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Yr3 Surgery: Orthopaedics > Shoulder 1 > Flashcards

Shoulder 1 Flashcards

1
Q

Remind yourself of the bony anatomy of the shoulder

A
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2
Q

State the 4 rotator cuff muscles

A
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3
Q

State the origins and insertions of each of the muscles of the rotator cuff

A
  • Subscapularis:
    • O: subscapular fosssa of scapula
    • I: lesser tubercle of humerus
  • Supraspinatous:
    • O: supraspinous fossa of scapula
    • I: greater tubercle of humerus
  • Infraspinatous:
    • O: infraspinatous fossa of scapula
    • I: greater tubercle of humerus
  • Teres minor:
    • O: posterior aspect of superior half of lateral border of scapula
    • I: greater tubercle of humerus
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4
Q

Remind yourself of the ligaments of the shoulder

A

Extra notes:

  • Glenohumeral ligament has 3 parts: superior, middle, inferior
  • Transverse humeral ligmanet: between greater and lesser tubercle of humerus- long tendon of biceps brachii passes under it
  • Coracoclavicular ligament: composed of trapezoid and deltoid ligament. Conoid more medial
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5
Q

State some common shoulder conditions you need to be aware of

A
  • Impingement syndrome
  • ACJ arthritis
  • Frozen shoulder
  • Rotator cuff tears
  • Biceps tendinopathy
  • Dislocation
  • Fractures
    • Clavicular
    • Humeral shaft
    • Scapula & glenoid fractures
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6
Q

State some common shoulder problems in the following age groups:

  • Young adult <30yrs
  • Middle age 40-60yrs
  • Elderly >65yrs
  • Pain and weakness at any age
A
  • Young adult <30yrs- more likely to have instability
  • Middle age 40-60yrs- impingement/ACJ arthritis, frozen shoulder
  • Elderly >65yrs- arthritis, frozen shoulder
  • Pain and weakness at any age- any age, rule out rotator cuff tear
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7
Q

State some differentials for shoulder shoulder symptoms

A
  • Cervical spine pathology
  • Brachial plexus injury
  • Infection
  • Tumourss
  • Thoracic outlet/inlet syndrome
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8
Q

State some key aspects of a history for someone presenting with shoulder problems

A
  • Age
  • Sex
  • Pain (SQITARS)**​
  • Stiffness (timing?)
  • Instability
  • History of trauma
  • How it is affecting activities of daily living
  • Hand dominance
  • Occupation
  • Sports/hobbies
  • PMH
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9
Q

If someone describes their pain as the following, suggest what the diagnosis could be:

  • Pain at ACJ joint
  • Severe
  • Pain at night
  • Aggravated by overhead activities
  • Assoicated weakness
  • Lack of active & passive movement
A
  • Pain at ACJ joint- ACJ OA
  • Severe- rule out septic arthritis, acute calcific tendinitis
  • Pain at night- arthritis, rotator cuff tear
  • Aggravated by overhead activities- impingement syndrome, ACJ arthritis
  • Assoicated weakness- rotator cuff trear
  • Lack of active & passive movement- frozen shoudler or arthritis
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10
Q

If a young person presents with shoulder instability and has had previous significant injury in the joint, what might be going on?

If a young person presents with shoulder instability but has never injured the joint, what might be going on?

A
  • Recurrent dislocation or they can’t trust the joint
  • Muscle coordination problems
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11
Q

What is impingement syndrome/subacromial impingement syndrome?

Who is it common in?

How does it present?

A
  • Inflammation and irritation of the structures passing through the subacromial space. Structures: supraspinatus ligament, long head of biceps and subacromial bursa
  • Middle age (40-60yrs) but may also see in young pts who are active or in manual professions
  • Presents wtih:
    • Progressive pain in anterior superior shoulder
    • Pain exacerbated by abduction
    • Pain releived by rest
    • Weakness
    • Stiffness
    • Reduced range of motion
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12
Q

State some risk factors for developing impingement syndrome

A
  • Repetitive use of shoulder (repetitive microtrauma can cause inflammation of tendons)
  • Weakness in rotator cuff muscles (muscular imbalances may shift humerus proximally and decrease SA space)
  • Congential or acquired anatomical variations in shape and gradient of acromion (decrease SA space)
  • Instability of glenohumeral joint (superior subluxation of humerous decreasing SA space)

