Orthopaedics - Shoulder and Elbow Flashcards
How can indirect trauma cause a radial head fracture?
Axial loading of the forearm causes the radial head to be pushed against the capitulum - most common with arm extended and pronated
What is an Essex-Lopresti fracture?
Fracture of the radial head with disruption of the distal radio-ulnar joint
What is a ‘Sail sign’?
Elbow effusion seen on lateral projection X Ray - seen as elevation of the anterior fat pad
What classification is used for radial head fractures? Briefly outline this
Mason Classification
- Non or minimally displaced (<2mm)
- Partial articular fracture with >2mm displacement or angulation
- Comminuted fracture and displacement (complete)
How are Mason type 1 injuries treated?
Non operatively - sling immobilisation for <1wk followed by early mobilisation
How are Mason type 2 injuries treated?
If no mechanical block - same as type 1
If mechanical block then ORIF
How are Mason type 3 injuries treated?
ORIF or radial head excision or replacement
What is a Monteggia fracture?
A proximal ulnar fracture with dislocation of the proximal head of the radius
What is a Galeazzi fracture?
Fracture of the distal 1/3 of the radius with dislocation of the distal radioulnar joint
What is the typical history for mechanism of injury for olecranon fractures?
FOOSH
What might be seen on examination of an olecranon fracture?
Tenderness over posterior aspect of the elbow, inability to extend the elbow against gravity
What classifications can be used to describe olecranon fractures?
Mayo classification
Schatzker classification
When is surgical management indicated in olecranon fractures?
Displacement >2mm
What non-surgical management is there for olecranon fractures?
Immobilisation in 60-90 degrees elbow flexion and early introduction of movement at 1-2 weeks
What surgical management can be given for olecranon fractures?
- Tension band wiring
- Olecranon plating
What muscle causes displacement of the proximal fracture fragment in olecranon fractures?
Triceps brachii
What does tennis elbow refer to?
Lateral epicondylitis
What does golfers elbow refer to?
Medial epicondylitis
What does the term epicondylitis mean?
Chronic symptomatic inflammation of the forearm tendons of the elbow - caused by microtears in the tendons due to repetitive injury
Where does the common extensor tendon attach in the elbow?
Lateral epicondyle
What are the clinical features of lateral epicondylitis?
Pain in the elbow radiating down the forearm - tends to worsen over weeks-months
However full range of movement despite pain
What are the two specific tests for lateral epicondylitis?
Cozens + Mills
Describe Cozen’s test
Hold the patients elbow flexed to 90 degrees, radially deviated and pronated –> then ask the patient to extend their wrist against resistance
Describe Mills test
Palpate the lateral epicondyle whilst pronating the patients forearm, flexing the wrist and extending the elbow
What DDx should be considered for lateral epicondylitis?
- Cervical radiculopathy
- Elbow osteoarthritis
- Radial carpal tunnel syndrome
What conservative management is there for epicondylitis?
- Reduction of repetitive actions
- Analgesia + topical NSAIDs
- Corticosteroid injections
- Physiotherapy
- Orthoses (brace)
What surgical management can be used for epicondylitis?
Open or arthroscopic debridement of tendinitis and/or release or repair of damaged tendon insertions
What is the prognosis of lateral epicondylitis?
Self limiting - spontaneously improves in 80-90% of people in 1-2 years
What is seen on clinical examination of medial epicondylitis?
Tenderness over the pronator teres and flexor carpi radials tendons + insertion
What is adhesive capsulitis?
Frozen shoulder - contraction and adherence of the glenohumeral joint capsule onto the humeral head
What demographic does adhesive capsulitis tend to affect?
Women
Peaks in 40-70yrs
What conditions is secondary adhesive capsulitis associated with?
- Rotator cuff tendinopathy
- Previous trauma/surgery
- Inflammatory conditions
- Diabetes mellitus
What are the three stages of adhesive capsulitis?
- Painful
- Freezing
- Thawing
What are the main clinical features of adhesive capsulitis?
- Generalised deep + constant pain of shoulder
- Pain often disturbs sleep
- Joint stiffness
- Reduction in function
- Limited ROM principally in external rotation + flexion
What are the main DDx for adhesive capsulitis?
