Shoulder Flashcards
What could occur if shoulder dislocations are not managed correctly?
Chronic joint instability
Chronic pain
What is the most common type of shoulder dislocation?
Anterior (anterior-inferior)
What is the usually mechanism of anterior shoulder dislocations?
Force being applied to an extended, abducted and externally rotated humerus
What are the causes of posterior shoulder dislocations?
Seizures
Electrocution
Direct trauma to anterior shoulder
What may you observe in someone with an anterior shoulder dislocation?
Loss of shoulder contours - asymmetrical
Anterior bulge from head of humerus may be seen
What nerves may be injured in an anterior shoulder dislocation?
Axillary nerve as this wraps around the humeral neck
Some case suprascapular nerve
What assessment should be done before and after reduction in shoulder dislocations?
Neurovascular
What views on x-ray for the shoulder should be requested for in shoulder dislocation?
AP
Y-scapula
Axillary
What other things should be considered in shoulder dislocations?
Fractures
Soft tissue injuries
What does the Axillary nerve innervate?
Sensory - regimental badge area
Motor - deltoid and teres minor
What are the associated injuries with anterior shoulder dislocations?
Labral tear/bankart lesion
Bony bankart lesion
Hill-sachs defect
Humeral avulsion of the glenohumeral ligament (HAGL)
Greater tuberosity or surgical neck fracture
Nerve injury
Rotator cuff injury - usually in elderly
What is the initial investigations for shoulder dislocations?
X-rays - trauma shoulder series
What is the initial management in the emergency department for shoulder dislocations?
Adequate analgesia- gas/air, oramorph, i.v. Morphine
Closed reduction - Hippocratic method
Broad-arm-sling
What are the other options if closed reduction is unsuccessful in shoulder dislocations?
Manipulation under GA in theatre - x-ray guidance
Open-reduction
When would you not attempt closed reduction in shoulder dislocations?
When there is a associated surgical neck of humerus fracture - this requires ORIF
What imaging should be arranged if labral or rotator cuff injury/ ongoing instability is suspected in shoulder dislocations?
MRI ateriogram
What should be done after shoulder reduction in shoulder dislocation?
Repeat x-ray + neurovascular exam
If happy the put in broad- arm sling + physio and review pt in fracture clinic in 2 weeks
When would surgical treatment be warranted in the future for shoulder dislocations?
Ongoing shoulder pain and instability
Large Hill-Sachs defect or bony bankart lesions
What should be done if Axillary nerve function is compromised?
Physio and reassess in 6 weeks
If still no improvement the refer to nephrophysiologist for nerve conduction studies.
What are the complications/ prognosis of shoulder dislocations?
Chronic pain
Limited mobility
Stiffeness
Recurrent shoulder dislocations - more common in younger pts
Adhesive capsulitis
Nerve damage
Rotator cuff injuries
Degenerative joint disease - OA
What questions should be asked specifically in history of frozen shoulder?
Is sleep affected by night pain?
History of DM
What is a significant examination finding in frozen shoulder?
Loss in ROM in both active and passive is the same
Loss of arm swing and atrophy of deltoid muscle - late stage
What are the secondary cause of adhesive capsulitis?
Trauma Surgery Rotator cuff tendinopathy Subacromial impingement syndrome Biceps tendinopathy Known joint arthropathy
What are the three stages of adhesive capsulitis and how long do they roughly last?
Freezing/painful - pain at rest and movement + loss of ROM - (6 wks - 9 months)
Frozen/stiff - pain improves but significant reduction in ROM (another 4-9 months)
Thawing - no/little pain, slow improvement in ROM - (5-26 months)
Which movements are usually affected in frozen shoulder initially?
External rotation
Flexion
Abduction
What are the differential diagnosis for frozen shoulder?
OA - ether the glenohumeral joint or acromioclavicular joint
Subacromial impingement syndrome - passive movement preserved
Muscular tear
Autoimmune disease - polymyalgia rheumatica
What investigations should requested for adhesive capsulitis?
Usually clinical diagnosis
X-ray - rule out fractures or OA
MRI - can reveal thickening of glenohumeral joint capsule but also rule out other conditions
What should be done if someone presents with frozen shoulder with no obvious risk factors or cause?
HBA1c an blood glucose should be measured as this may confirm DM
What can happen over many years in frozen shoulder?
Disuse osteopenia
Roughly how long will frozen shoulder last if untreated?
2-3 years
What is the conservative management for adhesive capsulitis?
Education and reassurance
Physio
Adequate analgesics
Glenohumeral steroid injections
What are the surgical options for adhesive capsulitis?
MUA - manipulation under GA - to remove adhesions - risk of dislocation
Arthrogaphic distension
Surgical release of the glenohumeral joint capsule
What are the complications of adhesive capsulitis?
Small proportion will never regain full ROM
Recurrence in contralateral shoulder
What structures run with the Subacromial space?
Rotator cuff tendons
Long head of biceps
Coraco-acromial ligament
Subacromial bursa
Which individual is SAIS most common?
Pts under 25
Active individuals or in manual professions
What are the findings on history/examination of a pt with SAIS?
Pain on overhead activity
Night pain
Painful arc
What tests can be perform on examination on someone with suspected SAIS?
Hawkins-Kennedy test
Empty can test
Neers impingement test
Scarf test
What is the most common pathology of SAIS?
Degenerative
What are the differential diagnosis of SAIS?
