Shoulder Flashcards
what is the clinical examination test for supraspinatus
Jobe’s
what is the clinical examination test for AC joint
scarf test
what is the most common cause of shoulder pain in YP
instability
painful arc
tendons of the rotator cuff (predominantly supraspinatus) are compressed in the subacromial space during movement producing pain
in painful arc, what does the patient typically present with
- painful arc around 60 to 120 degrees abduction as an inflamed area of suprapsinatus tendon passes through the subacromial space
- localised pain over anterior acromion that may radiate to deltoid and upper arm
causes of painful arc
- tendonitis
- subarcomial bursitis
- acromioclavicular OA with inferior osteophyte
- hooked acromion rotator cuff tear
painful arc: what should be excluded from history and examination
cervical radiculopathy
painful arc: what test recreates the patients pain
hawkins kennedy - internally rotation flexed shoulder
painful arc: treatment
- conservative - NSAIDs, analgesics, physio and subacromial injection of steroid - is usually enough
- subacromial decompression surgery to create more space for the tendon to pass through
- can be an open procedure or minimally invasive arthroscopic procedure
rotator cuff tear
- can tear with minimal or no trauma as a consequence of degenerative changes in the tendon
- tears can be partial or full thickness and usually involve supraspinatus large tears can extend into subscapularis and infraspinatus
rotator cuff tear: classic history
- sudden jerk in patient >40 with subsequent pain and weakness
- fairly common in over 60 year olds - asymptomatic due to tendon degeneration
- can also occur in YP due to a significant injury, although this is uncommon
action of rotator cuff muscles
- supraspinatus - initiation of abduction (15 degrees)
- external rotation - supra and infra spinatus and teres minor
- internal rotation - subscapularis
clinical features of rotator cuff tear
- pain and weakness on movement
- wasting of muscles
what can rotator cuff tear lead to
athritis:
- As the rotator cuff centres the humeral head on the glenoid, if it is torn the deltoid will pull the head upwards and abnormal forces on the glenoid lead to OA
- Anatomic shoulder replacement will fail, so a reverse one is used
rotator cuff tear: confirmation of tear
US is gold standard
or MRI
treatment of rotator cuff tear
- rotator cuff repair with subacromial decompression can be performed in an attempt to improve/maintain strength and prevent subsequent arthritis. however, tendon is usually diseased and failure of repair is common
- reverse geometry shoulder replacement can be used
- non-operative: physio to strength up remaining RC muscles can compensate for loss of supraspinatus. subacromial injection may help symptoms
reverse geometry shoulder replacement
- The ball and socket joint is reversed – this prevents the shoulder moving upwards when the deltoid contracts
- The centre of rotation of the glenohumeral joint is moved closer to the body, thus increasing the moment arm of the deltoid
- The deltoid’s function is thus improved
- This is a new technique, and therefore there are no long-term studies. It has a high complication rate, and the deltoid may ‘fatigue’ after around 7 years
adhesive capsulitis
frozen shoulder
joint capsule and glenohumeral ligaments become inflamed then thicken and contract
adhesive capsulitis: clinical features
- progressive pain and stiffness in patients, resolves around 18-24 months
- restriction of active and passive movement - especially external rotation
- bilateral in up to 20% patients
typical patient age and sex with adhesive capsulitis
female, between 40 and 60
adhesive capsulitis: aetiology
- who is particularly prone to it
- aetiology is unclear
- trauma
- shoulder surgery
- DIABETICS are more prone
- associated with hypercholesterolaemia
- related to Dupuytren’s disease (and both more common in diabetics)
adhesive capsulitis treatment
relief of pain and prevention of further stiffening - physio and analgesics
intra-articular injections (gleno-humeral) can help in the painful phase
if, once the pain has settled, the patient cannot tolerate functional loss due to stiffness, recovery can be hastened by MUA or surgical capsular release
acute calcific tendonitis
- Deposition of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the body, most commonly the rotator cuff tendons (80% supraspinatus)
- This cause acute and rapid deterioration, and results in acute onset of severe shoulder pain
- Pain may awake the patient from sleep.
