Session 8 Common Shoulder Conditions

Question 1

Most common shoulder dislocation

Answer 1

Anterior

Question 2

Why does head of humerus displace in an anterior direction

Answer 2

Due to pull of muscles and disruption of anterior capsule and ligaments

Question 3

Locations of displacement of humerus

Answer 3

60% are sub coracoid

30% are subglenoid

Question 4

Arm held in what position during dislocated shoulder anteriorly

Answer 4

External rotation and slight abduction

Question 5

Mechanisms of anterior shoulder dislocation

Answer 5

Hand behind head (abduction and external rotation). Forces arm further posterior

Direct blow to posterior shoulder

Question 6

Force of humeral head popping out of socket often causes

Answer 6

Part of glenoid labrum to be torn off - Bankart lesion or labral tear

Sometimes a small piece of bone is torn off with labrum

Question 7

Why does posterior aspect of humeral head sometimes become jammed against anterior lip of glenoid fossa in shoulder dislocation anteriorly

Answer 7

Tone of infraspinatus and teres minor muscles

Hills-Sachs lesion (indentation fracture)

Increased risk of secondary osteoarthritis

Question 8

Posterior dislocations of shoulder mechanism

Answer 8

Violent muscle contractions due to seizure, electrocution or lightening strike

Arm flexed across body and pushed posteriorly

Blow to anterior shoulder

Question 9

Posterior shoulder dislocation presentation

Answer 9

Internally rotated and adducted

Flattening of shoulder with prominent coracoid process

Cannot be externally rotated into anatomical position

Question 10

X ray sign of posterior dislocation of shoulder

Answer 10

Lightbulb sign

Question 11

Injuries commonly associated with posterior shoulder dislocation

Answer 11

Fractures, rotator cuff tears, Hills-Sachs lesions

Question 12

Inferior dislocation mechanism

Answer 12

Forceful traction on arm when its fully extended over head

Question 13

Injuries associated with inferior dislocation

Answer 13

Damage to nerves, rotator cuff tears, injury to blood vessel

Question 14

Most common complication of shoulder dislocation

Answer 14

Recurrent dislocation due to damage to stabilising tissues leading to increased risk of osteoarthritis

Question 15

Other complications of shoulder dislocation

Answer 15

Damage to axillary artery- haematoma, absent pulses or cool limb, more common in old as blood vessels less elastic

Axillary nerve injuries- usually recover fully

Cords of brachial plexus or musculocutaneous nerve damaged- rare

Fractures - usually traumatic, first-time dislocation, or age 40+

Rotator cuff muscle tears - older

Question 16

80% of clavicle fractures occur in

Answer 16

Middle third

Question 17

Common cause of clavicle fracture and treatment

Answer 17

Fall onto shoulder or outstretched hand

Sling or surgery

Question 18

Surgery needed in clavicle fracture if

Answer 18

• Complete displacement, severe - - - -displacement causing tenting of skin with risk of puncture
• Open fractures
• Neurovascular compromise
• Interposed muscle
• Floating shoulder (clavicle fracture with ipsilateral fracture of glenoid neck)

Question 19

What happens to position of arm and clavicular fragments in a displaced mid-clavicular fracture

Answer 19

Sternocleidomastoid muscle elevates medial segment

Trapezius unable to hold lateral segment up against weight of upper limb so shoulder drops

Arm is pulled medially by pectoralis major (adduction)

Question 20

General complications associated with fracture healing

Answer 20

Non-union or malunion

Question 21

Local complications of clavicle fracture

Answer 21

Pneumothorax injury

Injury to neurovascular structures- subscapular nerve damaged by medial elebation

or supraclavicular nerves (C3 and 4) results in Parasthesia of upper chest anterioly

Question 22

Rotator cuff tear is

Answer 22

A tear of one or more tendons of the 4 rotator cuff muscles of shoulder

Most commonly Supraspinatus

Question 23

Rotator cuff tears reason

Answer 23

Acute
Chronic
Age related degeneration - degenerative micro-trauma model

Question 24

Principles of degenerative microtrauma model

Answer 24

Blood supply decreases 
Age-related degeneration 
Chronic microtrauma 
Partial tendon tears 
Full tears 
Inflammatory cells cause oxidative stress
Tenocyte apoptosis 
Further degeneration

