SHOULDER Flashcards
What classification is used for the clavicle fracture?
Allman classification system – determined by the anatomical location of the fracture along the clavicle
How do clavicle fractures uually appear and present?
What are the risks assoiciated with a clavicle fracture?
- Risks: forming an open fracture as the bone is so close to the surface of the skin
- Check neurovascular status of the upper limb, given the propensity for brachial plexus injuries following a clavicle fracture
How are clavicle fractures managed?
- Most can be treated conservatively, even those with significant deformity, as evidence has shown no long-term benefit to surgical management
- Sling: to ensure that the elbow is well supported and improves the deformity. Keep it on until pt regains pain free movement
- Early movement of the shoulder joint is recommended, to prevent the development of frozen shoulder in these patients
- Open fractures: need surgical intervention
- Malunion: usually performed 2-3 months post-injury
- Healing time for most clavicular fractures in adults is 4-6 weeks
What are the rotator cuff muscles?
The rotator cuff is a group of 4 muscles that support and rotate the glenohumeral joint
The rotator cuff is composed of four muscles:
- Supraspinatus– abduction
- Infraspinatus – external rotation
- Teres minor – external rotation
- Subscapularis – internal rotation
SIT muscles attach to the greater tuberosity of the numeral head; Supraspinatous, Infraspinatous and Teres Minor
These muscles maintain stability of the shoulder joint
What are some of the RFs for rotator cuff tears?
- age
- trauma
- overuse
- repetitive overhead shoulder motions e.g. athletes, certain occupations
How do rotator cuff tears presentation or specific examination findings?
- Pain over the lateral aspect of shoulder and an inability to abduct the arm above 90 degrees
Examination:
- Tenderness over the greater tuberosity and subacromial bursa regions
- Specific tests:
- Jobe’s test/the ‘empty can test’ - tests supraspinatus
- Gerber’s lift-off test - tests subscapularis
- Posterior cuff test - tests infraspinatus and teres minor
How are rotator cuff tears Ixd and mxd?
Ix:
- X-ray - exclude a fracture
- USS: assess the size of the tear
Mx:
- Presentation < 2 weeks since injury: conservative - analgesia and physiotherapy
- Steroid injections into the subacromial space can be used if medication doesn’t help
- > 2 weeks: or remaining symptomatic despite conservative management should be referred for surgical intervention
What is the main complication of a rotator cuff tear?
Adhesive capsulitis
What is adhesive capsulitis?
the glenohumeral joint capsule becomes contracted and adherent to the humeral head
How does adhesive capsulitis present?
Sx and examination
- shoulder pain and a reduced range of movement in the shoulder
- generalised deep and constant pain of the shoulder, that often disturbs sleep
- Associated symptoms include joint stiffness and a reduction in function
On examination
- loss of arm swing and atrophy of the deltoid muscle
- Limited range of motion, mainly affecting external rotation and flexion of the shoulder
- reduced range on both passive and active movenents
How is adhesive capsulitis ixd and mxd?
Ix:
- Clinical one – X-ray to rule out fractures
- MRI imaging;
- HbA1c and blood glucose (as it often presents in diabetics)
Mx
- Self-limiting condition ( recurrence is common) - recovery occurs over months to years; some patients never recover full range of movement.
- Activity encouraged, physio
- Analgesia
- Steroid injection
- Surgery: manipulation under general anaesthetic to break the capsular adhesions to the humerus, or arthroscopic release of the glenohumeral joint capsule
Whast type of shouolder dislocations can you get and how do these arise?
- Anterior dislocation: caused by force being applied to an extended, abducted, and externally rotated humerus~
- Posterior dislocation: seizures or electrocution, but can occur through trauma (a direct blow to the anterior shoulder or force through a flexed adducted arm)
Mx
- Mx A-E if the injury was induced during trauma
- Reduction, immobilisation and rehabilitation
- Analgesia for the reduction process – give Entonox
- Assess the neurovascular status both pre- and post-reduction
- Broad-arm sling for 2 weeks post reduction
- Physio
How does a shoulder dislocation present?
Painful shoulder, acutely reduced mobility - patients will be reluctant to move the affected limb
Examination
- Asymmetry with the contralateral side
- Loss of shoulder contours (from a ‘flattened deltoid’)
- Anterior bulge from the head of the humerus
How is a shoilder dislocation Ixd and mxd?
Examination: test NVS - axillary nerve and regiments badge
X ray - light bulb sign - posterior dislocation
What are some of the additional injuries you can get with a shoulder dislocation?
