Shoulder 2 Flashcards
The shoulder joint is very mobile and hence unstable; what is the chance of a young person re-dislocating their shoulder after a traumatic first dislocation?
80%
Define a shoulder dislocation
Humeral head loses its articualtion with glenoid cavity of scapula
The type of shoulder classification is classified based on the relation of the humeral head to the….
Infraglenoid tubercle
State the three types of shoulder dislocation
Which is most common
- Anterior
- Posterior
- Inferior (luxatio erecta. Rare)
Anteriorinferior (usually just termed anterior) is most common; accounting for ~95% of dislocations
Describe the likely mechanisms of injury for the following:
- Anterior dislocation
- Posterior dislocation
- Inferior dislocation
Anterior dislocation
- Direct force to posterior shoulder
- Injury in which shoulder is forced into extension, abduction and externally rotation e.g. fall on oustretched hand
Posterior
- Direct blow to anterior shoulder
- Injury in which shoulder is forced into flexion, adduction and internal rotation
- Typically caused by seizures or electrocution
Inferior
- Hyperabduction
- Axial force on overhead arm
State some risk factors for shoulder dislocation
- Injury
- Seizure
- Previous dislocation
- Repetitive shoulder motion causing laxity of ligaments
State symptoms of shoulder dislocation
- Pain
- Acute reduced mobility and range of motion
- Feeling of instability
What might you find on clinical examination of someone with:
- Anterior dislocation of shoulder
- Posterior dislocation of shoulder
Anterior Dislocation
- Shoulder looks square
- Anterior bulge of humeral head
- Arm abducted and externally rotated
Posterior Dilocation
- Arm held internally rotated
- No external rotation possible
What must you assess when there has been a shoulder injury?
Assess neurovascular status. Axillary and suprascapular nerves are especially at risk
State some injuries associated with shoulder dislocations
Bony injuries
- Bony Bankart lesions
- Hill-Sachs lesions
- Fracture of greater tuberosity
- Fracture of surgical neck of humerus
Labral, ligamentous and rotator cuff injuries
- (soft) Bankart lesions
- Glenohumeral liagment avulsion
- Rotator cuff injuries
What is a Bankart lesion?
What is a bony Bankart lesion?
- Bankart lesion= avulsion of anteriorinferior glenoid labrum and inferior glenohumeral ligament
- Bony bankart= avulsion of anteriorinferior glenoid labrum and inferior glenohumeral ligament alongside a fracture of the anterior inferoir glenoid cavity of the scapula
What is a Hill Sach’s lesion?
Impaction injury to the chondral surface of the posterior and superior portions of humeral head (present in 80% traumatic dislocations)
What investigations would you do if you suspect shoulder dislocation?
- X-ray shoulder (in particular a trauma shoulder series is required: anterior-posterior, Y-scapular [lateral] and axial views)
- MRI shoulder (if suspect labral or rotator cuff injuries)
What type of shoulder dislocation does this x-ray show? (AP view)
Anterior dislocation
Typical X-ray findings in anterior shoulder dislocation include:
- AP view: the humeral head will lie medial and inferior to the glenoid fossa.
- Lateral view: the humeral head will lie anterior and inferior to the glenoid fossa.
- The humeral head will also lie inferior to the coracoid process and this is typically most obvious in the lateral view.
What type of shoulder dislocation does this x-ray show? (AP view)
Posterior shoulder dislocation
Typical X-ray findings in posterior shoulder dislocation include:
- AP view: the glenohumeral joint will be widened and the humeral head will take on a classic “light bulb” appearance due to forced internal rotation of the humerus. Also be widened joint space.
- Lateral view: the humeral head will lie posterior to the glenoid fossa.
Discuss the management of shoulder dislocations
When they first present do A-E as often injuries occur following trauma so ensure pt is stable and assess for other injuries.
Mainstay of treatmen is “reduction, immobilisation & rehabilitiation”
- Closed reduction
- Immobilise joint in broad-arm sling for ~2weeks (may need longer for posterior)
- Rehabilitation- physiotherapy to restore ROM, function and strenthen rotator cuff muscles & other pericapsular muscles
-
Surgery may be required for:
- Ongoing shoulder pain
- Joint instability
- Large Hill-Sachs defects
- Large (bony) Bankart lesions
*NOTE: must assess neurovascular status pre- and post- reduction
State some potential complications of shoulder dislocations
- Chronic pain
- Limited mobility
- Stiffness
- Reoccurence
- Instablity
- Dead arm syndrome
- Can’t trust arm
- Feels like shoulder pops out
- Adhesive capsulitis
- Nerve damage
- Rotator cuff injry
- Degeneratvie joint disease e.g. OA
What is dead arm sydnrome?
