Shoulder Flashcards
Winged scapula
Damage to long thoracic nerve causing weakness of serratus anterior
Axillary nerve lesion
Deltoid wasting
Inability to abduct
Regimental badge paraesthesia
Nerve causing elbow fleixion and supination
Musculocutaneous nerve which innervates biceps brachii
Which nerve damaged in humeral neck fracture or dislocation
Axillary nerve
Which nerve damaged in humeral midshaft fracture
Radial nerve causing wrist drop
Erb’s palsy
Caused by shoulder dystocia when delivering baby with macrosomia
Damage to C5 - C6 therefore waiter’s tip
Klumpke’s palsy
Caused by sudden upwards jerk of hand e.g. grabbing tree
Damage to C8 - T1
- claw hand as cant flex fingers and abduct
Most common type of shoulder dislocation
Anterior
Bankart lesion
Tear of anteroinferior glenoid labrum
Hill Sachs lesion
• Cortical depression in the posterolateral part of the
humeral head following impaction against the
glenoid rim during anterior dislocation
Presentation of anterior shoulder dislocation
- Shoulder contour lost: appears square
- Bulge in infraclavicular fossa: humeral head
- Arm supported
- Severe pain
Mx of shoulder dislocation
- Assess for neurovascular deficit: esp. axillary N.
- X-ray: AP and lateral (Y) view
- Reduction under sedation
- Rest arm in a sling for 3-4wks
- Physio
Complications of shoulder dislocation
- Recurrent dislocation
* Axillary N. injury
Rotator cuff tear
Secondary to degeneration or a sudden jolt or fall
- Partial tears → painful arc
- Complete tear - drop arm sign
Rx: open or arthroscopic repair
Sign of complete rotator cuff tear
Drop arm sign:
- Shoulder tip pain
- Inability to abduct the arm
- Active abduction possible following passive
abduction to 90 degrees
- Lowering the arm beneath this → sudden drop
Epidemiology of clavicle fractures
Adolescents and young adults
60 + yo - associated with osteoporosis
Allman classification system
Type I – middle third of the clavicle - generally stable but significant deformity is usually present
Type II – lateral third of the clavicle
When displaced - unstable
Type III – medial third of the clavicle
- commonly associated with multi-system polytrauma
- can be associated with neurovascular compromise as mediastinum is posterior - can get pneumothorax or haemothorax
How are clavicle fractures done
direct - trauma directly onto the clavicle
indirect - fall onto the shoulder
Displacement of clavicle fractures
Medial fragment - displaces superiorly - due to the pull of the sternocleidomastoid muscle
Lateral fragment - displaces inferiorly from the weight of the arm
Clinical features of clavicle fractures
Sudden-onset localised severe pain
Worse on active movement of the arm
On examination:
- focal tenderness
- deformity and mobility at the fracture site
- essential that any threatened skin is recognised - implies impending conversion to an open injury
- Ensure to check the neurovascular status of the upper limb - brachial plexus injuries
Investigations for clavicle fracture
Shoulder examination
Neurovascular examination
Basic obs
Xray - 2 views
Mx of clavicle fractures
Conservative: Sling - elbow well supported - kept on until free movement of shoulder Early movement recommended
Surgical (not common)
- if open fracture
- very commented or shortened
- bilateral fractures
- failed union after 2 - 3 months
Complications of clavicle fractures
Non - union
Haemothorax
Pneumothorax
Brachial plexus injury
Healing time for clavicle fractures
4-6 weeks
Rotator cuff muscles and action
Supraspinatus - abduction
Infraspinatus - external rotation
Teres minor - external rotation
Subscapularis - internal rotation
Acute vs chronic rotator cuff tear
Acute - lasting <3 months
Chronic - lasting > 3 months
Pathophysiology of rotator cuff tears
Acute tears - within tendons with pre-existing degeneration with minimal force.
Or young individuals - large force - often occur alongside other injuries.
Chronic tears - degenerative microtears to the tendon, most commonly from overuse
Risk Factors for rotator cuff tears
Age
Trauma
Overuse and repetitive overhead shoulder motions - cricketers
BMI>25
Smoking
Diabetes mellitus
Presentation of rotator cuff tears
Pain over the lateral aspect of shoulder
Inability to abduct the arm above 90 degrees
Common in the dominant arm.
