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T&O > Shoulder > Flashcards

Shoulder Flashcards

1
Q

What could occur if shoulder dislocations are not managed correctly?

A

Chronic joint instability

Chronic pain

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2
Q

What is the most common type of shoulder dislocation?

A

Anterior (anterior-inferior)

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3
Q

What is the usually mechanism of anterior shoulder dislocations?

A

Force being applied to an extended, abducted and externally rotated humerus

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4
Q

What are the causes of posterior shoulder dislocations?

A

Seizures
Electrocution
Direct trauma to anterior shoulder

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5
Q

What may you observe in someone with an anterior shoulder dislocation?

A

Loss of shoulder contours - asymmetrical

Anterior bulge from head of humerus may be seen

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6
Q

What nerves may be injured in an anterior shoulder dislocation?

A

Axillary nerve as this wraps around the humeral neck

Some case suprascapular nerve

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7
Q

What assessment should be done before and after reduction in shoulder dislocations?

A

Neurovascular

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8
Q

What views on x-ray for the shoulder should be requested for in shoulder dislocation?

A

AP
Y-scapula
Axillary

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9
Q

What other things should be considered in shoulder dislocations?

A

Fractures

Soft tissue injuries

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10
Q

What does the Axillary nerve innervate?

A

Sensory - regimental badge area

Motor - deltoid and teres minor

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11
Q

What are the associated injuries with anterior shoulder dislocations?

A

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

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12
Q

What is the initial investigations for shoulder dislocations?

A

X-rays - trauma shoulder series

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13
Q

What is the initial management in the emergency department for shoulder dislocations?

A

Adequate analgesia- gas/air, oramorph, i.v. Morphine
Closed reduction - Hippocratic method
Broad-arm-sling

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14
Q

What are the other options if closed reduction is unsuccessful in shoulder dislocations?

A

Manipulation under GA in theatre - x-ray guidance

Open-reduction

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15
Q

When would you not attempt closed reduction in shoulder dislocations?

A

When there is a associated surgical neck of humerus fracture - this requires ORIF

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16
Q

What imaging should be arranged if labral or rotator cuff injury/ ongoing instability is suspected in shoulder dislocations?

A

MRI ateriogram

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17
Q

What should be done after shoulder reduction in shoulder dislocation?

A

Repeat x-ray + neurovascular exam

If happy the put in broad- arm sling + physio and review pt in fracture clinic in 2 weeks

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18
Q

When would surgical treatment be warranted in the future for shoulder dislocations?

A

Ongoing shoulder pain and instability

Large Hill-Sachs defect or bony bankart lesions

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19
Q

What should be done if Axillary nerve function is compromised?

A

Physio and reassess in 6 weeks

If still no improvement the refer to nephrophysiologist for nerve conduction studies.

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20
Q

What are the complications/ prognosis of shoulder dislocations?

A

Chronic pain
Limited mobility
Stiffeness
Recurrent shoulder dislocations - more common in younger pts

Adhesive capsulitis
Nerve damage
Rotator cuff injuries
Degenerative joint disease - OA

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21
Q

What questions should be asked specifically in history of frozen shoulder?

A

Is sleep affected by night pain?

History of DM

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22
Q

What is a significant examination finding in frozen shoulder?

A

Loss in ROM in both active and passive is the same

Loss of arm swing and atrophy of deltoid muscle - late stage

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23
Q

What are the secondary cause of adhesive capsulitis?

A 
Trauma 
Surgery 
Rotator cuff tendinopathy 
Subacromial impingement syndrome 
Biceps tendinopathy 
Known joint arthropathy
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24
Q

What are the three stages of adhesive capsulitis and how long do they roughly last?

A

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)

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25
Q

Which movements are usually affected in frozen shoulder initially?

A

External rotation
Flexion
Abduction

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26
Q

What are the differential diagnosis for frozen shoulder?

A

OA - ether the glenohumeral joint or acromioclavicular joint

Subacromial impingement syndrome - passive movement preserved

Muscular tear

Autoimmune disease - polymyalgia rheumatica

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27
Q

What investigations should requested for adhesive capsulitis?

A

Usually clinical diagnosis

X-ray - rule out fractures or OA

MRI - can reveal thickening of glenohumeral joint capsule but also rule out other conditions

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28
Q

What should be done if someone presents with frozen shoulder with no obvious risk factors or cause?

A

HBA1c an blood glucose should be measured as this may confirm DM

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29
Q

What can happen over many years in frozen shoulder?

A

Disuse osteopenia

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30
Q

Roughly how long will frozen shoulder last if untreated?

A

2-3 years

31
Q

What is the conservative management for adhesive capsulitis?

A

Education and reassurance
Physio
Adequate analgesics
Glenohumeral steroid injections

32
Q

What are the surgical options for adhesive capsulitis?

A

MUA - manipulation under GA - to remove adhesions - risk of dislocation

Arthrogaphic distension

Surgical release of the glenohumeral joint capsule

33
Q

What are the complications of adhesive capsulitis?

