- use knee arthroscopy (pump fluid into joint)
ROTATOR CUFF TEARS
i) what is the main cause of these?
ii) which two muscle tendons are most commonly affected?
iii) what two symptoms are commonly seen?
iv) what % of over 60s have a full thickness tear? when would repair of these be implicated?
v) give another cause of RC tears? what sx technique may be used to repair it?
i) degenerative
ii) tendons of supra and infraspinatus
iii) weakness and pain
iv) 15% of over 60s have a full thickness tear which is often asymptomatic
- would repair if symptomatic
v) RC tears can be due to trauma eg falls
- repair with arthroscopy
GLENOHUMERAL JOINT PROBLEMS/ARTHRITIS
i) name three GH joint problems
ii) name three types of arthritis seen at the joint?
iii) give four symptoms of arthritis
iv) what may occur after a rotator cuff tear? how does this occur?
i) osteoarthritis, frozen shoulder, instability
ii) OA, inflammatory arthritis and cuff tear arthritis
iii) stiffness, crepitus and grinding, achy pain at rest/night, pain with activity
iv) post RC tear > RC tear arthritis
- tear can destab GH joint which impinges on acromium which causes arthritis
SHOULDER REPLACEMENT
i) what condition may this be utilised in?
ii) what is replaced in anatomic replacement? what provides the fulcrum for the power muscles? in which situation would this not be possible?
iii) when would a reversed shoulder replacement be performed? what does it create and allow?
iv) what ultimately needs to be restored for the joint to work?
i) may be used in glenohumeral arthritis
ii) anatomical - replace arthritic parts of joint
- rotator cuff provide fulcrum
- cant do if there is failure of the RC muscles eg cuff tear arthritis as the RC is torn
iii) reverse replacement > if RC is torn
- creates a mechanical fulcrum for power muscles
- allows power muscles to move the arm and keep joint stable
iv) the fulcrum needs to be restored for the joint to work
FROZEN SHOULDER
i) what is it also known as? what happens?
ii) what is the hallmark symptom? name another symptom
iii) what type of movement is lost? which specific movement is implicated?
iv) how may xray appear?
v) name three groups of people it has a higher prevalence in
i) adhesive capsulitis
- inflammed and thickened joint capsule
ii) hallmark symptom = stiffness
- also get pain
iii) loss of passive movement (doctor also cant move arm)
- external rotation is spec implicated
iv) xray may be normal
v) 40-60 yrs, female, diabetic
FROZEN SHOULDER TREATMENT
i) what is first line treatment? according to natural history how long does it take to resolve?
ii) what can be injected?
iii) what is hydrodilatation? what does it allow?
iv) what may be done surgically?
i) non surgical - takes 2 years to resolve
ii) steroid injections or
iii) hydrodilatation - steroidal fluid injected to rupture the tight capsule and increase motion
iv) sx - capsule release and manipulation via keyhole
SHOULDER INSTABILITY
i) what is the most common type of dislocation? what happens?
ii) what age group at the first dislocation are more prone to it recurring?
iii) tearing of which ligament can cause shoulder instability?
iv) give two risk factors for shoulder instability?
v) name three surgical treatments that can be given and when they are implicated
i) anterior dislocation - humeral head moves forward from joint
ii) younger age of first disloc - more likely to have more
iii) tearing of anterior labrum (bankart lesion)
iv) collision sport eg rugby
- joint hypermobility
v) arthroscopic stabilisation (labral repair)
- open stabilisation (capsule tightening)
- bony procedures (augment the glenoid - if lots of bone is missing take from hip)
TRAUMATIC CONDITIONS
i) name two types of bony trauma
ii) name two types of soft tissue trauma
iii) how is a pec major rupture identified on observation?
iv) how may a proximal humeral fracture be treated?
v) what can be the two causes of acromiocalvicular joint dislocation? how is this fixed?
i) fractures and dislocation
ii) biceps problem or pec major rupture
iii) pec major rupture - see nipple drop lower on the side of rupture
iv) prox humeral fracture - treat with nails and plates
v) AC joint disloc can be due to arthritis or dislocation
- problem with shoulder blade movement so fix down with sutures