On examination:
Tenderness over the greater tuberosity and subacromial bursa regions
Massive rotator cuff tears - Supraspinatus and infraspinatus atrophy
Specific Tests
Empty can test - tests supraspinatus
Gerber’s lift-off test - tests subscapularis
- internally rotate arms so hands on back and push
Posterior cuff test - tests infraspinatus and teres minor
- arm positioned at patient’s side, with the elbow flexed to 90°. Patient externally rotates their arm against resistance
Investigations of a rotator cuff tear
Urgent Xray - exclude fracture
Ultrasonograhy - presence and size of tear
MRI - detect the size, characteristics and location of any tear
When to treat rotator cuff tears with conservative treatment
Conservative management - if not limited by pain or loss of function
- if within 2 weeks since the injury
- if unsuitable for surgery
Conservative management for a rotator cuff tear
Analgesia
Physiotherapy with activity modification
Corticosteroid injections into the subacromial space
Surgical Management of rotator cuff tears
Arthroscopic or open repair
Complications of rotator cuff tears
Adhesive capsulitis
Enlargement of tear
Complications of rotator cuff tears
Adhesive capsulitis
Enlargement of tear
Mechanism of proximal humeral fracture
Low energy injuries in elderly patients -osteoporosis
FOOSH
Less commonly occur in younger patients - high energy traumatic injury, often associated soft tissue or neurovascular injuries.
Risk factors for proximal humeral fracture
Increased risk of osteoporosis:
- female
- early menopause
- prolonged steroid use
- recurrent falls, and frailty.
Clinical Features of proximal humeral fractures
Pain around upper arm and shoulder
Restriction of arm movement and abduction
Significant swelling and bruising of the shoulder - can spread to the chest and down the arm
Axillary nerve damage - loss of sensation in - regimental Badge Area and loss of power of the deltoid muscle
Investigations of proximal humeral fracture
Bloods - FBC, U+Es, LFTs , coagulation and Group and Save
If pathological - serum Ca and myeloma screen
Xray - 2 views
Mx of proximal humeral fracture
Conservative:
- immobilisation - polysling
- early mobilisation 2 - 4 weeks post injury
Surgical
- If multiple segment injuries
Surgical management of proximal humeral fracture
Head splitting fracture - ORIF
Surgical neck or combined humeral shaft - intramedullary nailing
Complex injuries - Hemiarthroplasty
Low demand patients, or patients who require revision after a failed previous procedure - Reverse shoulder arthroplasty
Complications of proximal humeral fractures
Reduced range of movement - extensive physio required for approx 1 year
Avascular necrosis of the humeral head - anterior and posterior circumflex arteries
Scapular fracture mechanism of injury
Rare
High energy trauma
Mx of scapular fracture
90% non operative
10% - ORIF if glenohumeral instability, displaced scapular neck, or complex fracture patterns
Floating shoulder
Scapular neck fracture is associated with a clavicle fracture - requires fixation
Biceps tendinopathy pathophysiology and epidemiology
Painful, swollen, and structurally weaker tendon that is at risk of rupture
Common in younger individuals who are active e.g. cricket and in older individuals with degenerative tendinopathy
Clinical features of biceps tendinopathy
Pain worse with stressing the tendon (and alleviated through rest and ice therapy)
Weakness of flexion and supination and stiffness.
On examination: Tenderness over tendon.
Loss of muscle bulk due to disuse atrophy
Special tests for biceps tendinopathy
Speed test - proximal biceps tendon
– The patient stands with their elbows extended and their forearms supinated. They then forward flex their shoulders against the examiners resistance
Yergason’s test- distal biceps tendon – The patients stands with their elbows flexed to 90 degrees and their forearm pronated. They actively supinate against the examiners resistance
Investigations for bicep tendinopathy
Clinical
Bloods - FBC + CRP
Xray - to exclude other causes
Rarely used:
USS - thickening of tendons
MRI - thickened tendons and inflammation
Mx of biceps tendinopathy
- Rest
- Ice
- Physio
- Analgesia - NSAIDS
- USS guided steroid injections
Surgical mx of biceps tendinopathy
Rare:
Arthroscopic tenodesis (tendon is severed and reattached)
Tenotomy (division of the tendon) for decompression
Biceps tendon rupture classification
Complete - through entire tendon
Partial - remains partly intact
Mechanism of biceps tendon rupture
Sudden forced extension of a flexed elbow
Risk factors for biceps tendon rupture
Previous episodes of biceps tendinopathy Steroid use Smoking Chronic kidney disease (CKD) Fluoroquinolone abx
Clinical features of biceps rupture
Sudden onset pain and weakness at the affected area.
Feeling of a “pop” during the incident.
Examination:
Marked swelling and bruising in the antecubital fossa.
As the proximal muscle belly retracts (due to loss of counter traction) a bulge may appear - “reverse Popeye sign”
Special test for biceps tendon rupture
Hook test - for distal rupture
The elbow is actively flexed to 90º and fully supinated, the examiner attempts to ‘hook’ their index finger underneath the lateral edge of the biceps tendon (which cannot be done in a ruptured biceps tendon)
Ix of biceps rupture
Mostly clinical
USS for diagnosis
MRI if USS inconclusive
Mx of biceps rupture
If lower demand - conservative approach
- Analgesia and physiotherapy
Surgery:
Anterior single-incision or a dual incision technique performed within few weeks of injury
Why can flexion and supination still occur in biceps tendon rupture?
Due to brachialis and supinator
