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Surgery Block > Orthopaedics - Shoulder and Elbow > Flashcards

Orthopaedics - Shoulder and Elbow Flashcards

1
Q

How can indirect trauma cause a radial head fracture?

A

Axial loading of the forearm causes the radial head to be pushed against the capitulum - most common with arm extended and pronated

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2
Q

What is an Essex-Lopresti fracture?

A

Fracture of the radial head with disruption of the distal radio-ulnar joint

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3
Q

What is a ‘Sail sign’?

A

Elbow effusion seen on lateral projection X Ray - seen as elevation of the anterior fat pad

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4
Q

What classification is used for radial head fractures? Briefly outline this

A

Mason Classification

  1. Non or minimally displaced (<2mm)
  2. Partial articular fracture with >2mm displacement or angulation
  3. Comminuted fracture and displacement (complete)
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5
Q

How are Mason type 1 injuries treated?

A

Non operatively - sling immobilisation for <1wk followed by early mobilisation

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6
Q

How are Mason type 2 injuries treated?

A

If no mechanical block - same as type 1

If mechanical block then ORIF

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7
Q

How are Mason type 3 injuries treated?

A

ORIF or radial head excision or replacement

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8
Q

What is a Monteggia fracture?

A

A proximal ulnar fracture with dislocation of the proximal head of the radius

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9
Q

What is a Galeazzi fracture?

A

Fracture of the distal 1/3 of the radius with dislocation of the distal radioulnar joint

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10
Q

What is the typical history for mechanism of injury for olecranon fractures?

A

FOOSH

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11
Q

What might be seen on examination of an olecranon fracture?

A

Tenderness over posterior aspect of the elbow, inability to extend the elbow against gravity

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12
Q

What classifications can be used to describe olecranon fractures?

A

Mayo classification

Schatzker classification

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13
Q

When is surgical management indicated in olecranon fractures?

A

Displacement >2mm

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14
Q

What non-surgical management is there for olecranon fractures?

A

Immobilisation in 60-90 degrees elbow flexion and early introduction of movement at 1-2 weeks

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15
Q

What surgical management can be given for olecranon fractures?

A
  • Tension band wiring

- Olecranon plating

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16
Q

What muscle causes displacement of the proximal fracture fragment in olecranon fractures?

A

Triceps brachii

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17
Q

What does tennis elbow refer to?

A

Lateral epicondylitis

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18
Q

What does golfers elbow refer to?

A

Medial epicondylitis

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19
Q

What does the term epicondylitis mean?

A

Chronic symptomatic inflammation of the forearm tendons of the elbow - caused by microtears in the tendons due to repetitive injury

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20
Q

Where does the common extensor tendon attach in the elbow?

A

Lateral epicondyle

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21
Q

What are the clinical features of lateral epicondylitis?

A

Pain in the elbow radiating down the forearm - tends to worsen over weeks-months
However full range of movement despite pain

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22
Q

What are the two specific tests for lateral epicondylitis?

A

Cozens + Mills

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23
Q

Describe Cozen’s test

A

Hold the patients elbow flexed to 90 degrees, radially deviated and pronated –> then ask the patient to extend their wrist against resistance

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24
Q

Describe Mills test

A

Palpate the lateral epicondyle whilst pronating the patients forearm, flexing the wrist and extending the elbow

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25
Q

What DDx should be considered for lateral epicondylitis?

A
  • Cervical radiculopathy
  • Elbow osteoarthritis
  • Radial carpal tunnel syndrome
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26
Q

What conservative management is there for epicondylitis?

A
  • Reduction of repetitive actions
  • Analgesia + topical NSAIDs
  • Corticosteroid injections
  • Physiotherapy
  • Orthoses (brace)
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27
Q

What surgical management can be used for epicondylitis?

A

Open or arthroscopic debridement of tendinitis and/or release or repair of damaged tendon insertions

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28
Q

What is the prognosis of lateral epicondylitis?

A

Self limiting - spontaneously improves in 80-90% of people in 1-2 years

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29
Q

What is seen on clinical examination of medial epicondylitis?

A

Tenderness over the pronator teres and flexor carpi radials tendons + insertion

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30
Q

What is adhesive capsulitis?

A

Frozen shoulder - contraction and adherence of the glenohumeral joint capsule onto the humeral head

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31
Q

What demographic does adhesive capsulitis tend to affect?

A

Women

Peaks in 40-70yrs

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32
Q

What conditions is secondary adhesive capsulitis associated with?

A
  • Rotator cuff tendinopathy
  • Previous trauma/surgery
  • Inflammatory conditions
  • Diabetes mellitus
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33
Q

What are the three stages of adhesive capsulitis?

A
  1. Painful
  2. Freezing
  3. Thawing
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34
Q

What are the main clinical features of adhesive capsulitis?

