Orthopaedics - shoulder & arm Flashcards
What is adhesive capsulitis?
Glenohumeral joint capsule becomes contracted and adherent to the humeral head
Can result in shoulder pain and a reduced range of movement in the shoulder
More common in women, peak onset is between 40-70 years old
Describe clinical features of adhesive capsulitis
Generalised deep and constant pain of the shoulder (often disturbs sleep)
Joint stiffness, reduction in function
Examination – loss of arm swing, atrophy of the deltoid muscle, generalised tenderness on palpation
Limited range of motion – principally affecting external rotation and flexion of the shoulder
List the differential diagnosis of adhesive capsulitis
Acromioclavicular pathology
Subacromial impingement syndrome
Muscular tear
Autoimmune disease
List investigations done for adhesive capsulitis
Diagnosis is typically a clinical one
Plain film radiographs – generally unremarkable, rule out other causes
MRI imaging – reveal thickening of the glenohumeral joint capsule
More common in diabetic patients
Describe the management of adhesive capsulitis
Self-limiting condition however recurrence is not uncommon
Initial management – involves education and reassurance, patients should be encouraged to keep active & physiotherapy
Simple analgesics & glenohumeral joint corticosteroid injections may be considered for those patients failing to improve
Surgical intervention – joint manipulation under general to remove capsular adhesions to the humerus, arthrogaphic distension/surgical release of the glenohumeral joint capsule
What is biceps tendinopathy?
Tendinopathy = used to encompass a variety of pathological changes that occur in tendons, typically due to overuse -> results in a painful, swollen and structurally weaker tendon that is risk of rupture
Can occur in both the proximal and distal bicep tendons – common in younger active individuals & older individuals with more of a degenerative tendinopathy
Describe the clinical features of biceps tendinopathy
Pain made worse with stressing the tendon, associated with weakness and stiffness
Examination – patient will demonstrate tenderness over the affected tendon, may be loss of muscle bulk due to disuse atrophy
List the special tests that can be performed specifically for biceps tendinopathy
Speed test (proximal biceps tendon) – patient stands with their elbows extended & their forearms supinated. They then forward flex their shoulders against the examiners resistance
Yergason’s test (distal biceps tendon) – patient stands with their elbows flexed to 90 degrees and their forearm pronated. Actively supinate against the examiners resistance
List investigations for biceps tendinopathy
Largely clinical
Blood tests and plain film radiographs can be undertaken as first line investigations, exclude other differentials
Describe the management of biceps tendinopathy
Majority – treated conservatively, with the use of analgesia & ice therapy as first line
Physiotherapy
USS steroid injections can be useful in cases unresponsive to initial conservative management
List risk factors for bicep tendon rupture
Previous episodes of biceps tendinopathy
Steroid use
Smoking
Chronic kidney disease
Use of fluoroquinolone antibiotics
Describe clinical features of biceps tendon rupture
Sudden onset pain and weakness at the affected area
Patient often report the feeling of a pop during the incident
Examination – marked swelling and bruising in the antecubital fossa, ‘reverse popeye sign’
What is the hook test (for potential distal tendon rupture)?
Elbow is actively flexed to 90 degrees and fully supinated, the examiner attempts to hook their index finger underneath the lateral edge of the biceps tendon
List investigations for bicep tendon rupture
Can be diagnosed clinically
Confirmation obtained via ultrasound imaging
If USS inconclusive, an MRI scan may be warranted to further assess
Describe the non-operative management of biceps tendon rupture
For lower demand patients, a conservative approach may be most suitable
Analgesia and physiotherapy form the mainstay of conservative management, often allowing for significant recovery of muscle strength and function
Describe the operative management of biceps tendon rupture
An anterior single incision or a dual incision technique will be required
Operation involves forming a bone tunnel in the radius and re-inserting the ruptured tendon end
Surgical repair should occur within a few weeks of initial injury, otherwise tendon will retract and scar (reconstruction with tendon allograft is therefore often required)
Main complications: injury to lateral antebrachial cutaneous nerve, posterior interosseous nerve or radial nerve
Describe the classification of clavicle fractures
Allman classification system
Type I – fracture of the middle third of the clavicle
Type II – fracture involving the lateral third of the clavicle
Type III – fracture in the medial third of the clavicle, commonly associated with multi-system polytrauma
Describe pathophysiology of clavicle fractures
Will occur through either a direct/indirect mechanism of injury
Medial fragment will often displace superiorly due to the pull of SCM
Lateral fragment will displace inferiorly from the weight of the arm
Describe the clinical features of clavicle fractures
Sudden-onset localised severe pain, made worse on active movement of the arm
Examination – focal tenderness, with deformity and mobility at the fracture site
List investigations for clavicle fractures
Plain film anteroposterior and modified-axial radiographs of affected clavicle
CT (rarely indicated) – may be needed to assess medial clavicle injuries
Describe non-operative management of clavicle fractures
Most can be treated conservatively
Initial treatment – with a sling, which should be properly applied so that elbow is well supported & improves the deformity (generally kept on until the patient regains pain-free movement of the shoulder)
Early movement of shoulder joint is recommended (to prevent frozen shoulder)
Describe surgical management of clavicle fractures
All open fractures will need surgical intervention
Remainder – reserved for very comminuted fractures or those that are very shortened, bilateral fractures
Fractures that have failed to unite – open-reduction internal-fixation (ORIF) will be necessary 2-3 months post-injury
List complications of clavicle fractures
Non-union (most associated with distal third clavicular fractures)
Neurovascular injury
Any puncture (haemothorax or pneumothorax)
Describe a humeral shaft fracture
Bimodal distribution – younger patients due to high energy trauma & elderly patients following low impact injuries
Can also occur as pathological fractures
Outline the clinical features of a humeral shaft fracture
Pain and deformity
Radial nerve involvement – reduced sensation over the dorsal 1st webspace & weakness in wrist extension
Examination – check & document neurovascular status, assess for open wounds
What is a Holstein-Lewis fracture?