A

Small proportion will never regain full ROM

Recurrence in contralateral shoulder

34
Q

What structures run with the Subacromial space?

A

Rotator cuff tendons
Long head of biceps
Coraco-acromial ligament
Subacromial bursa

35
Q

Which individual is SAIS most common?

A

Pts under 25

Active individuals or in manual professions

36
Q

What are the findings on history/examination of a pt with SAIS?

A

Pain on overhead activity
Night pain

Painful arc

37
Q

What tests can be perform on examination on someone with suspected SAIS?

A

Hawkins-Kennedy test
Empty can test
Neers impingement test
Scarf test

38
Q

What is the most common pathology of SAIS?

A

Degenerative

39
Q

What are the differential diagnosis of SAIS?

A

Muscular tear
Neurological pain
OA
Frozen shoulder

40
Q

What investigations should be ordered for someone with suspected SAIS?

A

USS

MRI

41
Q

What are the conservative management options for SAIS?

A

Analgesia - NSAIDS
Physio
Subacromial space steroid injections

42
Q

After what period of time would you consider further surgical management of SAIS?

A

6 months of conservative and still significant impact on quality of life

43
Q

What are the surgical options for SAIS?

A

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

44
Q

What are the complications of SAIS?

A

Rotator cuff degeneration and tear
Adhesive capsulitis
Complex regional pain syndrome

45
Q

What are the classifications of rotator cuff tears?

A

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
46
Q

What are the two cause of rotator cuff tears?

A

Trauma

Degenerative - more common

47
Q

What are the risk factors for rotator cuff tears?

A

Increasing age
Trauma
Overuse and repetitive overhead shoulder motions

BMI>25, smoking, DM

48
Q

What are the clinical feature of rotator cuff tears?

A

Pain on lateral aspect of shoulder - tenderness over greater tuberosity
Inability to abduct arm above 90 degrees

Atrophy my be seen in massive tears

49
Q

What are the special tests performed on examination of rotator cuff tears and what are they testing?

A

Empty can test (Jobes test) - supraspinatus

Gerbers lift-off test - subscapularis

Posterior cuff test - infraspinatus an tere minor

50
Q

What are the differential diagnosis for rotator cuff tears?

A

Fracture
Glenohumeral subluxation
Brachial plexus injury
Radiculopathy

51
Q

What investigations should be requested for rotator cuff tears?

A

X-ray - rule out fractures - may show evidence of reduced acromiohumeral distance

USS

MRI

52
Q

What are the indications for conservative management and what are the options in rotator cuff tears?

A

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

53
Q

What are the surgical options for rotator cuff tears?

A

Arthroscopic repair

Open repair

54
Q

Who has poorer outcomes after surgery of rotator cuff tears?

A

Large or massive tears
>65 yrs old
Poor compliance to rehab program
Current smokers

55
Q

What is the main complication of rotator cuff tears?

A

Adhesive capsulitis

Enlargement of tear

56
Q

What is the most common site for shoulder fracture?

A

Proximal humerus

57
Q

What is the normal mechanism of a proximal humeral fracture?

A

Low energy in elderly pts with osteoporosis on FOOSH

58
Q

What are the risk factors for low energy proximal humeral fractures?

A

Osteoporosis risk factors:

  • female
  • Early menopause
  • Prolonged steroid use
  • Recurrent falls
  • frailty
59
Q

What are the clinical feature for proximal humeral fractures?

A

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

60
Q

Which structures may be damaged in proximal humeral fractures?

A

Axillary nerve

Circumflex vessels

61
Q

What investigations should be done for proximal humeral fractures?

A

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

62
Q

What is the classification system used for proximal humeral fractures?

A

Neer classification system

63
Q

Which 4 segment of the proximal humerus is the neer classification system based off?

A

Greater tuberosity
Lesser tuberosity
Articular segment (anatomical neck)
Humeral shaft (surgical neck)

64
Q

What is the conservative management for, minimally displaced with no neurovascular compromise, proximal humeral fractures?

A

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

65
Q

What are the surgical options for proximal humeral fractures?

A

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

66
Q

What are the complication of proximal humeral fractures?

A

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

67
Q

What is the the age distribution of olecranon fractures?

A

Bimodal age distribution- high energy in young and low-energy indirect in elderly

68
Q

What is the mechanism of injury in indirect olecranon fractures?

A

FOOSH

69
Q

How can you tell on examination if the triceps mechanism is damaged in olecranon fractures?

A

Inability to extend the elbow against gravity

70
Q

What investigations would be requested in suspected olecranon fractures?

A

Routine bloods

X-ray - AP and lateral

CT for more complex injuries

71
Q

What classifications systems are the for olecranon fractures?

A

Mayo classification

Schatzker classification

72
Q

What are the non-operative management for olecranon fractures?

A

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

73
Q

What are the operative management option for olecranon fractures?

A

Displacement >2mm

Tension band wiring - if fracture proximal to the coronoid process
Olecranon plating - if at the level or distal to the coronoid process

T&O (13 decks)

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