A
  • Generalised deep + constant pain of shoulder
  • Pain often disturbs sleep
  • Joint stiffness
  • Reduction in function
  • Limited ROM principally in external rotation + flexion
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35
Q

What are the main DDx for adhesive capsulitis?

A
  • Acromioclavicular pathology
  • Subacromial impingement syndrome
  • Muscular tear
  • Autoimmune disease (eg. SLE, polymyalgia, RA)
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36
Q

What is seen on MRI of a shoulder with adhesive capsulitis?

A

Thickening of the glenohumeral joint capsule

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37
Q

What is the management of adhesive capsulitis?

A

Self limiting condition (but recurrence common)

  • Education
  • Reassurance
  • Physio
  • Analgesia (paracetamol/NSAIDs)
  • Joint injections if persists
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38
Q

What surgical intervention may be given for adhesive capsulitis?

A

Joint manipulation under general anaesthetic - remove capsular adhesions

39
Q

What does subacromial impingement syndrome (SAIS) refer to?

A

Inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space

40
Q

What different pathologies does SAIS encompass?

A
  • Rotator cuff tendinosis
  • Subacromial bursitis
  • Calcific tendinitis
41
Q

Who does SAIS tend to most frequently affect?

A

Patients <25yrs

Typically active individuals or those in manual professions

42
Q

What are intrinsic mechanisms causing SAIS?

A

Pathologies of the rotator cuff tendons due to tension

  • Muscular weakness
  • Shoulder overuse
  • Degenerative tendinopathy
43
Q

What are extrinsic mechanisms causing SAIS?

A

Pathologies of the rotator cuff tendons due to external compression

  • Anatomical factors
  • Scapular musculature
  • Glenohumeral instability
44
Q

What are the main symptoms of SAIS?

A

Progressive pain in the anterior superior shoulder - Typically exacerbated by abduction + rest relief
May have some weakness/stiffness

45
Q

What tests can be done in examination for SAIS?

A
  • Neers impingement test

- Hawkins test

46
Q

What is Neers impingement test?

A

Arm placed by the patients side, fully internally rotated and then passively flexed
+ve = pain on anterolateral shoulder

47
Q

What is Hawkin’s test?

A
  • Shoulder and elbow flexed to 90
  • Examiner stabilises humerus + passive internal rotation of arm
    =ve = pain on anterolateral shoulder
48
Q

What are the main DDx for SAIS?

A
  • Muscular tear
  • Neurological pain
  • Frozen shoulder syndrome
  • Acromioclavicular pathology
49
Q

What imaging can be used to confirm SAIS? What is seen on it?

A

Shoulder MRI

  • Subacromial osteophytes
  • Sclerosis
  • Subacromial bursitis
  • Humeral cystic changes
  • Narrowing of subacromial space
50
Q

What does conservative management consist of in SAIS?

A
  • Analgesia (eg. NSAIDs)
  • Regular physio
  • Corticosteroid injections
51
Q

When is surgical intervention indicated for SAIS?

A

SAIS persisting >6months, without response to conservative management

52
Q

What surgical intervention can be used in SAIS?

A
  • Repair of muscular tears
  • Removal of subacromial bursa
  • Removal of a section of the acromion
53
Q

What are the main complications of SAIS?

A
  • Rotator cuff degeneration
  • Rotator cuff tear
  • Adhesive capsulitis
  • Cuff tear arthropathy
  • Complex regional pain syndrome
54
Q

How are rotator cuff tears classified?

A

Acute <3wks
Chronic >3wks
+
Partial vs full thickness

55
Q

How are full thickness tears subdivided?

A

Small <1cm
Medium 1-3cm
Large 3-5cm
Massive >5cm/multiple tendons

56
Q

What is the pathophysiology behind chronic rotator cuff tears?

A

Degenerative micro tears in the tendon - most commonly from overuse

57
Q

What are the risk factors for rotator cuff tears?

A
  • Age
  • Trauma
  • Overuse
  • Repetitive overhead shoulder motions
  • BMI >25
  • Smoking
  • DM
58
Q

What may be seen on examination of a rotator cuff tear?

A
  • Pain over lateral aspect of shoulder
  • Inability to abduct arm >90°
  • Tenderness over greater tuberosity + subacromial bursa
59
Q

What specific tests can be done on examination for rotator cuff tears?

A
  • Jobe’s test
  • Gerber’s loft off test
  • Posterior cuff test
60
Q

What is Jobe’s test?

A 
'Empty can test' for supraspinatus
- Shoulder in 90° abduction + 30° forward flexion
- Internally rotate fully 
- Push downwards on arm
\+ve = weakness on resistance
61
Q

What is Gerber’s lift off test?

A

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

62
Q

What is the posterior cuff test?

