Ortho - Upper limb Flashcards
Biceps brachii.
a) Attachment
b) Function
c) Rupture causes what sign?
a) Long head (supraglenoid tubercle of scapula), short head (coracoid process), insertion at radial tuberosity via bicipital aponeurosis.
b) Supination of forearm and flexion at elbow
c) Popeye sign
Shoulder pain: common causes
a) Young
b) Middle aged
c) Elderly
d) All ages (less common causes)
e) Causes of referred pain to shoulder
a) Instability disorders. Rotator cuff disorders
b) Rotator cuff disorders. Frozen shoulder.
c) Glenohumeral joint OA, Rotator cuff
d) - Inflammatory arthritis / PMR (women especially)
- Septic arthritis.
- Acromioclavicular joint disorders.
- Metastatic bone disease
- Referred pain
e) - Neck
- Gallbladder (gallstones, cholecystitis)
- Heart (ACS) and lungs
- Malignancy
- Ectopic pregnancy
Shoulder pain: red flags
a) Trauma, pain and weakness, or sudden loss of ability to actively raise the arm (with or without trauma)
b) Any shoulder mass or swelling
c) Red skin, painful joint, fever or the person is systemically unwell
d) Trauma leading to loss of rotation and abnormal shape
e) New symptoms of inflammation in several joints: suspect inflammatory arthritis.
a) suspect acute rotator cuff tear.
b) suspect malignancy.
c) suspect septic arthritis.
d) possible shoulder dislocation.
e) inflammatory arthritis/ PMR
Joint instability.
a) Subluxation
b) Dislocation
c) More common in who?
a) Subluxation refers to a joint in which there is partial displacement of the articular surfaces but still some joint surface-to-surface contact.
b) A dislocated joint has lost all cartilage surface-to-surface contact.
c) Young, FHx, ligament damage, athletes
Scapular winging
a) muscular cause
b) neuronal cause
a) Serratus anterior/trapezius
b) Long thoracic nerve lesion / C5/6/7
Rotator cuff muscles.
a) Give the 4 muscles and the movements /tests that isolate each
b) Give their job as a whole
c) Proportion of people over age 60 and age 70 with a rotator cuff disorder
d) Give some types of rotator cuff disorders (what is the most common?)
e) Clinical features of rotator cuff disorders
a) - Supraspinatus: abduction (first 15 degrees), resistance against empty can test
- Infraspinatus/teres minor: external rotation, resistance against external rotation
- Subscapularis: internal rotation (resistance against hand lift-off/ belly press)
b) Glenohumeral joint stability (prevent deltoid from lifting the head of humerus up)
c) 60% over 60 and 70% over 70 (leads to rotator cuff arthropathy)
d) Most common: subacromial impingement syndrome. Others: rotator cuff tear (partial or full thickness), rotator cuff tendonitis, rotator cuff bursitis
e) - Pain in anterior/superior shoulder
- Worse on raising arm
- May be associated with weakness (more likely if tear)
- O/E: Worse on abduction/flexion, specific tests
Rotator cuff disorders: management
a) General (also applicable to frozen shoulder)
b) When to refer to orthopaedics - urgent and routine
a) - Rest and gradually build up activity
- Analgesia (paracetamol, NSAIDs or codeine
- Consider CS injection (no more than 2 injections in each shoulder, and don’t repeat if previously no benefit)
- Physiotherapy referral
b) - Acute tear suspected (urgent)
- Red flags (urgent)
- Failure of conservative management (for 3 months?)
- Severe functional limitation/pain
Acromioclavicular joint arthritis
a) What test elicits pain?
a) Cross-arm (scarf) test
Nerve injury: give causes and presentation
a) Axillary
b) Radial
c) Ulnar
d) Median
e) Musculocutaneous
a) Anterior shoulder dislocation : weakness of abduction (deltoid) and regimental badge/C5/C6 sensory loss
b) Mid-humeral fracture : weakness in wrist/finger extension and dorsal hand sensory loss
c) Cubital tunnel syndrome/medial epicondylar fracture: weakness in finger abduction, ulnar aspect of hand sensory loss
d) Carpal tunnel/supracondylar fracture of humerus: weakness in thumb opposition/wrist flexion, medial aspect of hand sensory loss
e) Shoulder injury/surgery: weak elbow flexion and forearm supination (biceps), lateral forearm sensory loss
Calcific tendonitis.
a) What is it?
b) Cause? (which itself is usually secondary to…?)
a) Calcification of the rotator cuff tendons
b) Prolonged subacromial impingement, which itself is usually secondary to rotator cuff disorder
Subacromial impingement vs. differentials.
a) If weakness prominent - consider…?
b) If weakness and shooting pain/paraesthesia - ?
c) If stiffness prominent/more generalised pain - ?
d) Test for impingement
a) Rotator cuff tear, neurological deficit
b) Neuro (e.g. thoracic outlet syndrome, cervical radiculopathy, brachial plexus injury)
c) Frozen shoulder / OA
d) Neer’s impingement test (fully internally rotate shoulder, then passively flex. Positive if painful reproduction)
4 year old girl fell off a pony and presents with painful swollen upper arm just above the elbow. You struggle to palpate the radial pulse.
a) Likely diagnosis
b) Management
a) Supracondylar fracture of the humerus
b) Orthopaedic emergency due to vascular compromise
67 year old woman falls while out shopping and complains of pain in her arm, clutching it to her side. There is full range of movement in the wrist and no obvious deformity
a) Likely diagnosis
b) If there was a wristdrop, What would be more likely?
a) Fractured surgical neck of humerus
b) humeral shaft fracture (causing radial nerve palsy)
27 year old cricketer presents with pain in the right shoulder following bowling in a game. Pain at night in right shoulder. Also some pain in neck.
-O/E: painful limitation of abduction and internal rotation. Good external rotation.
a) Likely diagnosis
b) Management
a) Supraspinatus tear: most common rotator cuff tear, leads to limited abduction (painful arc) and internal rotation
b) - Arrange urgent USS (most cost effective modality for rotator cuff imaging)
- NSAIDs while waiting
- If tear extensive - refer to orthopaedics for surgical repair
- If partial tear - physiotherapy, rest and NSAIDs (note: only refer to physio the once diagnosis is confirmed so exercises can be targeted)
Acute shoulder dislocation: management
a) Initial
b) And then…
c) indication for referral to shoulder surgeon
d) Recovery time
a) - Reduction and analgesia
- Confirm no axillary nerve/vessel damage.
- XR before and after reduction to look for any fracture or soft tissue injury
b) Fracture clinic referral, physiotherapy 6 weeks, consider need for surgery
c) 1st dislocation, recurrent painful dislocation, refractory to PT, associated injuries (eg rotator cuff tear, fracture), significant impact on ADLs/ QoL
d) 3 - 4 months
