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Shoulder > Shoulder > Flashcards

Shoulder Flashcards

1
Q

*

Articulations at the shoulder joint

A

Sternoclavicular joint
Acromioclavicular joint
Glenohumeral joint
Scapulothoracic, not a true joint but works with AC and SC

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2
Q

What type of joint is the sternoclavicular, acromioclavicular and glenohumeral joint.

A

SC and AC - synovial plane
GH - synovial ball and socket

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3
Q

Bones involved with the sternoclavicular joint

A

Manubrium of sternum and clavicle

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4
Q

Bones involved with the acromioclavicular joint

A

Acromium process of scapula and lateral end clavicle

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5
Q

Bones involved with the glenohumeral joint

A

Scapula (glenoid fossa) and humerus

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6
Q

Type of cartilage and membrane in the joint

A

Hyaline cartilage and synovial membrane

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7
Q

what is it attached to?

Describe the shoulder capsule

A

Attached to labrum and glenoid rim to articular margins of humerus

Except inferiorly where extends 1-2cm onto the neck (lax inferiorly- mobility).

Reinforced by rotator cuff and biceps long head.

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8
Q

Additional features in the shoulder joint

A

Sternoclavicular joint - Fibrocartilage disk for congruency, shock absorption

Acromioclavicular disc- Unknown

Glenohumeral join- Bursae, Labrum- congruency

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9
Q

Movements at the shoulder joint

A

Abduction
Adduction
Flexion
Extension
Internal rotation
External rotation

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10
Q

3 muscles

Rotator cuff muscles

A

Supraspinatus
Infraspinatus
Teres minor and subscapularis

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11
Q

5 muscles

Muscles that make up the shoulder girdle

A

Pec major
Pec minor
Deltoids
Trapezius
Serratus anterior

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12
Q

4 muscles

Shoulder flexors

A

Anterior deltoid
Coracobrachialis
Pec major
Weakly - Biceps brachii

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13
Q

3 muscles

Shoulder extension muscles

A

Posterior deltoid
Latissimus dorsi
Teres major

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14
Q

5 muscles

Internal rotators

A

Subscapularis
Pec major
Latissimus dorsi
Teres major
Anterior aspect of deltoid

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15
Q

2 muscles

External rotators

A

Infraspinatus
Teres minor

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16
Q

3 muscles

Adduction

A

Pec major
Latissimus dorsi
Teres major

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17
Q

4 muscles - 3 points of degrees

Abduction

A

Supraspinatus - 0-15
Middle fibres of deltoid - 15-90
Trap and serratus anterior beyond 90 degrees

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18
Q

Ligament pathology

A

AC joint sprain

Disruption of the middle and inferior GH ligaments

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19
Q

Blood and nerve supply pathology

A

Referral from neck - cervical radiculopathy

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20
Q

Muscle shoulder pathology

A

GH stability

Rotator cuff pathology/subacromial shoulder pain

Includes rotator cuff tendinopathy, rotator cuff tears and subacromial bursitis.

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21
Q

Articulations pathology

A

Atraumatic - dislocation *GH
Traumatic - GH, AC joint

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22
Q

Bone pathology

A

Fractures- clavicle, humerus

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23
Q

Hyaline cartilage pathology-

A

OA-
AC joint
GH joint

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24
Q

Capsule pathology

A

RA - GH joint

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25
Q

Synovial membrane pathology

A

Adhesive capsulitis/ frozen shoulder

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26
Q

Additional features pathology

A

Damage to glenoid labrum

Superior Labral tear from ant. To post. (SLAP)
Bankart – damage to inferior, anterior labrum.
=ongoing instability

Rotator cuff pathology/ subacromial shoulder pain

Includes rotator cuff tendinopathy, rotator cuff tears and subacromial bursitis

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27
Q

Diagnostic categories

A

1) Those that need onward referral
2) Referred from the neck
3) Traumatic injuries- fractures, dislocations and AC joint sprain
4) Atraumatic pathology - Instability, Acromioclavicular joint disease, Glenohumeral joint disease – Frozen shoulder, Arthritis and Rotator Cuff Tendinopathy