Question 25

What shoulder injury is often asymptomatic

Answer 25

Rotator cuff tear

Question 26

Most common rotator cuff tear presentation

Answer 26

Anterolateral shoulder pain, often radiating down the arm

Pain when leaning on elbow and pushing down

Pain when reaching forward/flexing shoulder

Pain-restricted movement above the horizontal position

Weakness of shoulder abduction

Question 27

Scans for rotator cuff tear

Answer 27

MRI and ultrasound

Question 28

What is impingement syndrome

Answer 28

Supraspinatus tendon impinges on coraco-Acromial arch leading to irritation and inflammation

Question 29

3 causes of impingement syndrome

Answer 29

Thickening of coracoacromial ligament
Inflammation of Supraspinatus tendon
Subacromial osteophytes

Question 30

Impingement syndrome symptoms

Answer 30

Shoulder abducted or flexed narrows space

Pain, weakness and reduced ROM

Worsened by shoulder overhead movement or at night

Dull lingering pain

Grinding or popping during movement

Question 31

Most common form of impingement syndrome

Answer 31

Impingement of Supraspinatus tendon under acromion during abduction

Painful arc between 60 and 120 degrees

Question 32

What is calcific Supraspinatus tendinopathy

Answer 32

Presence of deposits of hydroxyapatite in tendon of Supraspinatus

Can occur in any tendon of rotator cuff

Question 33

Presentation of calcific Supraspinatus tendinopathy

Answer 33

Acute or chronic pain

Aggravated by abducting or flexing the arm above the level of the shoulder or by lying on the shoulder

Mechanical symptoms- stiffness, snapping sensation, catching, or reduced range of movement of the shoulder

Question 34

Theories of calcific tendinopathy

Answer 34

Regional hypoxia leads to tenocytes being transformed into chondrocytes and laying down cartilage

Ectopic bone formation from metaplasia of mesenchymal stem cells normally present in tendons into osteogenic cells

Question 35

Calcific deposits visibility

Answer 35

Visible on X ray

Crystalline in resting phase

Eventually re absorbed by phagocytes- this stage causes most pain. Look like toothpaste and appear cloudy on x ray

Question 36

Calcific Supraspinatus tendinopathy

Answer 36

Treatment is initially conservative with rest and analgesia. Surgical treatment is sometimes required for persistent symptoms

Question 37

What is adhesive capsulitis

Answer 37

Frozen shoulder

Capsule of glenohumoral joint becomes inflamed and stiff, greatly restricting movement and causing chronic pain

Question 38

Frozen shoulder presentation

Answer 38

Constant pain
Worse at night
Exacerbated by movement and cold weather

Question 39

Cause of frozen shoulder

Answer 39

Possible autoimmune component, triggered by localised trauma

Question 40

Risk factors for frozen shoulder

Answer 40

Female 
Epilepsy with tonic seizures 
Diabetes Mellitis 
Trauma to shoulder 
CVD
Parkinson’s

Question 41

Frozen shoulder treatment

Answer 41

Physiotherapy, analgesia and anti-inflammatory medication

Manipulation under anaesthesia to break up adhesions and scar tissue to restore ROM

Typically resolves with time- 90% regain motion

More likely opposite shoulder will become affected

Question 42

Features of osteoarthritis in shoulder

Answer 42

Usually 50+

Commonly affects acromioclavicular joint rather than glenohumoral

Question 43

Treatment ladder for shoulder OA

Answer 43

Activity mods
Analgesia
NSAIDs
Glucosamine and chondroitin sulphate nutritional supplements
Steroid injections
Hyaluronic acid injections for lubrication
Arthroscopy (remove loose pieces of damaged cartilage)
Hemiarthroplasty (replace humeral head) or total shoulder replacement (and glenoid)