- Acromioclavicular pathology
- Subacromial impingement syndrome
- Muscular tear
- Autoimmune disease (eg. SLE, polymyalgia, RA)
What is seen on MRI of a shoulder with adhesive capsulitis?
Thickening of the glenohumeral joint capsule
What is the management of adhesive capsulitis?
Self limiting condition (but recurrence common)
- Education
- Reassurance
- Physio
- Analgesia (paracetamol/NSAIDs)
- Joint injections if persists
What surgical intervention may be given for adhesive capsulitis?
Joint manipulation under general anaesthetic - remove capsular adhesions
What does subacromial impingement syndrome (SAIS) refer to?
Inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space
What different pathologies does SAIS encompass?
- Rotator cuff tendinosis
- Subacromial bursitis
- Calcific tendinitis
Who does SAIS tend to most frequently affect?
Patients <25yrs
Typically active individuals or those in manual professions
What are intrinsic mechanisms causing SAIS?
Pathologies of the rotator cuff tendons due to tension
- Muscular weakness
- Shoulder overuse
- Degenerative tendinopathy
What are extrinsic mechanisms causing SAIS?
Pathologies of the rotator cuff tendons due to external compression
- Anatomical factors
- Scapular musculature
- Glenohumeral instability
What are the main symptoms of SAIS?
Progressive pain in the anterior superior shoulder - Typically exacerbated by abduction + rest relief
May have some weakness/stiffness
What tests can be done in examination for SAIS?
- Neers impingement test
- Hawkins test
What is Neers impingement test?
Arm placed by the patients side, fully internally rotated and then passively flexed
+ve = pain on anterolateral shoulder
What is Hawkin’s test?
- Shoulder and elbow flexed to 90
- Examiner stabilises humerus + passive internal rotation of arm
=ve = pain on anterolateral shoulder
What are the main DDx for SAIS?
- Muscular tear
- Neurological pain
- Frozen shoulder syndrome
- Acromioclavicular pathology
What imaging can be used to confirm SAIS? What is seen on it?
Shoulder MRI
- Subacromial osteophytes
- Sclerosis
- Subacromial bursitis
- Humeral cystic changes
- Narrowing of subacromial space
What does conservative management consist of in SAIS?
- Analgesia (eg. NSAIDs)
- Regular physio
- Corticosteroid injections
When is surgical intervention indicated for SAIS?
SAIS persisting >6months, without response to conservative management
What surgical intervention can be used in SAIS?
- Repair of muscular tears
- Removal of subacromial bursa
- Removal of a section of the acromion
What are the main complications of SAIS?
- Rotator cuff degeneration
- Rotator cuff tear
- Adhesive capsulitis
- Cuff tear arthropathy
- Complex regional pain syndrome
How are rotator cuff tears classified?
Acute <3wks
Chronic >3wks
+
Partial vs full thickness
How are full thickness tears subdivided?
Small <1cm
Medium 1-3cm
Large 3-5cm
Massive >5cm/multiple tendons
What is the pathophysiology behind chronic rotator cuff tears?
Degenerative micro tears in the tendon - most commonly from overuse
What are the risk factors for rotator cuff tears?
- Age
- Trauma
- Overuse
- Repetitive overhead shoulder motions
- BMI >25
- Smoking
- DM
What may be seen on examination of a rotator cuff tear?
- Pain over lateral aspect of shoulder
- Inability to abduct arm >90°
- Tenderness over greater tuberosity + subacromial bursa
What specific tests can be done on examination for rotator cuff tears?
- Jobe’s test
- Gerber’s loft off test
- Posterior cuff test
What is Jobe’s test?
'Empty can test' for supraspinatus - Shoulder in 90° abduction + 30° forward flexion - Internally rotate fully - Push downwards on arm \+ve = weakness on resistance
What is Gerber’s lift off test?
Tests subscapularis
- Internally rotate arm so dorsal surface of hand rests on lower back
- Patient lifts hand off back against resistance
+ve = weakness in lifting hand away
What is the posterior cuff test?