age and sex of usual acute calcific tendonitis patient
female, 50-60
what is acute calcific tendonitis related to
related to, and may cause, adhesive capsulitis
management of acute calcific tendonitis
- Pain relief is achieved with subacromial steroid and local anesthetic injection
- Condition is self-limiting with pain easing as calcification resorbs.
milwaukee shoulder syndrome
- Hydroxyapatite crystal deposition in or around the glenohumeral joint, causing a destructive shoulder arthropathy
- Crystals are not detected under light or polarised microscopy, but Alizarin stain shows red clumps – cornerstone of diagnosis
instability of shoulder
- occurs in young patients
- painful abnormal translation movement and/or recurrent dislocation and subluxation
- anterior dislocation is more common than posterior
traumatic instability
traumatic anterior dislocation - potentially doesn’t stabilise and develop recurrent dislocations and subluxaions
Bankart and Hill Sachs lesion
- anterior shoulder dislocation often results in detachment of the anterior glenoid labrum and capsule - Bankart lesion
- if a bit of bone breaks off fromthe glenoid it is known as a bony bankart lesion
- posterior humeral head can impact on the anterior glenoid producing an impaction fracture of the posterior head - Hill Sachs lesion
what is often assoicated with anterior shoulder dislocation
fracture of greater tuberosity or rotator cuff tear
Hill Sachs lesion
compare the re-dislocation rate in the under 20s to over 30s
80% in U20s and 20% in O30s
how are most anterior shoulder dislocations managed
sling for several weeks followed by physio
what factors predispose one to recurrent dislocations
bankart lesion
how are recurrent (traumatic) dislocations treated
occur when shoulders do not stabilise after dislocation and develop recurrent dislocations/subluxations
Bankart repair: reattachment and tightening of torn labrum and ligaments of shoulder
what nerve can be damaged in dislocation
axillary nerve in quadrangular space
- badge patch area, deltoid and teres minor
managemnent of associated greater tuberosity fracture with anterior dislocation
- usually reduces after reduction of GH joint
- may need fixed if it is substantially displaced
clinical presentation of shoulder dislocation
- arm held in adducted position
- loss of symmetry and contour
- nerve injury - axillary
- x rays confirm injury
name some shoulder relocation techniques
- traction
- hippocratic
- holding weight
- kocher manoeuvre
- use a x ray to confirm reduction
- most managed with a sling followed by physio
x ray findings of posterior shoulder dislocation
- light bulb sign
- widened glenohumeral joint: rim’s sign
- trough line sign: the anterior aspect of the humeral head becomes impacted against the posterior glenoid rim, can cause a compression fracture
treatment of posterior shoulder dislocation
closed reduction, sling and physio
atraumatic instability
patients with generalised ligamentous laxity (Ehlers-Danlos, Marfan’s) can have pain from recurrent multidirectional subluxation or disclocations
treatment is difficult as soft tissue procedures may not work
what sign is used to assess inferior instability of the shoulder
sulcus sign
inflammation of long head of biceps tendon
causes anterior shoulder pain - attaches to the supraglenoid tubercule - with pain on resisted biceps contraction
what happens if the long head of the inflamed biceps tendon ruptures
relief of symptoms
some are left with a bunched up biceps - POPEYE shoulder
acromioclavicular joint arthritis
common
often overlaps with impingement
may be due to trauma
glenohumeral joint arthritis causes
may be due to rotator cuff tear, instability, previous surgery or idiopathic
glenohumeral joint arthritis CF
pain, usually in the front of the shoulder
crepitus
loss of movement, especially external rotation
how can glenohumeral joint arthritis be treated
joint replacement surgery - arthroplasty
complications - infection, instability, stiffness, nerve damage, loosening
what is arthroplasty
replacing/remodelling/realigning a joint articular surface
anterior shoulder dislocation
treatment of sternovlacivular joint dislocation
Anterior do well if they are left alone.
Posterior can compress the trachea, oesophagus, or brachiocephalic vein.
- Dyspnoea, dysphagia, venous congestion
- Reduced
greater tuberosity fracture