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28
Q

Common age of shoulder instability

A

10-36

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29
Q

Common age of AC joint disease

A

> 30 years

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30
Q

Common age of glenohumeral joint issues (frozen shoulder, arthritis)

A

35-65

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31
Q

Common age for rotator cuff tendinopathy

A

35-75 years

32
Q

People that need onward referral

A

Malignancy-
Weight loss, night pain, night sweats and fever

Acute rotator cuff-
Trauma, pain and weakness

Septic arthritis -
fever or systemically unwell, red skin, hot, painful joint

Unreduced dislocation -
Loss movement, trauma leading to loss of rotation and abnormal shape

Inflammatory arthritis-
Swelling, early morning stiffness, FH RA, swollen joint +- heat

Neurological lesion-
Gait disturbances, unexplained muscle wasting and weakness, sensory loss
UMN - babinski and clonus
LMN - reflexes, dermatomes and myotomes

33
Q

What is it and what is the most common cause

Cervical radiculopathy

A

Pain in one or both upper extremities which corresponds to the dermatome of the involved cervical nerve root.

Most common cause degenerative change: disc herniation, spondylosis (spinal OA) causing bony hypertrophy of facet joints.

34
Q

Symptoms reproduced with what types of movement

Urgent referral if…

Cervical radiculopathy- objective

A

Symptoms reproduced with Neck active and passive ROM. +/- Changes in Dermatomes, Myotomes and reflexes.

Urgent referral if severe or progressive motor weakness or severe or progressive sensory loss

If 4-6 weeks or more or neurological signs refer to confirm diagnosis (medical Rx)

<4-6 weeks and no objective neurological signs = conservative management

35
Q

Cervical radiculopathy
Subjective

A

pins and needles, numbness, weakness, aggravating and easing linked to neck, symptoms may go down the arm

36
Q

Cervical radiculopathy-
treatment

A

Reassurance that prognosis is good in most cases.

Most will improve regardless of treatment.

88% will improve within four weeks with non-operative treatment (Childress and Becker 2016)

Encourage activity and return to normal lifestyle (inc work). If neck restricted not to drive. No collars.

37
Q

Clavicle fracture subjective

A

Localised pain.
Pain and function reflective of stage of healing.

38
Q

Clavicle fracture objective

A

Obs: protracted shoulder girdle position

Difficulty with active Protraction, Retraction, elevation and depression and active and passive GH flexion and abduction through elevation.

39
Q

Clavicle fracture treatment

A

Common shoulder fractures (child>adult)

Sling 2-6 weeks of immobilisation

Reassurance- good outcome in >90% cases of minimally displaced or not displaced at 24 weeks (Robinson et al 2004)

Sometimes will need physio for AROM, stretches, strengthening with an aim to return function.

40
Q

closed pack positon

Clavicle fracture
Sternoclavicular joint

A

(synovial plane = gliding)
Close packed position: Maximum shoulder elevation.

41
Q

What movements

Clavicle fracture

Acromioclavicular joint

A

(synovial plane = gliding)

During Abduction and flexion the clavicle rotates about its long axis posteriorly. If unable, the movement of the scapula is affected which affects GH joint flex and Ab.

42
Q

AC joint sprain
Ligaments involved and role of the AC joint

A

Coracoclavicular ligament
Acromioclavicular ligament
Coracoacromial ligament

Role of AC joint:
Allows overhead and across the body movement

Transmits force from arm to rest of body during activities such as pushing, pulling and lifting

43
Q

Subjective AC joint sprain

A

Localised pain over AC joint, aggravated by heavy lifting, over head and across the body movements.

44
Q

Observation,palpation, movements

AC joint sprain objective

A

Obs- swelling, bruising, hard lump may be present at top of shoulder.

