Shoulder Flashcards
What is the commonest cause of shoulder pain in people aged 10-30?
Instability ➔ dislocations
What is the commonest cause of shoulder pain in people aged 40-60?
Shoulder impingement syndrome
What is the commonest cause of shoulder pain in people aged 60+?
Osteoarthritis
Define shoulder instability
Inability to maintain the humeral head in the glenoid fossa during function, associated with symptoms e.g. stiffness or pain
Describe the pathophysiology of shoulder instability
- Structural causes:
- Damage after major injury
- Structural deficit predisposing to instability following minor injury
- Muscle imbalance
Outline the Stanmore classification of shoulder instability
Differentiate shoulder laxity from shoulder instability
- Laxity:
- Asymptomatic hypermobile joint
- Maintains the humeral head in the glenoid fossa
- Instability:
- Symptomatic e.g. stiffness or pain
- Inability to maintain the humeral head in the glenoid fossa
How can shoulder joint instability be assessed?
- Beighton test: hyper mobility/laxity
- Apprehension test: assess anterior dislocation on forced external rotation
- Shoulder relocation test: performed after +ve apprehension test,
- Apply posterior pressure on humeral head
Outline the treatment options for shoulder instability
- Analgesia
- Assessment and acute reduction
- Encourage early mobilisation
- I (traumatic): Surgery
- II (atraumatic) or III (muscle patterning): Rehabilitation ± surgery
Define joint dislocation and subluxation
Dislocation: complete disruption of the joint
Subluxation: partial dislocation followed by relocation
Describe the different types of shoulder dislocations
- Anterior dislocation (95%):
- Sports-related (young)
- Fall on outstretched hand (older)
- Posterior dislocation (2-4%):
- Seizures and electric shock
- Can occur with fall on outstretched hand, or trauma to anterior shoulder
- Inferior dislocation (0.5%): Traumatic injury pushing arm downwards.
Give three symptoms of shoulder dislocation
- Severe shoulder pain
- Limited motion of the shoulder
- Shoulder bruising or abrasion
- Swelling
What signs may be seen with shoulder dislocation?
- Swelling
- Loss of normal contour of the shoulder
- Sulcus sign: inferior instability
- Deltoid muscle wasting: axillary nerve impingement
- Arterial injury
What is the Lightbulb sign in regards to the shoulder?
- Abnormal AP radiograph appearance of the humeral head
- Posterior shoulder dislocation
- Appears due to internal rotation.
Which nerve is most commonly affected with shoulder dislocations?
Axillary nerve
Provide three injuries associated with a traumatic shoulder dislocation?
- Bankart lesion (90%):
- Detachment of glenoid labrum from its antero-inferior surface
- Hill-Sach lesion (66%):
- Postero-lateral humeral head compression fracture
- Humeral head impacts the anterior glenoid
- SLAP lesion (5-7%):
- Superior labral tear where the long head of biceps tendon attaches
- Fracture dislocation
- Rotator cuff tear: more often in older patients
- Nerve injury
What is the probability of reoccurrence for shoulder dislocations in <20s
90%
Decreases to 25% for people in their 30s
List three stabilising factors of the shoulder joint
- Glenoid and glenoid labrum
- Glenohumeral ligaments
- Joint capsule
- Rotator cuff muscles
- Negative intraarticular pressure
- Friction
Define shoulder impingement syndrome
- Supraspinatus tendonitis/subacromial bursitis
- Occurs on elevation or internally rotation of the humerus
- At 60-120o of abduction
May cause bicips tendonitis and rupture
What special test is diagnostic of shoulder impingement on examination?
Describe the management options of shoulder impingement syndrome
- Rest; avoid excessive aggrevation
- Paracetamol ± NSAIDs or codiene
- Physiotherapy: recover normal range of motion
- Steroid injection
- Operative treatment
- Subacromial decompression
- Anterior acromioplasty: may remove calcification in tendon
Define adhesive capsulitis of the shoulder
- Significantly restricted active and passive movements of the shoulder
- Characteristic impaired external rotation
- May be primary (idiopathic) or secondary
Name two associations of secondary adhesive capsulitis
- Trauma
- Rotator cuff injury
- Thyroid dysfunction
- Diabetes mellitus: 20% will have an episode
- Cardiovascular disease
Describe the illness course of adhesive capsulitis of the shoulder
Progression through three overlapping phases
- Painful: Progressive diffuse shoulder pain lasting weeks-months
- Stiffness: Reducing ROM up to 1 year; improving pain
- Resolution: Weeks-months of gradually improving ROM
What movement will rule out adhesive capsulitis as a differential diagnosis?
Normal external rotation
Name two differential diagnoses for adhesive capsulitis of the shoulder
- Polymyalgia rheumatica: acute onset in limb girdle
- Pancoast tumour: systemic features, hoarse voice
- Posterior dislocation: seizures and electric shocks
Describe the management for adhesive capsulitis of the shoulder
- Encourage arm movement; avoid aggravating movements
- Paracetamol ± NSAIDs or codiene; hot packs
- Physiotherapy
- Intra-articular corticosteroid injection
- Surgery
- Manipulation under anaesthesia
- Shoulder arthroscopy
What is Os Acromiale?
What is its significance?
- Developmental defect: failure to fuse the acromial process
- Usually asymptomatic
- May cause secondary shoulder impingement syndrome
What special tests assess rotator cuff integrity?
- Empty can test: supraspinatus (abduction)
- Infraspinatus test: infraspinatus (external rotation)
- Horn blowers test: teres minor (external rotation)
- Gerber’s lift off test: subscapularis (internal rotation)
- Drop arm test: 2+ tendon tear; esp. supraspinatus
What test can assess for acromioclavicular joint disorder
Scarf test
Name two complications of a proximal humeral fracture
- Mal-union/non-union of humeral fracture
- Avascular necrosis
- Screw penetration
- Nerve damage: axillary commonest
- Adhesive capsulitis
- Post-traumatic arthritis
How does acromioclavicular osteoarthritis present?
- Pinpoint tenderness/pain over acromioclavicular joint
- Painful arc between 170-180 degrees
- Positive Scarf test
- Swelling; stiffness; crepitus
Describe the pathophysiology of rotator cuff tear arthropathy
- Rotator cuff tear no longer holds the humeral head in the glenoid
- Humerus displaces superiorly and moves against the acromion
Differentiate between glenohumeral and acromioclavicular osteoarthritis
- GH:
- Pain centred in the back of shoulder
- May intensify with changes in weather
- Complain of deep ache
- AC:
- Pinpoint pain across AC joint
- May radiate to neck.
Outline the treatment options for arthritis of the shoulder
- Rest, activity modification, ice
- Physiotherapy
- Paracetamol ± NSAIDs or codeine
- Corticosteroid injections
- Surgical
- GH OA: Arthroscopy; Arthroplasty
- AC OA: Acromioplasty/subacromial decompression