-
SLAP tear: Superior Labrum Anterior Posterior tear is when the humerus dislocates from the shoulder, and it tears part of the labrum off from the Glenoid with it
- Slap tears usually occur at the point where the biceps tendon anchors into the labrum - this is where the labrum rips
- Bankart lesions: tears of the anterior glenoid labrum, due to recurrent dislocations
- Hill-Sachs: defects are impaction fractures, affecting the chondral surface of the posterior portions of the humeral head
What is subacromial impingement syndrome
- inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion at the shoulder
- Occurs when there is impingement between the coracoacromial arch and the supraspinatus tendon or subacromial bursa
How does subacrominal impingent syndrome present and what arethe positive findings on. examin ation?
- Sx: progressive pain in the anterior superior shoulder. Exacerbated by shoulder abduction
- Test for Subacromial impingement by looking for the painful arc
- Painful arc involves pain between 60-120 degrees on shoulder abduction
- It is at this point which the subacromial space is at its narrowest, leading to impingement and pain
How is subacromial impingement syndrome investigated + managed?
- Ix: MRI
- Mx: analgesia: NSAIDs, physio.
- 2nd: corticosteroid injections in the subacromial space
- Surgery: repairing muscular tears and removal of subacromial bursa
How does biceps tendinopathy arise?
- Tendinopathy involves a painful, swollen, and structurally weaker tendon, at risk of rupture
- Can be caused by repetitive flexion movements, such as in cricket and tennis, or in degenerative tendinopathy
How does biceps tendinopathy present?
Presentation: pain, made worse with stressing the tendon. Weakness, stiffness
Examination: tenderness over the affected tendon
How is biceps tendopathy investigated and managed?
Ix: USS - look for thickened and inflamed tendons
Mx: conservative: analgesia – NSAIDs. Physio.
2nd: US guided steroid injections
Complications: Chronic cases are at an increased risk of having a biceps tendon rupture
What are some of the RFS for humeral shaft fracture?
osteoporosis, increasing age, or previous fractures
How do humeral shaft fracturespresent?
- Pain and deformity are the predominant features of this injury
- Risk of damage to the radial nerve, as it runs along the humerus within the spiral groove
- If the radial nerve is affected the patient will complain of reduced sensation over the 1st dorsal webspace and weakness in wrist extension
How can humeral shaft fractures be managed?
- Re-alignment of the limb
- Most humeral shaft fractures can be treated conservatively in a functional humeral brace
- Full bone union can take 8-12 weeks
- Surgical fixation is needed in a minority of patients and will typically involve open reduction and internal fixation with a plate or intramedullary nail - ORIF
What are the causes of shoulder dislocation
- Anterior most common – caused by force being applied to an extended, abducted, and externally rotated humerus
- Posterior – electrocution or seizure, can be caused by arm trauma
What are the common clinical features of shoulder dislocation?
- painful shoulder
- reduced mobility
- instability
- asymmetry
- loss of shoulder contour
- anterior bulge from humeral head.
What are the rotator cuff muscles and what are there actions?
- Supraspinatus– abduction
- Infraspinatus – external rotation
- Teres minor – external rotation
- Subscapularis – internal rotation
- SIT muscles attach to the greater tuberosity of the humeral head
- These muscles maintain stability of the shoulder joint
What are the RFs for rotator cuff tears?
What are the specific tests used in a shoulder exam?:
- Jobe’s test/ ‘empty can test’ - tests supraspinatus
- Gerber’s lift-off test - tests subscapularis
- Posterior cuff test - tests infraspinatus and teres minor
What are the Ix of
- Ix: X-rays: a trauma shoulder series is required, including AP, Y-scapular, and axial views
- The ‘light bulb sign’ suggests posterior dislocation, as the humerus is internally rotated
- USS: assess the size of the tear
How would you manage a rotator cuff?
- Presentation < 2 weeks since injury: conservative - analgesia + physiotherapy
- Steroid injections into the subacromial space can be used if medication doesn’t help
- > 2 weeks: or remaining symptomatic despite conservative management should be referred for surgical intervention – surgical repair
What is biceps tendinopathy? How is it caused? How does it present?
Tendinopathy involves a painful, swollen, and structurally weaker tendon, at risk of rupture
Repetitive flexion movements, such as in cricket and tennis, or in degenerative tendinopathy
Presentation
- Pain, made worse with stressing the tendon
- Weakness
- Stiffness
Examination: tenderness over the affected tendon
How is biceps tendinopathy investigated and managed?
- Ix: USS - look for thickened and inflamed tendons
- Mx: conservative: analgesia – NSAIDs. Physio.
- 2nd: US guided steroid injections
Complications: biceps tendon rupture
