Orthopaedics: Upper Limb

Question 1

What forms the shoulder girdle?(5)

Answer 1

Scapula, Clavicle, Proximal Humerus, Deltoid, Rotator Cuff muscles

Question 2

Primary source of stability within the shoulder joint

Answer 2

Rotator cuff muscles

Question 3

Movement provided by supraspinatous

Answer 3

initiation of abduction

Question 4

Movement provided by infraspinatous

Answer 4

external rotation

Question 5

Movement provided by teres minor

Answer 5

external rotation

Question 6

Movement provided by subscapularis

Answer 6

internal rotation

Question 7

Shoulder problems commonly encountered by young adults

Answer 7

Instability problems

Question 8

Shoulder problems commonly encountered by middle aged adults

Answer 8

Rotator cuff tears - grey hair = cuff tear

Question 9

Shoulder problems commonly encountered by the elderly

Answer 9

Osteoarthritis

Question 10

Which muscle tends to be most commonly affected by painful arc?

Answer 10

supraspinatous

Question 11

Pathophysiology of painful arc?

Answer 11

tendons of the rotator cuff are compressed in the subacromial space during movement

Question 12

What degree of movement is affected by painful arc (impingement syndrome)?

Answer 12

60-120 degrees

Question 13

Causes of impingement syndrome (painful arc; 4)

Answer 13

tendonitis, subacromial bursitis; acromioclavicular OA with inferior osteophyte, hooked acromion rotator cuff tear

Question 14

Where does pain from impingement syndrom radiate to?

Answer 14

deltoid and upper arm

Question 15

Test for impingement syndrome (painful arc)

Answer 15

Hawkins-Kennedy test - flexion of the shoulder followed by internal rotation (turning the forearm down)

Question 16

Treatment options for painful arc/impingement syndrome (2)

Answer 16

Conservative; physiotherapy, NSAIDs, subacromial steroid injections (up to 3), analgesia; surgical decompression either open or arthroscopically

Question 17

Most common muscle to tear in the rotator cuff

Answer 17

Supraspinatous

Question 18

Classic history of a rotator cuff tear injury

Answer 18

sudden jerk in a patient, >40 years old, subsequent pain and weakness

Question 19

What change is seen with supraspinatous tears?

Answer 19

weakness initiating abduction

Question 20

What change is seen with infraspinatous tears?

Answer 20

weakness of external rotation

Question 21

What change is seen with subscapularis tears?

Answer 21

weakness of internal rotation

Question 22

Test for supraspinatous tear

Answer 22

Jobes test

Question 23

How is Jobes test carried out?

Answer 23

Testing Supraspinatous - arms out in front, slight abducted, straight and hands pronated so thumbs are facing floor. Ask patient to maintain position while you push down

Question 24

How do you test infraspinatous?

Answer 24

Arms locked by side, elbows at 90˚ and abduct forearms - test by pushing against your resistance

Question 25

How do you test subscapularis?

Answer 25

have dorsum of the hand against the buttocks and ask patient to push hand back against you

Question 26

Treatment of impingement syndrome/painful arc

Answer 26

Conservative - physiotherapy to strengthen other muscles to compensate for supraspinatous +/- subacromial injection; Surgical repair which may fail as tendons are usually diseased.

Question 27

Adhesive capsulitis

Answer 27

progressive pain and stiffness of the shoulder in patients between 40 and 60. resolves after 18-24months

Question 28

Stages of adhesive capsulitis

Answer 28

Freezing (2-9mnths, most painful); frozen (4-12mnths); thawing

Question 29

Principle sign of adhesive capsulitis is…

Answer 29

loss of external rotation (tested for by having arms at 90˚ by the side and asking to push out

Question 30

Associations of adhesive capsulitis (3)

Answer 30

diabetes, hypercholesteraemia, duputrens disease

Question 31

Treatment of adhesive capsulitis?

Answer 31

physiotherapy and analgesia, intra-articular injections (pain phase), surgery is cannot tolerate the functional loss due to stiffness

Question 32

pathophysiology of adhesive capsulitis

Answer 32

capsule and glenohumeral ligaments become inflammed and then thicken.

Question 33

Acute calcific tendonitis of the shoulder

Answer 33

Acute onset severe shoulder pain caused by calcium deposits on the supraspinatous tendon just proximal to the greater tuberosity

Question 34

Treatment for acute calcific tendonitis of the shoulder

Answer 34

pain relief from subacromial steroid and LA injections - condition is self-limiting and pain will ease as calcification resorbs.

Question 35

Instability of the shoulder joint

Answer 35

painful and abnormal translational movement or subluxation AND/Or recurrent dislocation

Question 36

Traumatic instability

Answer 36

traumatic anterior dislocation which should settle and stabilise with rest and physiotherapy post-reduction

Question 37

What age group are more likely to have recurrent dislocations of the shoulder?

Answer 37

<20years at the time of first location predicts an 80% chance of recurrence

Question 38

Age group least likely to have recurrent dislocations of the shoulder?

Answer 38

> 30 years at the time of first location predicts a 20% chance of recurrence

Question 39

What is atraumatic instability?

Answer 39

patients with generalised ligamentous laxity can have pain from recurrrent multi-directional subluxation and dislocations

Question 40

Treatment for traumatic instability with dislocation recurrence?

Answer 40

Bankart repair –> re-attaches labrum and capsule to the anterior glenoid