Fracture of the distal third of the humerus resulting in the entrapment of the radial nerve
Resultant neuropraxia to the radial nerve will result in loss of sensation & a wrist drop deformity
Urgent surgical management is indicated
List investigations of humeral shaft fracture
Anteroposterior (AP) and lateral plain film radiographs of the humerus
Severely comminuted cases – CT imaging may be requested
Describe the non-operative management of humeral fractures
Mainstay – re-alignment of the limb & majority can be treated conservatively in a functional humeral brace
Suitable for conservative management - < 20 degrees anterior angulation, <30 degrees varus/valgus angulation & with <3cm of shortening
Describe the surgical management of humeral fractures
Typically involves open reduction and internal fixation (ORIF) with a plate
Intramedullary nailing may be indicated in the presence of pathological fractures, polytrauma or severely osteoporotic bones
List complications of a humeral shaft fracture
Non-union and mal-union are important complications
Around 90% of radial nerve injuries will improve within 3 months any intervention
Describe the classification of rotator cuff tears
Classified as either acute (<3 months) or chronic (>3 months), either partial thickness or full thickness tears
Full thickness tears can be further classified into small, (<1cm), medium (1-3cm), large (3-5cm) or massive (>5cm or involves multiple tendons) tears
List the actions of the different rotator cuff muscles
Supraspinatus – abduction
Infraspinatus – external rotation
Teres minor – external rotation
Subscapularis – internal rotation
Describe the pathophysiology of rotator cuff tears
Acute tears – occur in tendons with pre-existing degeneration, typically occurring alone following minimal force
Chronic tears – occur in individuals with degenerative microtears to the tendon
List risk factors for rotator cuff tears
Age
Trauma
Overuse
Repetitive overhead shoulder motions
Obesity, smoking & diabetes mellitus
Outline the clinical features of rotator cuff tears
Pain over the lateral aspect of the shoulder
Inability to abduct the arm above 90 degrees
Examination – tenderness over the greater tuberosity & subacromial bursa regions
Describe the specific tests of rotator cuff muscles
Jobe’s tests (tests supraspinatus) – place the shoulder in 90 degree abduction and 30 degree of forward flexion and internally rotate fully, gently push downwards on the arm
Gerber’s lift-off test (tests subscapularis) – internally rotate the arm so the dorsal surface of hand rests on lower back, then ask the patient to life hand away from back against examiner resistance
Posterior cuff test (tests infraspinatus and teres minor) – the arm positioned at patient’s side, with the elbow flexed to 90 degrees, then the patient is instructed to externally rotate their arm against resistance
List investigations for rotator cuff muscles
Should have an urgent plain film radiograph to exclude a fracture
Once fracture has been excluded, use ultrasonography to establish the presence & size of tear, whilst MRI imaging can be used to detect the size, characteristics & location of the tear
Describe conservative management of rotator cuff tears
Preferred in patients who are not limited by pain/loss of function
Presenting within 2 weeks since injury can be managed conservatively – analgesia & physiotherapy with activity modification
Describe surgical management of rotator cuff tears
Presenting 2 weeks since the injury/remaining symptomatic despite conservative management
Repairs can be done arthroscopically or via open approach
Name the main complication of rotator cuff tears
Adhesive capsulitis
Compare anterior vs posterior dislocation of the shoulder
Anterior dislocation – caused by force being applied to an extended, abducted and external rotated humerus
Posterior dislocation – typically caused by seizures or electrocution, but can occur through trauma (a direct blow to the anterior shoulder/force through a flexed adducted arm)
List the clinical features of shoulder dislocations
Painful shoulder, acutely reduced mobility & feeling of instability
Examination – an asymmetry with the contralateral side, loss of shoulder contours and an anterior bulge from the head of the humerus
Describe the associated injuries of shoulder dislocations
Bony:
-bony barkart lesions: fractures of the anterior inferior glenoid bone, most commonly present in those with recurrent dislocations
-hill-sachs defects: impaction injuries to the chondral surface of the posterior and superior portions of the humeral head
-fractures of the greater tuberosity & surgical neck of humerus can also occur
Labral, ligamentous and rotator cuff:
-soft bankart lesions: avulsions of the anterior labrum and inferior glenohumeral ligament
-glenohumeral ligament avulsion
-rotator cuff injuries
List the investigations for shoulder dislocations
Plain radiographs: at least 2 views performed (AP, Y-scapular and/or axial views)
MRI of shoulder may be useful for soft tissue injuries
Describe the x-ray findings for different shoulder dislocations
Anterior – humeral head is completely displaced out of glenoid fossa
Posterior – ‘light bulb sign’ = as the humerus is fixed in internal rotation
Y view is very useful for differentiating between anterior and posterior dislocations
Describe the management of shoulder dislocations
A to E trauma assessment
Appropriate analgesia
Principle – reduction, immobilisation and rehabilitation (a closed reduction, such as Hippocratic method, should be performed by a trained specialist)
Once reduced, the arm should be performed be placed in to a broad-arm sling (typically 2 weeks with early physiotherapy)
List complications of shoulder dislocations
Chronic pain
Limited mobility
Stiffness
Recurrence
Adhesive capsulitis, nerve damage & rotator cuff injury
Degenerative joint disease
What is the most common site of a shoulder fracture?