Tests infraspinatus and teres minor - Arm on patients side - Elbow flexed to 90° - Patient externally rotates arm against resistance \+ve = weakness on resistance
What investigation should be done for a patient presenting with features of a rotator cuff tear?
Urgent plain film radiograph - exclude fracture
What may be seen on X-Ray of a chronic rotator cuff tear?
- Reduced acriomoclavicular distance
- Sclerosis
- Cyst formation at insertion point
What further imaging is done for a rotator cuff tear? Why?
USS - establish tear presence and size
MRI - detect size, characteristics and location
When is conservative management indicated for a rotator cuff tear?
If presenting within 2 weeks of injury
What conservative management is there for a rotator cuff tear?
- Analgesia
- Physiotherapy
- Activity modification
- Corticosteroid injections
What surgical management is there for rotator cuff tears?
Arthroscopic or open repair
What complications are there of rotator cuff tears?
- Adhesive capsulitis*
- Enlargement of the tear within 5yrs
What age groups do clavicular fractures tend to affect?
- Adolescents and young adults
- >60y/o (onset of osteoporosis)
How are clavicular fractures classified?
Outline this system
Allman classification system
1 - # of middle 1/3
2 - # of lateral 1/3
3 - # of medial 1/3
What are the risks of a type 3 clavicular fracture? Why do these occur?
Neuromuscular compromise, pneumothorax or haemothroax –> mediastinum sits directly behind medial third
How will the fragments of a clavicular fracture displace?
Medial - superiorly (pull of SCM)
Lateral - inferiorly (weight of the arm)
Why is there risk of open injury in clavicular fractures?
Subcutaneous location
What differentials should be considered in a clavicular fracture?
- Sternoclavicular dislocation
- Acromioclavicular joint separation
What imaging is required to assess a clavicular fracture?
Plain film anteroposterior and modified axial radiographs
How are clavicular fractures usually managed?
Majority conservatively - sling
+ encouragement of early movement of the shoulder
(keep sling on until patient regains pain free movement of the shoulder)
When is surgical management used for clavicular fractures?
- Open #
- Very comminuted #
- Very shortened
- Bilateral #
- # that has failed to unite (ORIF)
What are the main complications to look for in clavicular fractures?
- Non-union
- Neuromuscular injury
- Puncture injury
What is the average healing time for a clavicular fracture?
4-6weeks
What is the most common type of shoulder dislocation?
Anteroinferior
How is an anterior shoulder dislocation normally caused?
Force applied to an extended, abducted and externally rotated humerus
How are posterior shoulder dislocations typically caused?
Seizures or electrocution or trauma
What clinical features may be seen on examination of a shoulder dislocation?
- Asymmetry
- Loss of shoulder contours
- Anterior bulge from head of humerus
What bony injuries are shoulder dislocations commonly associated with?
- Bony Bankart lesions
- Hill-Sachs defect
- # of greater tuberosity and surgical neck of humerus
What labral/ligamentous problems are associated with shoulder dislocations?
- Soft Bankart lesions
- Glenohumeral ligament avulsion
- Rotator cuff injury
What is a bony bankart lesion?
Fracture of the anterior inferior glenoid bone
What is a soft bankart lesion?
Avulsion of the anterior labrum and inferior glenohumeral ligament
What is a Hill-Sachs defect?
Impaction injury to the chondral surface of the posterior and superior portions of the humeral head
What is a trauma series for imaging of a shoulder dislocation?
Plain X ray comprising of:
- Anterior-posterior
- Y-scapular
- Axial
What is the ‘light bulb’ sign seen in?
Posterior shoulder dislocation
What management is there for shoulder dislocations?
- Analgesia
- Closed reduction
- Broad arm sling
- Physiotherapy
If closed reduction doesn’t work - MUA
What complications may occur post shoulder dislocation?
- Chronic pain
- Limited mobility
- Stiffness
- Recurrence
- Adhesive capsulitis
- Nerve damage
- Rotator cuff injury
- Degenerative joint disease
How is the type of shoulder dislocation classified?
Based on the relation of the humeral head to the infraglenoid tubercle