Palpation: specific tenderness over AC joint

Difficulty with GH flexion through elevation and horizontal adduction (Cross body test)

45
Q

AC joint sprain treatment

A

Ligament healing times: 6-8 weeks, in this time protect from over stretching (may use sling)

Physio: normalise joint ROM, muscle lengths, proprioception, minimise your chance of re-injury (return to work or sport 8-12 weeks)

46
Q

Grade sprain

A

MILD: Grade I (intact joint minor tear of acromioclavicular ligaments)

Grade II (up to 50% and stretching of ligaments)

SEVERE: Grade III (>50% vertical subluxation)= Orthopaedic opinion

47
Q

Fall-arm position

Traumatic dislocation- how does it happen?

A

Arm outstretched in an externally rotated and abducted position

48
Q

Most common direction of dislocation

A

Anterior

49
Q

Traumatic GH disclocation
Restrictions

Anterior dislocations assess with…

A

Restrictions:
Concave glenoid,
labrum,
capsule,
superior, middle and inferior GH ligament
long head of biceps
rotator cuff.

Damage to labrum and middle and inferior GH ligaments
Rotator Cuff tears
Gr tuberosity fracture

50
Q

Traumatic Gh joint disclocation

A

Orthopaedic instruction.
Obs: position of joint, posture
AROM as comfortable

51
Q

Traumatic Gh joint dislocation
Subjective

A

Mechanism, relocation -time, who, where, pre-existing sh instability? Next clinic appointment.

52
Q

Traumatic Gh joint dislocation - treatment

A

A&E and fracture clinic. Orthopaedic management and review.
Following assessment and reduction:
*Early mobilization as pain allows, course of physiotherapy usually 4-12 weeks.
*Urgent Ortho opinion if pain and weakness 2-3 weeks post dislocation, suspect rotator cuff tear.

53
Q

Prognosis of 1st traumatic dislocation

A

At 1-year - recurrent instability rate was 39% (Olds et al. 2015), 55.7% within first two years and 66.8% by the fifth year

54
Q

Risk factors with disclocation and recurrent instability

A

<40 years olf - 13 x
men - 3 x
Gretaer tuberosity fracture- 7 x
Hyperlaxity - 3 x

55
Q

What two things cause this instability?

Atraumatic instability

A

GH joint Synovial ball and socket with 3 degrees of freedom

Mobility; the shoulder joint is capable of large complex movements in all anatomical planes.

Stability; because of the lack of congruency stability is largely dependent on muscles, capsule and ligaments.

Increased mobility + decreased stability = imbalance

56
Q

Atraumatic instability- objective

A

Performing functional movements that reproduce symptoms. Often instability tests are not required.
Normally full active range of motion, Proprioception
Muscle power: isometric test rotator cuff in different positions. Ax whole kinetic chain e.g. squat, SLS, bridge

57
Q

Atraumatic instability- subjective

A

Onset (gradual vs sudden), “falls out” versus “pulled out”. Doesn’t feel right, not is place. Feels like it needs to click.

PMH: Connective tissue Disorders (EDS, Marfans), hypermobility

58
Q

Atraumatic instability treatment-

A

Conservative rehabilitation program.
Rotator cuff strengthening, proprioception, building speed and using the whole kinetic chain.
Psychological aspect-to address any contributing factors, regain confidence and reduce fear.
Improve general activity
Prognosis: Aim to return to activity and function

59
Q

Frozen shoulder

A

A painful contracture of the GH joint capsule which leads to stiffness and disability.
3 phases 1) Painful 2-9 months 2) Stiffness 4-12 months 3) Resolution 12-42 months
Recently classified as pain predominant and stiffness predominant

60
Q

Frozen shoulder-

Objective

A

Reduced AROM and PROM
Capsular pattern - limited Ex rot
Reduced Accessory movements: convex humeral head glides in opposite direction to angular movement of bone.