A 
Tests infraspinatus and teres minor
- Arm on patients side
- Elbow flexed to 90°
- Patient externally rotates arm against resistance
\+ve = weakness on resistance
63
Q

What investigation should be done for a patient presenting with features of a rotator cuff tear?

A

Urgent plain film radiograph - exclude fracture

64
Q

What may be seen on X-Ray of a chronic rotator cuff tear?

A
  • Reduced acriomoclavicular distance
  • Sclerosis
  • Cyst formation at insertion point
65
Q

What further imaging is done for a rotator cuff tear? Why?

A

USS - establish tear presence and size

MRI - detect size, characteristics and location

66
Q

When is conservative management indicated for a rotator cuff tear?

A

If presenting within 2 weeks of injury

67
Q

What conservative management is there for a rotator cuff tear?

A
  • Analgesia
  • Physiotherapy
  • Activity modification
  • Corticosteroid injections
68
Q

What surgical management is there for rotator cuff tears?

A

Arthroscopic or open repair

69
Q

What complications are there of rotator cuff tears?

A
  • Adhesive capsulitis*

- Enlargement of the tear within 5yrs

70
Q

What age groups do clavicular fractures tend to affect?

A
  • Adolescents and young adults

- >60y/o (onset of osteoporosis)

71
Q

How are clavicular fractures classified?

Outline this system

A

Allman classification system
1 - # of middle 1/3
2 - # of lateral 1/3
3 - # of medial 1/3

72
Q

What are the risks of a type 3 clavicular fracture? Why do these occur?

A

Neuromuscular compromise, pneumothorax or haemothroax –> mediastinum sits directly behind medial third

73
Q

How will the fragments of a clavicular fracture displace?

A

Medial - superiorly (pull of SCM)

Lateral - inferiorly (weight of the arm)

74
Q

Why is there risk of open injury in clavicular fractures?

A

Subcutaneous location

75
Q

What differentials should be considered in a clavicular fracture?

A
  • Sternoclavicular dislocation

- Acromioclavicular joint separation

76
Q

What imaging is required to assess a clavicular fracture?

A

Plain film anteroposterior and modified axial radiographs

77
Q

How are clavicular fractures usually managed?

A

Majority conservatively - sling
+ encouragement of early movement of the shoulder
(keep sling on until patient regains pain free movement of the shoulder)

78
Q

When is surgical management used for clavicular fractures?

A
  • Open #
  • Very comminuted #
  • Very shortened
  • Bilateral #
  • # that has failed to unite (ORIF)
79
Q

What are the main complications to look for in clavicular fractures?

A
  • Non-union
  • Neuromuscular injury
  • Puncture injury
80
Q

What is the average healing time for a clavicular fracture?

A

4-6weeks

81
Q

What is the most common type of shoulder dislocation?

A

Anteroinferior

82
Q

How is an anterior shoulder dislocation normally caused?

A

Force applied to an extended, abducted and externally rotated humerus

83
Q

How are posterior shoulder dislocations typically caused?

A

Seizures or electrocution or trauma

84
Q

What clinical features may be seen on examination of a shoulder dislocation?

A
  • Asymmetry
  • Loss of shoulder contours
  • Anterior bulge from head of humerus
85
Q

What bony injuries are shoulder dislocations commonly associated with?

A
  • Bony Bankart lesions
  • Hill-Sachs defect
  • # of greater tuberosity and surgical neck of humerus
86
Q

What labral/ligamentous problems are associated with shoulder dislocations?

A
  • Soft Bankart lesions
  • Glenohumeral ligament avulsion
  • Rotator cuff injury
87
Q

What is a bony bankart lesion?

A

Fracture of the anterior inferior glenoid bone

88
Q

What is a soft bankart lesion?

A

Avulsion of the anterior labrum and inferior glenohumeral ligament

89
Q

What is a Hill-Sachs defect?

A

Impaction injury to the chondral surface of the posterior and superior portions of the humeral head

90
Q

What is a trauma series for imaging of a shoulder dislocation?

A

Plain X ray comprising of:

  • Anterior-posterior
  • Y-scapular
  • Axial
91
Q

What is the ‘light bulb’ sign seen in?

A

Posterior shoulder dislocation

92
Q

What management is there for shoulder dislocations?

A
  1. Analgesia
  2. Closed reduction
  3. Broad arm sling
  4. Physiotherapy

If closed reduction doesn’t work - MUA

93
Q

What complications may occur post shoulder dislocation?

A
  • Chronic pain
  • Limited mobility
  • Stiffness
  • Recurrence
  • Adhesive capsulitis
  • Nerve damage
  • Rotator cuff injury
  • Degenerative joint disease
94
Q

How is the type of shoulder dislocation classified?

A

Based on the relation of the humeral head to the infraglenoid tubercle

Surgery Block (12 decks)

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