*All of above can decrease subacromail space

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13
Q

The underlying cause of impingement syndrome can be divided into intrinsic & extrinsic mechanisms; state some intrinsic mechanism and some extrinsic mechanisms

A

Intrinsic (pathology of rotator cuff tendons due to tension)

  • Weakness rotator cuff
  • Overuse of shoulder leading to repetitive microtrauma
  • Degenerative tendinopathy (degenerative cahnges of acromion can lead to tearing of rotator cuff which allows proximal migration of humeral head)

Extrinsic (pathology of rotator cuff tendons due to external compression)

  • Anatomical varaitions in shape and/or gradient of acromion
  • Reduction in function of scapular muscles may reduce size of SA space
  • Abnormalty of glenohumeral joint can lead to superior subluxation of humerus and reduce SA space
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14
Q

What may you find on clinical examination of someone with impingement syndrome?

A
  • Reduced range of motion
  • Painful arc 60-120 degrees
  • Hawkins test positive
  • Neers impingement test positive
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15
Q

Explain how to do each of the following:

  • Neers Impingement test
  • Hawkins test
A

Neers Impingement test

Arm placed by pts side, fully internally rotated then passively flexed. If pain in anterolateral aspect of shoulder= positive

Hawkins test

Shoulder and elbow flexed to 90 degrees. Examiner stablises humerus and passively internally rottes the arm. If pain in anterolateral aspect of shoulder= positive

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16
Q

Diagnosis of impingement syndrome is mainly a clinical one however it is often confirmed with imaging; what imaging is used to confirm SAIS and what might you see?

A

MRI

  • Narrowing of subacromial space
  • Subacromial osteophytes and scleroisis
  • Subacromial bursitis
  • Humeral cystic changes
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17
Q

Discuss the management of impingement syndrome

A

1. Conservative

  • Analgesia e.g. paracetamol, NSAIDs
  • Physiotherapy
  • Activity modification

2. Corticosteroid injections in subacromial space

3. Athroscopic subacromial decompression surgery (if persists beyond 6 months without response to previous treatment). Options include:

  • Surgical repair of muscle tairs
  • Surgical removal of subacromial bursa (bursectomy)
  • Surgical removal of section of acromion (acriomioplasty)
18
Q

State some potential complications of SAIS

A
  • Rotator cuff degeneration and tear
  • Adhesive capsulitis
  • Cuff tear athropathy
  • Complex regional pain syndrome
19
Q

What is ACJ arthritis?

What age range does it commonly affect?

How does it present?

A
  • Osteoarthritis affecting the acromioclavicular joint
  • Middle aged (40-60yrs)
  • Presentation:
    • Pain in anterior, superior shoulder
    • Pain worse with overhead activities
    • Pain worse when bring arm across chest
    • Difficulty sleeping on affected side
20
Q

State some risk factors for developing ACJ arthritis

A
  • Repetitive overhead activity
  • Previous injury (e.g. AC joint separation)
  • Age
21
Q

What may you find on clinical examination of someone with ACJ arthritis?

A
  • Tender over ACJ
  • May be bigger bump over affected joint if there has been previous injury
  • Scarf test positive
22
Q

Explain how to do the scarf test

A
  • Shoulder flexed at 90 degrees
  • Elbow flexed at 90 degrees
  • Support elbow with your hand
  • Place other hand on pts scapula (you don’t want their scapula to move too much as this will interfere with results of test)
  • Push pts arm further into horizontal adduction/across chest

Positive result is pain in ACJ region

23
Q

Diagnosis of ACJ arthritis is mainly clinical however imaging may be done to rule out other pathologies e.g. USS, MRI, x-ray. What might you see on USS of pt with ACJ arthritis?

A

Partial tears of rotator cuff- no treatment required

24
Q

Discuss the management of ACJ arthritis

A

1. Conservative

  • Analgesia e.g. paracetamol, NSAIDs
  • Physiotherapy
  • Activity modification

2. Corticosteroid injections into ACJ

3. ACJ excision athroplasty

***PPT seems to suggest that x-ray required before intrarticular steroid injection

25
Q

What is adhesive capsulitis also known as?

What is adhesive capsulitis?

Who does it commonly affect?

