Shoulder Flashcards
3 main places shoulder problems can arise
ACJ
Subacromial space
Glenn numeral joint
At conditions are associated with the 3 places that problems can arise
ACJ - OA or RA
Subacromial space - impingement - subacromial inflamed bursa, rotator cuff problems weakness and tears
Gleno-numeral joint
Capsule - frozen shoulders, labral injuries -instability, OA
What are the joints in the shoulder
Glenn-numeral joint - ball and socket joint which is very mobile
ACJ
Sternoclavicular joint - saddle manubrium and the clavicle
Scapulocostal - physiological joint formed by an articulation of the anterior scapula and post thoracic rib cage
What are the shoulder stabilisers
Passive Glenoid and the labrum -ve intrarticular pressure Capsule and glenohumeral Active Rotator cuff muscles
How to asses the rotator cuff
Supraspinatus
Supraspinatus tested by patient internally rotates arm whilst in 45 degree abduction and 30 degree forward flexion with an extended elbow
Attempt to further adult against resistance on their elbow produces pain if weak or injured
How to assess the rotator cuff
Subscaplaris
Belly press - hands on belly and push elbows forwards against resistance results in pain or weak if injury or weak
Put hand with palm on the back and push out - pain or weakness injury
How to assess the rotator cuff
Infraspinatus and teres minor
Flex elbow to 90 degree elbows to side and internally rotate against resistance
What is the drop arm sign
Patient lowers arm lowly from 160 abduction
If the patient cant control he Armand it drop quickly to the side = rotator cuff tear
What is the test of ACJ disease
Scarf test
Tests for impingement
Painful arc between 60 and 120 abduction exacerbated when thumb pointing down (empty can) and better when thumb pointing up (full can)
Neer - passive flexion of the shoulder with a pronated arm whilst the scapula is stabilised
Hawkins - passive test arm positioned 90 degrees in scapular plane elbow bent at 90 arm passively rotates across the body
Hx for impingement
>50 Pain in deltoid region Pain on overhead activity Pain at night Pain radiated down the lateral aspect of the arm
What should you also examine when you examine the shoulder
First start by screening the neck - pain down the cervical spine any pain or reproduction of symptoms on movement
Move head forward backwards, left right, to the left ear to the right ear
Mx of impingement
Once clinical suspicion is made on x and exam
Then organise for a dynamic USS or MRI
Con - NSAIDS, rest physio
Steroid injections max 3
Surgery - arthroscopic subacromial decompression
Repair arthroscopically
What holds the clavicle in place
Sup AC ligament
Coraco clavicular ligament
In a dislocation the ligament can rupture an ma nee reconstruction in surgery via a hamstring graft synthetics
What are the 3 phases of a frozen shoulder
Pain
Stiffness
Resolutions
How long can it take for a frozen shoulder to resolve
3 years
What are risk factors for a frozen shoulder
Diabetes
CV disease
What is a frozen shoulder also called
Adhesive capsulitis
What causes frozen shoulder
Fibroelastic proliferation of the inferior shoulder capsule
Anterior capsule is in between the biceps tendon and the subscapsularis
This thickens os reduces rotation
Reduction in all movements
How is a frozen shoulder different from impingement
Loss of passive external rotation diff from impingement as this is maintained
Tx frozen shoulder
Con - active surveillance, physio, steroid injection
Arthroscopic subacromial decompression
Cuff relain arthroscpically is damaged due to the subscapualris being on the floor of the anterior capsule
What is the borders of the subacromial space
Roof - acromion, cocracoaromial ligament
Floor - rotator cuff muscles
What is inside the subacromial space
The subacromial bursa
What becomes inflamed in shoulder impingement
The subacromial bursa
As you elevate the arm this become squeezed and you get pain
What other structures can become damaged in impingement
Underlying rotator cuff
The bursa inflamed the rotator cuff can be inflamed too and this can lead to rotator cuff tears
Shoulder instability how to test for is
Sulcus sign
Anterior translation
Apprehension test
What means a shoulder is unstable
Recurrent shoulder dislocations
What are the 2 types of shoulder instability
Torn loose and born loose
TUBS and AMBRI
Traumatic and atraumatic
Atraumatic instability what is it
Often a teenager with no hx of trauma, but having general joint laxity
A=atraumatic
M= multidirectional- anterior and posterior
B=bilateral
R=rehabilitation is tx due to usually urgent not helping
I = inf capsular shift surgery only if rehab fails
Beware of habitual dislocations , a patient who purposely dislocated due to performing their dislocations they are less likely to respond to tx
What is traumatic instability
Dislocation is anterior, rarely inferior, really rarely posterior
Secondary to trauma - may be mild
Abduction + lateral rotation of the arm (putting on a coat) may cause dislocationor may be more traumatic such as a rugby tackle
Traumatic
Unidirectional
Bankart lesion
Surgery
What is a bankart lesion
Arise from avulsion of the glenoid labrum
What is a Hill-Sachs lesion
An impaction fracture of the humeral head following anterior dislocation
Tx - bone graft or metal implant
What age most likely affected by recurrent dislocation
<25 compared to >40 the latter group requires imaging of the rotator cuff as high risk of traumatic rupture rather than labral injury