61
Q

Frozen shoulder subjective

A

Idiopathic (gradual onset) or secondary to trauma.

Pain in deltoid region with worsening stiffness.

Difficulty doing up bra strap, putting on deodorant, putting on coat, changing gear in car

62
Q

Frozen shoulder treatment-

A

Symptoms settle in 18-24 months.

Analgesia–Paracetamol, NSAIDS, corticosteroid inj.

Physiotherapy for 6/52 then RV and either refer to secondary care or cont for 6/52.

To continue to use the arm when painful to maintain ROM, manual therapy, stretches, hydrotherapy, heat

63
Q

OA objective

A

Painful high arc on AROM
Positive cross body arm test.
Tender on palpation of AC joint

64
Q

OA subjective

A

Difficulty with activities above the head, washing hair, putting out washing.

Risk factors are those that do over-head work: painters, plasters, weight-lifters.

> 60 years for OA
20-50 years for injuries to AC joint.

65
Q

Treatment of OA- joint disease

A

Activity modification (avoiding cross over and heavy lifting), analgesia, referral to physio.
Physio- management of symptoms

66
Q

Subacromial shoulder pain

A

rotator cuff tendinopathy, rotator cuff tears and subacromial bursitis

67
Q

Rotator cuff disorders- objective

A

Painful arc of Abduction (in scapula plane). Pain between 70-120 degrees
-Pain worse if thumb down and against resistance.
*Isometric muscle testing – belly press +/- lift off sign for subscapularis
*Special tests- Hawkins and Kennedy and Neer.

68
Q

Rotator cuff disorders subjective

A

Can describe: “catches me out”, pain on lifting e.g. kettle, or activities with arm above head.
May describe a painful arc.

**Onset: **May occur gradually or after a change in activity/loading – sport, occupation, recent life change (moved house) or training
Sleep: May have night pain due to difficulty laying on shoulder

69
Q

Subscapularis - O and I

A

Origin: Entire under surface of the scapula (subscapular fossea).
Insertion: Less tubercle of the humerus.

70
Q

Latissimus dorsi - O and I

A

Origin – Posterior crest of the ilium (via the Thoracolumbar fascia).
Posterior sacrum.
Spinous processes of T7-L5.

Insertion – Intertubercular groove (between the greater and lesser tuberosities) of the humerus.

71
Q

Infraspinatus - O and I

A

Origin – Posterior surface of the scapula (below the spine of the scapula).
Insertion – Greater tuberosity on the humerus

71
Q

Teres minor O and I

A

Origin: Midsection of the lateral border of the scapula.
Insertion: Greater tuberosity on the humerus.

71
Q

Teres major O and I

A

Origin: Lower 1/3 of the lateral border of the scapula.
Insertion: Intertubercular goove (between the greater and lesser tubercles) of the humerus

71
Q

Supraspinatus O and I

A

Origin: Supraspinous fossa.
Insertion: Greater tuberosity of the humerus.

72
Q

Deltoid O and I

A

Origin –Outer 1/3 of the clavicle
Acromion process
Spine of the scapula
Insertion –Deltoid tuberosity on the humerus

72
Q

People that need onward referral

A

Malignancy
S) h/o cancer, weight loss, night pain, night sweats and fever O) Mass or swelling

Acute rotator cuff tear
S) Trauma, pain and weakness O) sudden inability to raise arm (with or without trauma)

Septic arthritis.
S) fever or systemically unwell O) Red skin, hot, painful joint

  1. Unreduced dislocation
    S) Loss Movement O) Trauma leading to loss of rotation and abnormal shape
  2. Inflammatory arthritis
    S) Swelling, Early Morning Stiffness (EMS), FH RA, O) Swollen joint +/- heat
  3. Neurological lesion
    S) Gait disturbance and O) Unexplained muscle wasting and weakness, sensory loss
    UMN- Babinski and clonus
    LMN- reflexes, dermatomes and myotomes.

Shoulder (2 decks)

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