Proximal humerus
Describe the aetiology of proximal humeral fractures
Low energy injuries occurring in elderly patients FOOSH – occurs primarily in the context of an osteoporosis
Younger patients as a result of high energy traumatic injury
List risk factors for low energy proximal humerus fractures
Female gender
Early menopause
Prolonged steroid use
Recurrent falls
Frailty
Describe the clinical features of proximal humerus fractures
Pain around the upper arm and shoulder with restriction of arm movement & inability to abduct their arm
Examination – likely to be significant swelling & bruising of the shoulder
Important to check axillary nerve & circumflex vessels: loss of sensation in the lateral shoulder & loss of power of the deltoid muscle
List investigations of proximal humerus fractures
Urgent bloods
Plain film radiographs – AP, lateral scapular & axillary views are all required
CT scan – can be used for preoperative planning
What classification system is used for proximal humeral fractures?
Neer classification system – based on the relationship between 4 main segments:
1) Greater tuberosity
2) Lesser tuberosity
3) Articular segment
4) Humeral shaft
Considered a separate part if there is displacement > 1cm or 45 degrees angulation
Describe the management of proximal humeral fractures
Majority can be managed conservatively
Patient requires immobilisation initially with early mobilisation inc. pendular exercises at 2-4 weeks post injury (must have a correctly applied polysling that allows their arm to hang)
Describe the surgical management of proximal humeral fractures
Surgical fixation – displaced, open or neurovascularly compromised fractures
Patients with multiple segment injuries may be managed with ORIF/intramedullary nailing
Hemiarthroplasty – can be performed in a small number of patients who experience complex injuries
Reverse shoulder arthroplasty – option for low demand patients (ball and socket portions of the shoulder joint are reversed)
List complications of a proximal humeral fracture
Reduced range of motion
Avascular necrosis of the humeral head
What is subacromial impingement syndrome (SAIS)?
Refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space
Most commonly occurs in patients < 25 years, typically in active individuals or in manual professions
Describe the pathophysiology of subacromial impingement syndrome
Intrinsic mechanisms – involve pathologies of the rotator cuff tendons due to tension:
1) Muscular weakness
2) Overuse of the shoulder
3) Degenerative tendinopathy
Extrinsic mechanisms – pathologies of the rotator cuff tendons due to external compression:
1) Anatomical factors
2) Scapular musculature
3) Glenohumeral instability
Describe the clinical features & examination findings of SAIS
Progressive pain in the anterior superior shoulder, classically exacerbated by abduction
Neers impingement test – arm is fully internally rotated & then passively flexed: is positive if there is pain in the anterolateral aspect of the shoulder
Hawkins test – shoulder & elbow are flexed to 90 degrees, with examiner stabilising the humerus and passively internally rotating the arm: is positive if pain in the anterolateral aspect of the shoulder
List differential diagnoses of SAIS
Muscular tear
Neurological pain
Frozen shoulder syndrome
Acromioclavicular pathology
List investigations for SAIS
Clinical diagnosis, often confirmed via additional imaging
MRI imaging
Describe the conservative management of SAIS
Sufficient analgesia, regular physiotherapy
Corticosteroid injections in the subacromial injections
Describe the surgical intervention of SAIS
SAIS persists beyond 6 months without response to conservative management -> surgical management:
1) Surgical repair of muscular tears
2) Surgical removal of the subacromial bursa
3) Surgical removal of a section of the acromion
List the complications of SAIS
Rotator cuff degeneration & tear
Adhesive capsulitis
Cuff tear arthropathy
Complex regional pain syndrome