Sudden sharp or ’paralyzing’ pain when the shoulder is moved forcibly into a position of maximum external rotation in elevation or is subjected to a direct blow. The patient is no longer able to perform a throwing movement with the control and the velocity that he achieved before the injury due to pain and numbness. It’s also called recurrent transient subluxation of the shoulder
Discuss the Stanmore classification for shoulder instability
Idea that there are broadly 2 reasons why shoulder becomes unstable:
- Structural- capsulolabral mechanism has been damaged by injury or is already deficient
- Non-structural- unbalanced muscle recruitment around shoulder
Stanmore classification uses three polar groups to classify shoulder dislocations: traumatic structure, atraumatic structural and muscle patterning non structural.
However, there can be much overlap between groups therefore Bayley’s triangle is used to represent this idea of continuity between three groups.
Suggest how each of the following categories of shoulder dislocation, from Stanmore classification, may present:
- Traumatic structural
- Atraumatic structural
- Muscle patterning
I Traumatic structural
• significant trauma
• often a Bankart’s defect
• usually unilateral
• no abnormal muscle patterning
II Atraumatic
• no trauma
• structural damage to the articular surfaces
• capsular dysfunction
• no abnormal muscle patterning
• not uncommonly bilateral
III Habitual non-structural (muscle patterning)
• no trauma
• no structural damage to the articular surfaces
• capsular dysfunction
• abnormal muscle patterning
• often bilateral
What might suggest that a shoulder dislocation is a non-structural muscle patterning (type III) dislocation?
Discuss the management for type III dislocations?
Pt features:
- High Beighton’ score
- Winging of scapula
- Lacks muscle coordination
- Lacks proprioception
- Underlying disorder e.g. Marfan’s, Ehlers-Danlos
Usual “reduction, immobilse, rehabilitation” but with lots and lots of PHYSIO
What two tests can we do for shoulder instability?
- Apprehension test: tests for glenohumeral capsule integrity (e.g. is there a labral tear) and anterior shoudler instability and
- Jobes relocation test:
Explain how to do the apprehension test
The patient can be supine or sitting (if sitting use one hand to stabilise back of shoulder). The therapist will flex the patient’s elbow to 90 degrees and abducts the patient’s shoulder to 90 degrees, maintaining neutral rotation. The examiner then slowly applies an external rotation force to the arm to 90 degrees while carefully monitoring the patient[1]. Patient apprehension from this maneuver, not pain, is considered a positive test
Explain how to do Jobe’s relocation test
Following positive result from apprehension test, apply posterior force to the shoudler. If pt shows relief/reduced apprehension this is a positive Jobe’s relocation test.
Rotator cuff trears are common; prevelance is around 20%. They can be classifed as acute or chronic and partial or full thickness. Explain the difference between:
- Acute & chronic
- Partial & full thickness
- Acute: tear occurs suddenly
- Chronic: progressive degenerative process with age caused by repetitive use leading to microrupture & inflammation
- Partial: only part of tendon has detached/torn from the bone
- Full thickness: entire tendon has detached/torn from the bone
Full thickness RCTs can be further classified into small, medium, large and massive. State the limits for each
- Small <1cm
- Medium 1-3cm
- Large 3-5cm
- Massive >5cm or involves mutliple tendon tears
Remind yourself of the action of each of the rotator cuff muscles
- Subscapularis: internal rotation of shoulder
- Supraspinatous: abduction of shoulder 0-15 degrees
- Infraspinatous: external rotation of shoulder
- Teres minor: external rotation of shoulder
AND all act to stablise the shoulder joint
Acute tears commonly occur in tendons with no existing degeneration; true or false?
False; acute tears often occur in tendons with pre-existing degeneration typically occuring alone followiing minimal force. HOWEVER, acute tears can also occur in tendons with no pre-existing damage when force is large enough- often alongside other injuries.
