Shoulder and Arm Flashcards
what classification system is used to classify clavicle fractures
Allman classification system
describe the allman classification system of clavicle fractures
determined by the anatomical location of the fracture along the clavicle
Type 1 = fracture of the middle third of the clavicle, usually stable although present with significant deformity
Type 2 = fracture involving the lateral third of the clavicle, often unstable
Type 3 = fracture of medial third of clavicle
why are type 3 clavicle fractures dangerous
fracture of the median third of the clavicle
mediastinum sits directly behind the medial aspect of the clavicle, therefore a fracture can be associated with neurovascular compromise, pneumothorax and haemothorax
what is the most common type of clavicle fracture
Allmans type 1 = 75%
fracture of the middle third of the clavicle
where do the medial and lateral fragments of the clavicle displace in the event of a break
medial fragment will displace superiorly due to the pull of the sternocleidomastoid
lateral fragment will displace inferiorly due to the weight of the arm
what nerve structure should you be worried about in a clavicle fracture
brachial plexus
clinical features of clavicle fracture
sudden onset localised severe pain
nearly always following trauma
pain made worse on movement of the arm
with any fracture what 2 general types of management are there
surgical and conservative
what determines whether a clavicle fracture requires conservative or surgical management
if its an open fracture then it requires surgical management
if its closed then it can be treated conservatively
how would you manage a closed clavicle fracture
conservative treatment
put arm in sling to stabilise fracture and support elbow
encourage movement of the shoulder joint to avoid frozen shoulder
remove sling when patient regains pain-free movement of the shoulder
what is the rotator cuff
it is a group of 4 muscles that support and rotate the glenohumeral joint
what muscles make up the rotator cuff
supraspinatus
infraspinatus
teres minor
subscapularis
how are rotator cuff tears classified
acute > 3 months
chronic < 3 months
and then partial or full thickness tears
risk factors for rotator cuff tears
age, trauma, overuse and repetitive overhead shoulder motions (e.g. athletes)
high BMI
smoking
diabetes
clinical features of a rotator cuff tear
pain over the lateral aspect of the shoulder and inability to abduct the arm above 90 degrees
on examination there is often tenderness over the greater tuberosity
what specific test tests the function of the supraspinatus
Jobe’s test - ‘empty can test’
position arm as if you are emptying a can and then push down on the arm, if there is weakness on resistance then it indicates an issue with supraspinatus and a positive test
what specific test tests the function of the subscapularis
Gerber’s lift off test
internally rotate arm such that the dorsal surface of the hand rests on your lower back, then ask the patient to lift their hand away from the back against examiners resistance
weakness on actively lifting the hand is a positive test and suggest issues with subscapularis
what specific test tests the action of the teres minor and infraspinatus
Posterior cuff test
arm positioned at patients side with elbow flexed 90 degrees, ask patient to then externally rotate the arm against examiners resistance
weakness against resistance suggests problems with teres minor and infraspinatus and a positive test
investigations into a rotator cuff tear
X ray shoulder to exclude fracture
then US and/or MRI to definitively establish size and location of the tear
in what kind of patient would conservative management of a rotator cuff tear be alright
patient who is not limited by pain or loss of function
or those who have significant co-morbidities and are unsuitable for surgery
when would surgical management of a rotator cuff tear be indicated
still symptomatic despite conservative treatment or a large/massive tear
what is the conservative management of a rotator cuff tear
analgesia and physiotherapy
and corticosteroid injections into the subacromial space can be trialled
where is the most common site of shoulder fracture and what mechanism is the main cause
proximal humerus fractures are the most common site of shoulder fracture and the main mechanism is a FOOSH in elderly people
these injuries primarily occur in the context of osteoporosis
risk factors for all osteoporotic type fractures
female gender
early menopause
prolonged steroid use
recurrent falls
frailty
what nerve and vessels should you be concerned about in a proximal humerus fracture
axillary nerve
circumflex vessels
what pattern of sensory and motor loss would you see in a patient with a damaged axillary nerve
loss of sensation in the lateral shoulder - ‘regimental badge area’
loss of power in the deltoid muscle (innervated by the axillary nerve)
why is it important to check neurovascular status in a proximal humerus fracture
close anatomical relationship between the humerus and axillary nerve
where a pathological cause of fracture is suspected, what other blood tests would you want on top of the routine ones
serum calcium
myeloma screen
what is conservative management of a proximal humerus fracture and what patients would be suitable
any patient with minimal displacement and no neurovascular compromise
immobilise the arm in a sling, the effect of gravity on the arm will aid in the reduction of the fragments of most humeral fractures
why is avascular necrosis of the humeral head a concern following proximal humerus fractures
risk of damage to the blood supply to the humeral head (circumflex arteries)
when is surgical fixation indicated in people with proximal humerus fractures
if it is an open fracture or there is neurovascular compromise
what are the different types of surgical management of a proximal humerus fracture
ORIF - open reduction internal fixation
intermedullary nailing
hemiarthroplasty
reverse shoulder arthroplasty (total shoulder arthroplasty)
what is the most common type of shoulder dislocation
anterior shoulder dislocation is most common - 95%
what is the classical mechanism of an anterior dislocation of the shoulder
force applied to an extended, abducted, externally rotated humerus
what mechanism of injury usually causes a posterior dislocation of the shoulder
seizures or electrocution
can occur through trauma (a direct blow to the anterior shoulder or force through a flexed adducted arm)
clinical features of dislocated shoulder
painful shoulder
acutely reduced mobility
feeling of instability
asymmetry with contralateral shoulder
what 2 nerves are mostly at risk from a dislocated shoulder
axillary nerve
subscapular nerves
what are the associated bony injuries that sometimes accompany shoulder dislocations
Bony Bankart lesions - fractures of the anterior inferior glenoid bone
Hill-Sachs defects - impaction injuries to the chondral surface of the posterior and superior portions of the humeral head
fractures of the greater tuberosity and the surgical neck of the humerus can occur
what does the ‘light bulb sign’ suggest in shoulder dislocations
posterior dislocation
management of shoulder dislocation
A to E assessment as shoulder dislocations often occur as a result of trauma
provide appropriate analgesia
reduction (closed reduction in dislocations), immobilisation, rehabilitation
(assess neurovascular status pre and post reduction)
once reduced, place in a sling
physiotherapy to restore ROM and strenghten rotator cuff