A
  • Frozen shoulder
  • Fibrosis of the glenohumeral joint capsule in which the glenohumeral joint capsule becomes contracted and adherent to the humeral head
  • Women> men, 40-70yrs
26
Q

Adhesive capsulitis can be categorised as primary or secondary; expalin the difference and state some conditions which can result in secondary adhesive capsulitis

A
  • Primary= idiopathic
  • Secondary= associated with a cause e.g. rotator cuff tendinopathy, SAIS, biceps tendinopathy, previous surgery or trauma, known joint athropathy
27
Q

Adhesive capsulitis is associated with inflammatory diseases and current theory suggests it may have an autoimmune element; true or false?

A

True, can be associated with thyroid disease, diabetes.

28
Q

If a person has had adhesive capsulitis in their left shoulder there is no increased risk of adhesive capsulitis in their right shoulder; true or false?

A

False- if previosuly been affected by adhesive capsulitis more susceptible to developing condition in the contralateral shoulder

29
Q

State some risk factors for adhesive capsulitis

A
  • Female
  • Age
  • Thyroid disease
  • Diabetes
  • Shoulder joint athropathy
  • SAIS
  • Rotator cuff tendinopathy
  • Previous surgery or trauma
  • Biceps tendinopathy
  • Previous adhesive capsulitis in other shoulder
30
Q

State symptoms of adhesive capsulitis

A
  • Deep, constant pain of shoulder that may radiate to bicep
  • Pain often distrubs sleep
  • Joint stiffness
  • Reduced movement
  • Limited range of motion (primarily affecting external rotation and flexion of shoulder)
31
Q

What might you find on clinical examination of someone with adhesive capsulitis?

A
  • Loss of arm swing when walking
  • Atrophy of deltoid muscle
  • Tenderness on palpation
  • Reduced range of motion
    • Reduced external rotation
    • Reduced flexion of shoulder
32
Q

What movement in particular is reduced in pts with adhesive capsulitis?

A
  • External rotation
  • Flexion of shoulder
33
Q

Diagnosis of adhesive capsulitis is largely clinical however you may do some investigations; state what investigations you may do and why

A
  • X-ray: rule out other pathology. In adhesive capsulitis x-rays often unremarkable
  • MRI: rule out other conditions affecting shoulder e.g. SIAS. But may see thickening of glenohumeral joint capsule in adhesive capsulitis
  • HbA1c and plasma glucose: more common in diabetic pts therefore may screen for diabetes
34
Q

Discuss the management of adhesive capsulitis

A

1. Conservative

  • Education (importnace of keeping active)
  • Reassurance (usually self-limiting)
  • Physiotherapy
  • Analgesia (e.g. paracetamol, NSAIDs)

2. Corticosteroid injection in glenohumeral joint

3. Surgery

  • Manipulate joint under general anaesthetic
  • Athoscopic release
  • Arthrographic distension
35
Q

How long can it take for adhesive capsulitis to get better?

When would we offer surgery?

A
  • Can take up to 2 yrs
  • Consider surgery if no improvement after 4-6 months of initial measures

*NOTE: a proportion of pts never recover full range of movement

36
Q

State some potential complications of adhesive capsulitis

A
  • Small proportion never regain full range of motion
  • Reoccurence in contralateral shoulder
37
Q

Adhesive capsulitis progresses in 3 stages; state the name of stage and what happens in each stage

A
  1. Freezing: 0-3 months, quite painful, insidious onset of pain & global loss of movement
  2. Frozen: 4-6 months, pain starts to get better but continued stiffness
  3. Thawing: 6+ months, symptoms & ROM improve
38
Q

Degenerative joint disease can present similarly to all conditions discusses in this deck; present with progressive pain and restricted ROM. State some causes of degnerative joint disease

A
  • OA
    • General wear & tear
    • Post-traumatic
    • Large cuff tear
  • RA
39
Q

It may be difficult to distinguish between degenerative joint disease and other pathology; what imaging could we do to try and rule out degenerative joint disease?

A

X-ray of joint

40
Q

Remind yourself of the role of each of the following ligaments:

  • Glenohumeral
  • Coracoacromial
  • Coracoclavicular
A
  • Glenohumeral: main source of stability for shoulder, prevent anterior dislocation
  • Coracoacromial: prevents superior dislocation
  • Coracoclavicular: maintain the alignment of the clavicle in relation to the scapula
  • Coracohumeral: prevents superior dislocation

Yr3 Surgery: Orthopaedics (14 decks)

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