Shoulder Flashcards
Two bursae associated with the shoulder
Subacromial bursa
Subascapular bursa
Name for the shoulder joint
Glenohumeral joint
Ligament round the shoulder joint
Capsular ligament
What forms the rotator cuff?
The tendons of the SITS muscles
Night pain and shoulder impingement?
Night pain not common
When will shoulder impingement hurt?
Pain on movement
Painful arc
Hawkins test
PAINFUL CRECENDO NOT ASSOCIATED WITH SHOULDER IMPINGEMENT
Differential diagnosis for shoulder impingement?
Shoulder impingement
Frozen shoulder
Shoulder instability
Bigliani acromial grading
flat inferiorly
curved
parallel to the humeral head with concave undersurface
considered most common type 3
hooked
most anterior portion of the acromion has a hooked shape
associated with increased incidence of shoulder impingement
convex (upturned)
most recent classification of acromion process shape
the undersurface of the acromion is convex near the distal end 4
no convincing correlation between a type 4 acromion and impingement syndrome exists 4, 5
OS acromiale
Unfused acceossory ossification centre
Rotator cuff tear signs & symptoms
Night pain
Weakness
Muscle wasting
Surgical ways of fixing shoulder problems
Cuff repair (feeding tendon through hole drilled in bone)
Suture anchor
Shoulder arthroplasty
Injection you could give into the shoulder
-From GPPC lecture
Steroid
Medrone with lignocaine (medrone is a steroid)
Which shoulder problem is more common in diabetics?
Frozen shoulder
Which bones form the shoulder girldle?
The scapula, the acromopn and the humerus and the supporting muscles including the deltoid and the muscles of the rotator cuff
Where do the supraspinatous, infraspinatous and teres minor attach to?
The greater tuberosity
Supraspinatous is responsible for initiating abduction
Infraspinatous and teres minor are external rotators
What does the subscapularis do?
Internal rotation
Subscapularis attaches to the lesser tuberosity
Shoulder condition with painful arc?
Shoulder impingement
Which tendons of the rotator cuff are usually compressed in shoulder impingement?
Supraspinatous
Where does pain of shoulder impingement typically radiate to?
The upper arm and deltoid
Pain may be felt under the lateral edge of the acromion
Which test can be used to re-create the pain of shoulder impingment?
Hawkins-kennedy test
Treatment for shoulder impingement
Treatment is conservative in the first instance with the majority of cases settling with NSAIDs, analgesics, physiotherapy and subacromial injection of steroid. Up to 3 subacromial injections may be required. Cases which do not improve with these interventions may benefit from subacromial decompression surgery to create more space for the tendon to pass through. This procedure can be done as an open procedure (through an incision large enough to visualise the subacromial space) or with minimally invasive arthroscopic techniques (when small instruments and a keyhole camera are inserted into the subacromial space to perform the surgery) .
The tendons of which muscle are usually involved in a rotator cuff tear?
Supraspinatous
Large tears can extend into the infrapinatous and subscapularis
How do you confirm a rotator cuff tear?
Ultrasound or MRI
What does supraspinatous do?
Initiation of abduction
What does subscapularis do?
Internal rotation
What does infraspinatous do?
External rotation
Treatment for rotator cuff tear
Surgery: Rotator cuff repair (open or arthroscopic) with subacromial decompression can be performed in an attempt to improve/maintain strength and to prevent subsequent arthritis from chronic cuff deficiency. However, the tendon is usually diseased and failure of repair occurs in around a third of cases. Very large tears may be irrepairable and the tendon may be retracted too far.
Non-operative: Many patients do well with physiotherapy to strengthen up the remaining cuff muscles which can compensate for the loss of supraspinatus. Subacromial injection may help symptoms.
Frozen shoulder
Progressive pain and stiffness of the shoulder in patients aged 40-60, resolving in 18-24 months
Principal clinical sign of frozen shoulder
Loss of external rotation
Which conditions are associated with frozen shoulder?
Diabetes
Hypercholesterolemia
Dupuytrens disease (similar thickened tissue is found histologically)
The capsule and the glenohumeral ligaments become inflamed and then thicken and contract
Which type of injection could you give in frozen shoulder?
Glenohumeral (glenohumeral rather than subacromial)
The 2 worst shoulder pains (says internet)
Calcific tendonitis
Frozen shoulder
Bankart operation
Can be used if recurrent shoulder dislocations
Re-attaches labrum and capsule to the anterior glenoid, which is where they were torn during the first dislocation
Conditions which cause ligamentous laxity?
Idiopathic
Marfans
Ehlers-Danlos
Treatment is difficult as soft tissue procedures may not work
What is the principal clinical sign of frozen shoulder?
Loss of external rotation
-Loss of external rotation also occurs in OA but patients affect tend to be elderly/older
What can cause a mucous cyst in your fingers?
Osteoarthritis
What injection may help to ease pain quickly in OA?
Steroid injection
Mucous cyst
outpouching of synovial fluid from DIPjt OA typical appearance may be painful may fluctuate/discharge may deform nail, cause ridge
Management:
you can leave them alone
excision
What type of joint is the thumb joint?
Saddle joint = moves in two planes
Which are the most common joints affected in OA?
1st most common: PIP/DIP
2nd most common: thumb CMP
SCAPHO-TRAPEZIAL-TRAPEZOID JOINT (STT)
Base of thumb OA
2nd most common joint for OA
thumb CMCjt is at 90˚ to hand
saddle joint, so moves in 2 planes
remember scapho-trapezial-trapezoid joint (STT)
often asymptomatic
pain at base of thumb
prevents pinch, grasp, sleep
Mx rest, splint, NSAIDs steroid injection surgery trapeziectomy (+/- tendon interposition)
How will base of thumb OA present?
Often asymptomatic
Pain at base of thumb
Prevents pinch, grasp, sleep
Treatment for base of thumb OA
Rest, splint NSAIDs,
Steroid injection
Surgery: trapeziectomy (+/- tendon interposition)
What is a ganglion?
Outpouching of synovial cavity
-usually painless but may feel tight
Rheumatoid arthritis
Auto-immune inflammatory joint disease
Results in ligament thinning + weakness
-capsules become lax, joints unstable
MCP joints dislocate, ulnar deviation
Swan-neck + Boutonniere deformity at PIP/DIP joints
Ligaments and joints in rheumatoid arthritis
Ligaments become thin and weak
Capsules become lax and joints unstable
Which hand deformities are found in rheumatoid arthritis?
Boutonniere and swan neck
heberdens and bouchards are found in OA
