Shoulder

Question 1

What is the commonest cause of shoulder pain in people aged 10-30?

Answer 1

Instability ➔ dislocations

Question 2

What is the commonest cause of shoulder pain in people aged 40-60?

Answer 2

Shoulder impingement syndrome

Question 3

What is the commonest cause of shoulder pain in people aged 60+?

Answer 3

Osteoarthritis

Question 4

Define shoulder instability

Answer 4

Inability to maintain the humeral head in the glenoid fossa during function, associated with symptoms e.g. stiffness or pain

Question 5

Describe the pathophysiology of shoulder instability

Answer 5

• Structural causes:
  
  • Damage after major injury
  • Structural deficit predisposing to instability following minor injury
• Muscle imbalance

Question 6

Outline the Stanmore classification of shoulder instability

Answer 6

Question 7

Differentiate shoulder laxity from shoulder instability

Answer 7

• 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

Question 8

How can shoulder joint instability be assessed?

Answer 8

• 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

Question 9

Outline the treatment options for shoulder instability

Answer 9

• Analgesia
• Assessment and acute reduction
• Encourage early mobilisation
• I (traumatic): Surgery
• II (atraumatic) or III (muscle patterning): Rehabilitation ± surgery

Question 10

Define joint dislocation and subluxation

Answer 10

Dislocation: complete disruption of the joint

Subluxation: partial dislocation followed by relocation

Question 11

Describe the different types of shoulder dislocations

Answer 11

• 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.

Question 12

Give three symptoms of shoulder dislocation

Answer 12

• Severe shoulder pain
• Limited motion of the shoulder
• Shoulder bruising or abrasion
• Swelling

Question 13

What signs may be seen with shoulder dislocation?

Answer 13

• Swelling
• Loss of normal contour of the shoulder
• Sulcus sign: inferior instability
• Deltoid muscle wasting: axillary nerve impingement
• Arterial injury

Question 14

What is the Lightbulb sign in regards to the shoulder?

Answer 14

• Abnormal AP radiograph appearance of the humeral head
• Posterior shoulder dislocation
• Appears due to internal rotation.

Question 15

Which nerve is most commonly affected with shoulder dislocations?

Answer 15

Axillary nerve

Question 16

Provide three injuries associated with a traumatic shoulder dislocation?

Answer 16

• 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

Question 17

What is the probability of reoccurrence for shoulder dislocations in <20s

Answer 17

90%

Decreases to 25% for people in their 30s

Question 18

List three stabilising factors of the shoulder joint

Answer 18

• Glenoid and glenoid labrum
• Glenohumeral ligaments
• Joint capsule
• Rotator cuff muscles
• Negative intraarticular pressure
• Friction

Question 19

Define shoulder impingement syndrome

Answer 19

• Supraspinatus tendonitis/subacromial bursitis
• Occurs on elevation or internally rotation of the humerus
• At 60-120^o of abduction

May cause bicips tendonitis and rupture

Question 20

What special test is diagnostic of shoulder impingement on examination?

Answer 20

Question 21

Describe the management options of shoulder impingement syndrome

Answer 21

• 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

Question 22

Define adhesive capsulitis of the shoulder

Answer 22

• Significantly restricted active and passive movements of the shoulder
  
  • Characteristic impaired external rotation
• May be primary (idiopathic) or secondary

Question 23

Name two associations of secondary adhesive capsulitis

Answer 23

• Trauma
• Rotator cuff injury
• Thyroid dysfunction
• Diabetes mellitus: 20% will have an episode
• Cardiovascular disease

Question 24

Describe the illness course of adhesive capsulitis of the shoulder

Answer 24

Progression through three overlapping phases

1. Painful: Progressive diffuse shoulder pain lasting weeks-months
2. Stiffness: Reducing ROM up to 1 year; improving pain
3. Resolution: Weeks-months of gradually improving ROM

Question 25

What movement will rule out adhesive capsulitis as a differential diagnosis?

Answer 25

Normal external rotation

Question 26

Name two differential diagnoses for adhesive capsulitis of the shoulder

Answer 26

• Polymyalgia rheumatica: acute onset in limb girdle
• Pancoast tumour: systemic features, hoarse voice
• Posterior dislocation: seizures and electric shocks

Question 27

Describe the management for adhesive capsulitis of the shoulder

Answer 27

• Encourage arm movement; avoid aggravating movements
• Paracetamol ± NSAIDs or codiene; hot packs
• Physiotherapy
• Intra-articular corticosteroid injection
• Surgery
  
  • Manipulation under anaesthesia
  • Shoulder arthroscopy

Question 28

What is Os Acromiale?

What is its significance?

Answer 28

• Developmental defect: failure to fuse the acromial process
• Usually asymptomatic
• May cause secondary shoulder impingement syndrome

Question 29

What special tests assess rotator cuff integrity?

Answer 29

• 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

Question 30

What test can assess for acromioclavicular joint disorder

Answer 30

Scarf test

Question 31

Name two complications of a proximal humeral fracture

Answer 31

• Mal-union/non-union of humeral fracture
• Avascular necrosis
• Screw penetration
• Nerve damage: axillary commonest
• Adhesive capsulitis
• Post-traumatic arthritis

Question 32

How does acromioclavicular osteoarthritis present?

Answer 32

• Pinpoint tenderness/pain over acromioclavicular joint
• Painful arc between 170-180 degrees
• Positive Scarf test
• Swelling; stiffness; crepitus

Question 33

Describe the pathophysiology of rotator cuff tear arthropathy

Answer 33

• Rotator cuff tear no longer holds the humeral head in the glenoid
• Humerus displaces superiorly and moves against the acromion

Question 34

Differentiate between glenohumeral and acromioclavicular osteoarthritis

Answer 34

• 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.

Question 35

Outline the treatment options for arthritis of the shoulder

Answer 35

• Rest, activity modification, ice
• Physiotherapy
• Paracetamol ± NSAIDs or codeine
• Corticosteroid injections
• Surgical
  
  • GH OA: Arthroscopy; Arthroplasty
  • AC OA: Acromioplasty/subacromial decompression