Muscular tear
Neurological pain
OA
Frozen shoulder
What investigations should be ordered for someone with suspected SAIS?
USS
MRI
What are the conservative management options for SAIS?
Analgesia - NSAIDS
Physio
Subacromial space steroid injections
After what period of time would you consider further surgical management of SAIS?
6 months of conservative and still significant impact on quality of life
What are the surgical options for SAIS?
Arthroscopic Subacromial decompression:
- surgical repair of muscular tears - requires immediate structured physio
- surgical removal of Subacromial bursa
- surgical removal of a section of the acromion
Followed by physio
What are the complications of SAIS?
Rotator cuff degeneration and tear
Adhesive capsulitis
Complex regional pain syndrome
What are the classifications of rotator cuff tears?
Acute < 3 months
Chronic > 3 months
Can be partial or full thickness
Full thickness can be classified into: Small <1 cm Medium 1-3 cm Large 3-5 cm Massive >5cm - multiple tendons
What are the two cause of rotator cuff tears?
Trauma
Degenerative - more common
What are the risk factors for rotator cuff tears?
Increasing age
Trauma
Overuse and repetitive overhead shoulder motions
BMI>25, smoking, DM
What are the clinical feature of rotator cuff tears?
Pain on lateral aspect of shoulder - tenderness over greater tuberosity
Inability to abduct arm above 90 degrees
Atrophy my be seen in massive tears
What are the special tests performed on examination of rotator cuff tears and what are they testing?
Empty can test (Jobes test) - supraspinatus
Gerbers lift-off test - subscapularis
Posterior cuff test - infraspinatus an tere minor
What are the differential diagnosis for rotator cuff tears?
Fracture
Glenohumeral subluxation
Brachial plexus injury
Radiculopathy
What investigations should be requested for rotator cuff tears?
X-ray - rule out fractures - may show evidence of reduced acromiohumeral distance
USS
MRI
What are the indications for conservative management and what are the options in rotator cuff tears?
Pts who are not limited by pain or loss of function, those who have significant co-morbities and are unsuitable for surgery, presenting within 2 weeks of injury
Analgesia and physio
Corticosteroid injections in Subacromial space
What are the surgical options for rotator cuff tears?
Arthroscopic repair
Open repair
Who has poorer outcomes after surgery of rotator cuff tears?
Large or massive tears
>65 yrs old
Poor compliance to rehab program
Current smokers
What is the main complication of rotator cuff tears?
Adhesive capsulitis
Enlargement of tear
What is the most common site for shoulder fracture?
Proximal humerus
What is the normal mechanism of a proximal humeral fracture?
Low energy in elderly pts with osteoporosis on FOOSH
What are the risk factors for low energy proximal humeral fractures?
Osteoporosis risk factors:
- female
- Early menopause
- Prolonged steroid use
- Recurrent falls
- frailty
What are the clinical feature for proximal humeral fractures?
Pain around upper arm and shoulder
Restriction of movement esp abduction
Significant swelling and bruising of shoulder which can spread to the chest and down the arm
Which structures may be damaged in proximal humeral fractures?
Axillary nerve
Circumflex vessels
What investigations should be done for proximal humeral fractures?
Urgent bloods - coagulation and G&S
If pathological suspected then serum calcium and myeloma screen
X-ray - AP, lateral scapular, Axillary views
CT - surgical planning
What is the classification system used for proximal humeral fractures?
Neer classification system
Which 4 segment of the proximal humerus is the neer classification system based off?
Greater tuberosity
Lesser tuberosity
Articular segment (anatomical neck)
Humeral shaft (surgical neck)
What is the conservative management for, minimally displaced with no neurovascular compromise, proximal humeral fractures?
Immobilisation intially with early mobilisation including pendulum exercises at 2-4 weeks post injury.
Correctly applied polysling that allows arm to hand and effect of gravity on the arm will aid the reduction of the fragments
What are the surgical options for proximal humeral fractures?
ORIF - head splitting fractures
IM nail - fracture involving surgical neck or shaft
Hemiarthroplasty - small number of pts with complex injuries who may have significant complications if treated with ORIF
Reverse shoulder arthroplasty - option fr low demand pts or pts who require revision after failed previous procedure
What are the complication of proximal humeral fractures?
Reduced range of motion and extensive physiotherapy will be required to regain full function an reduce pain. Can take up to a year.
AVN of humeral head - if blood supply (anterior + posterior humeral circumflex arteries) damaged - requires hemiarthroplasty or reverse shoulder arthroplasty
What is the the age distribution of olecranon fractures?
Bimodal age distribution- high energy in young and low-energy indirect in elderly
What is the mechanism of injury in indirect olecranon fractures?
FOOSH
How can you tell on examination if the triceps mechanism is damaged in olecranon fractures?
Inability to extend the elbow against gravity
What investigations would be requested in suspected olecranon fractures?
Routine bloods
X-ray - AP and lateral
CT for more complex injuries
What classifications systems are the for olecranon fractures?
Mayo classification
Schatzker classification
What are the non-operative management for olecranon fractures?
If displacement <2mm
Immobilisation in 60-90 degrees and early intro of range of motion at 1-2 weeks - increase use of non operative management in pts over 75 irrespective of displacement
What are the operative management option for olecranon fractures?
Displacement >2mm
Tension band wiring - if fracture proximal to the coronoid process
Olecranon plating - if at the level or distal to the coronoid process