State some risk factors for RCTs
- Age
- Trauma
- Overuse
- Repetitive overhead shoulder activities
- BMI >35
- Smoking
- Diabetes
State symptoms of a RCTs
- Pain over lateral aspect of shoulder
- Inability to abduct arm above 90degrees
- Weakness (especially abduction & external rotation)
What might you find on clinical examination of someone with a RCT?
- Tenderness over greater tuberosity & subacromial bursa region
- Supraspinatous & infraspinatous atrophy in massive RCTs
- Lack of active movements but passive movements possible
- Painful arc
- Shrug sign/pseudoparalysis
- Positive results in special tests:
- Empty can test
- Gerber’s lift off test
- Posterior cuff test
- Belly press test
What is painful arc?
Pain when abducting arm betwen 60-120 degress
Describe the empty can test
- The patient’s arm should be elevated to 90 degrees in the scapular plane, with the elbow extended, full internal rotation, and pronation of the forearm. This results in a thumbs-down position, as if the patient were pouring liquid out of a can. The therapist should stabilize the shoulder while applying a downwardly directed force to the arm, the patient tries to resist this motion. This test is considered positive if the patient experiences pain or weakness with resistance.
- Also called Jobe’s test
- Tests supraspinatous
Describe the Gerber’s lift-off test
To perform this test, the patient is asked to place the back of the affected arm (dorsum of the hand) in the mid lumbar spine area. The testing movement involves the patient performing internal rotation (IR), by lifting the hand off the back while the examiner places pressure on the hand. The test is considered to be positive if the patient cannot resist, lift the hand off the back or if she/he compensates by extending the elbow and shoulder
Describe the posterior cuff test
Describe the Belly press test
While in the standing position the patient puts a hand on the stomach and pushes as hard as possible. At the same time the patient moves the elbow forward, which puts the shoulder in even more rotation. The test is positive for a tear in the subscapularis muscle if there is weakness in one side compared to the other
What is Hornblower’s sign?
- Abduct shoulder to 90 degrees, flex elbow to 90 degrees and externally rotate arm. Examiner applies pressure to try and internally rotate arm, pt resists by externally rotating arm. Test is postive if there is weakness in external rotation resulting in pt adopting position as if they were going to blow a horn.
- Test for muscles that externally rotate shoulder- test is good for testing teres minor
For each of the special tests below, state what muscle they are testing:
- Empty can test
- Gerber’s lift-off test
- Posterior cuff test
- Belly press test
- Hornblower’s sign
Supraspinatous (abducter)
- Empty can test
Subscapularis (interal rotator)
- Gerber’s lift off test
- Belly press test
Infraspinatous & Teres minor (external rotators)
- Posterior cuff test
- Hornblower’s test
What investigations would you do if you suspect a RCT?
Clinical tests are very good at identifying pathology however tests are reqired to a.) rule out other pathology and b.) establish presence and extent of injury.
- Urgent x-ray: exclude fracture
- USS shoulder: used to establish presence and size of tear
- MRI shoulder: detect size, characteristics & location of tear
Management of RCTs is dependent on what two things?
- Type of tear
- Functional status of pt
All pts should be given conservative management. Which RCT pts would we try to avoid/not consider surgery in?
Conservative management preferred in pts who:
- Not limited by pain or loss of function
- Significant co-morbidities
- Unsuitable for surgery
Discuss the conservative management of RCTs
- Analgesia
- Physiotherapy
- Subacromial corticosteroid injection (ONLY if no surgery is planned)
Which RCT pts would we do surgery on?
- If still symptomatic despite conservative management 2 weeks since injury (NOTE: many acute cuff tears require surgery)
- Large & massive tears
Surgery for RCTs can be done….
- Atrhoscopically
- Open approach
If a pt has a cuff tear with arthritis, what surgery may we offer and why?
- Reverse shoulder replacement
- Put the ball part of joint on scapula and the socket part of joint on humerus. It makes the deltoid muscle a more efficient stabiliser of the shoulder to make up for the dysfunctioning of the rotator cuff.
Partial tears generally do not require surgery; true or false?
True
If someone presents 1-2weeks post injury with inability to move shoulder and has normal x-ray; what is most likely diagnosis?
Rotator cuff tear
What is the main complication of RCTs?
Adhesive capsulitis
