Shoulder And Arm

Question 1

What is the classification for clavicular fractures?

Answer 1

The Allman classification system.

Type 1 - fracture of the middle third
Type 2 - fracture of the lateral third
Type 3 - fracture of the medial third (associated with polytrauma).

Question 2

Where will the fracture fragments typically be in a fractured clavicle?

Answer 2

The medial fragment will usually be displaced superiorly due to the pull of SCM and the lateral fragment will be displaced inferiorly from the weight of the arm.

Question 3

What imaging should you request for a suspected clavicular fracture?

Answer 3

Plain film radiographs AP and modified axial.

CT is rarely needed but sometimes used if there is a medial (type 3) fracture as it can be difficult to assess on plain radiographs.

Question 4

What is the management for clavicular fractures?

Answer 4

Most are treated conservatively, as surgery has no long term benefit. Treatment is initially a sling, early movement is recommended to prevent frozen shoulder.

Surgical - open fractures require surgical management or if the fractures fails to unite after 2-3 months it will need ORIF.

Question 5

How are rotator cuff tears classified?

Answer 5

Acute < 3 months
Chronic > 3 months

Also partial vs full thickness tears.

Full thickness can be small, medium, large or massive.

Question 6

What 3 tests can be performed to assess the presence of a rotator cuff tear?

Answer 6

Jobe’s test (empty can) for supraspinatus.

Gerber’s lift off test for subscapularis.

Posterior cuff test for infraspinitus and teres minor.

Question 7

What imaging should be requested for a suspected rotator cuff tear?

Answer 7

urgent plain film radiograph of shoulder to exclude a fracture.

USS and MRI can then be used to assess the tear.

Question 8

How are rotator cuff tears managed?

Answer 8

Conservative management (within 2 weeks of injury) - analgesia, physiotherapy, activity modification. Sometimes steroid injections.

Surgical management (after 2 weeks / large/massive tears) - arthroscopic repair / open approach.

Question 9

What investigations should be requested for a suspected shoulder (proximal humeral) fracture.

Answer 9

Bloods - coag, group and save, serum calcium (if suspected cancer), myeloma screen.

Imaging - plain film radiographs AP, lateral scapular and axillary views.
CT may be needed for pre-operative planning.

Question 10

What classification is used for proximal humeral fractures?

Answer 10

The Neer classification system:

(Based on how many segments there are).

Question 11

What is the management for a proximal humeral fracture?

Answer 11

Mostly conservative - immobilisation + early mobilisation after 2-4 weeks. They should have a polysling as gravity helps to reduce the fragments.

Surgical - surgical fixation if displaced, open or neuro vascularly compromised:

1. ORIF / intramedullary nailing for patients with multiple segments.
2. Hemiarthroplasty - for some complex injuries.
3. Reverse shoulder arthroplasty - where ball and socket are reversed.

Question 12

What are the common bony and ligament outs injuries associated with shoulder dislocations?

Answer 12

Bony -
Bony bankart lesion = fracture of the anteroir inferior glenoid bone
Hill-Sachs lesion = impaction injury to chondral surface of humeral head.
Can also get fractures of the greater tuberosity and surgical neck.

Soft tissue -
Soft Bankart lesion = avulsion of anterior labrum.
Glenohumeral ligament avulsion.
Rotator cuff injuries.

Question 13

What imaging would you request for a suspected shoulder dislocation?

Answer 13

Plain film radiographs (trauma shoulder series) - AP, Y-scapular and axial views.

N.b. A ‘lightbulb sign’ suggests posterior dislocation, the humerus is fixed in internal rotation.

If labral or rotator cuff injuries are suspected we need an MRI of the shoulder.

Question 14

What is the management for a shoulder dislocation?

Answer 14

A to E assessment
Analgesia
Closed reduction (Hippocratic method)
Immobilisation (sling for 2 weeks)
Physiotherapy 

Future surgical treatment may be needed for large bankart / hill-Sachs defects or ongoing shoulder pain.

Question 15

What is a Holstein-Lewis fracture?

Answer 15

Fracture of the distal third of the humerus, resulting in entrapment of the radial nerve.

This causes loss of sensation over the dorsal 1st web space and a wrist drop deformity (loss of wrist extension).

It needs surgical management

Question 16

What imaging would you request for a suspected humeral shaft fracture?

Answer 16

AP and lateral plain film radiographs.

If the fracture is very comminuted we may need to do a CT for pre-op planning.

Question 17

What is the management for a humeral shaft fracture?

Answer 17

Conservative - realignment and functional humeral brace.

Surgical - ORIF with plate / intramedullary nailing.

Question 18

What are the 2 special. Tests for biceps tendinopathy?

Answer 18

Speed test (proximal biceps tendon) - elbows extended, patient tries to forward flex shoulders against resistance.

Yergason’s test (distal biceps tendon) - patient stands with elbows flexed to 90 egress and pronated, tries to supinate against examiners resistance.

Question 19

What are the three stages of adhesive capsulitis?

Answer 19

1 - initial painful stage
2 - freezing stage
3 - thawing stage.

However there is likely to be pain and reduced ROM throughout.

Question 20

What imaging would you request for a suspected frozen shoulder?

Answer 20

Typically a clinical diagnosis.

Plain film radiographs can rule out fractures.
MRI can reveal thickening of the glenohumeral joint capsule.

N.b. Frozen shoulder is more common in diabetics so HbA1c and blood glucose measurements might be checked.

Question 21

How is frozen shoulder managed?

Answer 21

It is self-limiting, recovery usually takes months to years and some patients will never gain back full ROM.

Initial management - reassurance, keep active, physiotherapy, analgesia, sometimes steroid injections.

Surgical - joint manipulation under GA to remove capsular adhesions.

Question 22

What are the 2 special tests for subacromial impingement syndrome?

Answer 22

Neers impingement test - arm by patients side, fully internally rotated and passively flexed, positive if pain.

Hawkins test - shoulder and elbow flexed to 90, arm is passively internally rotated, positive if pain.

Question 23

What is the management for impingement syndrome?

Answer 23

conservative - analgesia, physiotherapy, sometimes steroid injections.

Surgical - if it persists beyond 6 months without response to conservative management. Arthroscopic surgery - e.g. repair of tears / removal of bursa, removal of section of acromion.