Shoulder and Arm

Question 1

what classification system is used to classify clavicle fractures

Answer 1

Allman classification system

Question 2

describe the allman classification system of clavicle fractures

Answer 2

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

Question 3

why are type 3 clavicle fractures dangerous

Answer 3

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

Question 4

what is the most common type of clavicle fracture

Answer 4

Allmans type 1 = 75%

fracture of the middle third of the clavicle

Question 5

where do the medial and lateral fragments of the clavicle displace in the event of a break

Answer 5

medial fragment will displace superiorly due to the pull of the sternocleidomastoid

lateral fragment will displace inferiorly due to the weight of the arm

Question 6

what nerve structure should you be worried about in a clavicle fracture

Answer 6

brachial plexus

Question 7

clinical features of clavicle fracture

Answer 7

sudden onset localised severe pain

nearly always following trauma

pain made worse on movement of the arm

Question 8

with any fracture what 2 general types of management are there

Answer 8

surgical and conservative

Question 9

what determines whether a clavicle fracture requires conservative or surgical management

Answer 9

if its an open fracture then it requires surgical management

if its closed then it can be treated conservatively

Question 10

how would you manage a closed clavicle fracture

Answer 10

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

Question 11

what is the rotator cuff

Answer 11

it is a group of 4 muscles that support and rotate the glenohumeral joint

Question 12

what muscles make up the rotator cuff

Answer 12

supraspinatus

infraspinatus

teres minor

subscapularis

Question 13

how are rotator cuff tears classified

Answer 13

acute > 3 months

chronic < 3 months

and then partial or full thickness tears

Question 14

risk factors for rotator cuff tears

Answer 14

age, trauma, overuse and repetitive overhead shoulder motions (e.g. athletes)

high BMI

smoking

diabetes

Question 15

clinical features of a rotator cuff tear

Answer 15

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

Question 16

what specific test tests the function of the supraspinatus

Answer 16

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

Question 17

what specific test tests the function of the subscapularis

Answer 17

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

Question 18

what specific test tests the action of the teres minor and infraspinatus

Answer 18

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

Question 19

investigations into a rotator cuff tear

Answer 19

X ray shoulder to exclude fracture

then US and/or MRI to definitively establish size and location of the tear

Question 20

in what kind of patient would conservative management of a rotator cuff tear be alright

Answer 20

patient who is not limited by pain or loss of function

or those who have significant co-morbidities and are unsuitable for surgery

Question 21

when would surgical management of a rotator cuff tear be indicated

Answer 21

still symptomatic despite conservative treatment or a large/massive tear

Question 22

what is the conservative management of a rotator cuff tear

Answer 22

analgesia and physiotherapy

and corticosteroid injections into the subacromial space can be trialled

Question 23

where is the most common site of shoulder fracture and what mechanism is the main cause

Answer 23

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

Question 24

risk factors for all osteoporotic type fractures

Answer 24

female gender

early menopause

prolonged steroid use

recurrent falls

frailty

Question 25

what nerve and vessels should you be concerned about in a proximal humerus fracture

Answer 25

axillary nerve

circumflex vessels

Question 26

what pattern of sensory and motor loss would you see in a patient with a damaged axillary nerve

Answer 26

loss of sensation in the lateral shoulder - ‘regimental badge area’

loss of power in the deltoid muscle (innervated by the axillary nerve)

Question 27

why is it important to check neurovascular status in a proximal humerus fracture

Answer 27

close anatomical relationship between the humerus and axillary nerve

Question 28

where a pathological cause of fracture is suspected, what other blood tests would you want on top of the routine ones

Answer 28

serum calcium

myeloma screen

Question 29

what is conservative management of a proximal humerus fracture and what patients would be suitable

Answer 29

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

Question 30

why is avascular necrosis of the humeral head a concern following proximal humerus fractures

Answer 30

risk of damage to the blood supply to the humeral head (circumflex arteries)

Question 31

when is surgical fixation indicated in people with proximal humerus fractures

Answer 31

if it is an open fracture or there is neurovascular compromise

Question 32

what are the different types of surgical management of a proximal humerus fracture

Answer 32

ORIF - open reduction internal fixation

intermedullary nailing

hemiarthroplasty

reverse shoulder arthroplasty (total shoulder arthroplasty)

Question 33

what is the most common type of shoulder dislocation

Answer 33

anterior shoulder dislocation is most common - 95%

Question 34

what is the classical mechanism of an anterior dislocation of the shoulder

Answer 34

force applied to an extended, abducted, externally rotated humerus

Question 35

what mechanism of injury usually causes a posterior dislocation of the shoulder

Answer 35

seizures or electrocution

can occur through trauma (a direct blow to the anterior shoulder or force through a flexed adducted arm)

Question 36

clinical features of dislocated shoulder

Answer 36

painful shoulder

acutely reduced mobility

feeling of instability

asymmetry with contralateral shoulder

Question 37

what 2 nerves are mostly at risk from a dislocated shoulder

Answer 37

axillary nerve

subscapular nerves

Question 38

what are the associated bony injuries that sometimes accompany shoulder dislocations

Answer 38

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

Question 39

what does the ‘light bulb sign’ suggest in shoulder dislocations

Answer 39

posterior dislocation

Question 40

management of shoulder dislocation

Answer 40

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