Shoulder and elbow Flashcards by Nader Raafat

Presentation of rotator cuff tear

Older patient

Weakness

Diffuse lateral shoulder pain

After trauma if younger

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Special tests for rotator cuff tears

Belly-press or thumb up across back

Supraspinatus test (thumb up)

Thumbs down test (drop can test - impingement, tear, inflammation)

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Management of rotator cuff tears

Analgesia and physio if longstanding (not reparable in elderly due to poor blood supply)

Small tears –> manage as impingement

Medium tears –> surgical management (esp if acute, trauma)

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Pathophysiology of rotator cuff impingement

Tendinopathy with disordered collagen, inflammation

Beaking of acromion process with age

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Presentation of rotator cuff impingement

Painful arc (45-160 degrees)

40s-60s

Only on active movement, passive if acromion pressed

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Special tests for rotator cuff impingement

Empty can test (thumbs down for supraspinatus)

Hawkins-Kennedy test

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Management of impingement syndrome

Analgesia, physio, subacromial injections

Calcifying tendinopathy –> aspiration

‘Beaking’ of acromion –> surgical decompression

NSAIDs if calcifuing tendinopathy/AC osteoarthritis

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Special test for A-C joint dysfunction

Scarf test –> pain over acromioclavicular joint

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Management of shoulder arthritis

A-C joint: excision

G-H joint: fusion or replacement

For both: analgesia, physio

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Radiographic features of osteoarthritis

Joint space loss

Osteophytes

Subchondral sclerosis

cyst formation

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Presentation of shoulder arthritis

Pain, stiffness, loss of movement/function (esp external rotation)

Always consider referred neck pain!

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Presentation of frozen shoulder (i.e. adhesive capsulitis)

Painful freezing phase: Pain, reduction in ROM (abduction and external rotation), lasts approx 1 year

Frozen phase: Pain subsides, stiffness remains (6-12mo) Active + passive movement affected, worse at night

‘Thawing’ phase: ROM returns, lasts 1-3 years

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Investigation of rotator cuff tears

LA injection + ultrasonography

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Pathophysiology of frozen shoulder

Immobilisation, diabetes, thyroid disorders –> fibrosis and thickening of joint capsule restricting movement

Self-limiting condition, hydrodilatation may help (+ physio)

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Management of clavicular fractures

Collar and cuff sling for 4-6 weeks

Avoid heavy manual labour for 3mo

F/U X-rays at 2w, 6w, 3mo

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Presentation of acromio-clavicular joint dislocation

Direct blow to shoulder, young contact sports

Tender prominence over A-C joint, pain increased by adduction of shoulder

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Presentation of SCJ dislocation

Dyspnoea/dysphagia

Mediastinal compression

Upper limb paraesthesia

Follows high-energy trauma, investigated with CT, managed by thoracic surgeons

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History suggesting posterior shoulder dislocation

Electric shock

High-energy trauma

Epileptic fits

Forcible restraint

Need axillary/oblique views!

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Complications of shoulder dislocation

Brachial plexus injury

Axillary nerve injury

Rotator cuff tear (MRI/US if fx not returned by 4-6w)

Recurrent dislocation (esp in younger patients, encourage immobilisation for 3-4w)

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Presentation of scapulothoracic dissociation

Laterally displaced scapula + swelling + bruising

Neurovascular compromise in upper limb

Hx of high-energy trauma

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Causes of secondary elbow OA

Much more common than primary

Haemoglobinopathies

synovial proliferative disorders (e.g. chondromatosis)

Trauma

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Distinguishing medial and lateral epicondylitis

Medial = golfer/rower/thrower, affects forearm flexors (wrist pronated and flexed most painful)

Lateral = tennis elbow, overuse of extensors, painful extension (esp middle finger) against resistance

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Pathophysiology of epicondylitis

Fibroblast + collagen hypertrophy –> inflammation at insertion point

Angiofibroblastic hyperplasia!

Management of epicondylitis

Analgesia, rest, physiotherapy

90% improvement within 1 yr (self-limiting condition)

Presentation of cubital tunnel syndrome

Loss of sensation/paraesthesia over ulnar 1/5 fingers Weakness of ulnar motor function (e.g. splaying fingers) Pain worse at night and on flexion

Pathophysiology of cubital tunnel syndrome

RA/OA --\> narrowing of ulnar groove --\> nerve compression Valgus cubitus (e.g. following childhood supracondylar fracture) --\> traction on ulnar nerve

Management of cubital tunnel syndrome

Neurophysiology --\> confirm ulnar nerve and not C8 pathology Nighttime splinting Surgical decompression if symptoms don't improve

Management of distal humerus fracture

Above-elbow cast in mild cases Internal fixation for most Total arthroplasty in the elderly

Commonest complication of distal humerus fracture

Elbow stiffness, treated by release of ectopic bone (surgical)

Other complications of distal humerus fractures

Ulnar nerve injury Brachial artery injury Heterotopic ossification Post-traumatic arthritis Infection Compartment syndrome

Age group for supra-condylar fractures of the humerus

5-7 years old, commonly affect metaphysis (weak point)

Complications of supra-condylar fractures

Nerve damage (esp anterior interosseous, radial) Brachial artery damage (esp in completely displaced)

Complications of lateral condyle fractures in children

If not reduced and fixed, can lead to malunion + lateral arm drift + tardy ulnar nerve palsy (hand weakness, difficulty with fine movements) in adulthood Also AVN Higher risk compared to supracondylar fractures

Immobilisation period after elbow fractures/fracture-dislocations

10-14 days

Treatment of frozen shoulder aka adhesive capsulities

Physiotherapy, gentle exercises

What is a Hill-Sachs lesion

Compression fractures of posterolateral humeral head, typically secondary to frequent dislocations

Epidemiology of adhesive capsulitis

Females in 5th decade Assoc w/ hypothyroidism, diabetes

Differential for impingement syndrome

Calcific tendionopathy (40s) Supraspinatus tendinopathy (30s-50s) A-C joint OA (weight lifters)

Management of shoulder dislocation

N-V status assessment X-ray Sedation/anaesthesia Reduction Post-reduction X-ray + N-V Broad-arm sling NSAIDs + rotator cuff physio

Main motion lost in adhesive capsulitis

External rotation

Tendon in lateral epicondylitis (aka tennis elbow)

Extensor carpi radialis brevis

Tendon in medial epicondylitis (aka golfer's elbow)

Common flexor tendon: Flexor carpi radialis/ulnaris Palmaris longus Pronator teres Flexor digitorum superficialis

Test for anterior interosseous function

Motor branch of median nerve Test with OK sign

Commonest complication of elbow surgery

Ulnar nerve palsy

Clavicle examination findings

**Middle** - prev fracture **Distal** - A-C joint subluxation

Causes of scapular winging

Weakness of serratus anterior e.g. due to long thoracic nerve damage

Assessment of internal rotation

Thumb movement up back should reach inferior border of scapula

Assessing subscapularis strength

Belly press Lift off from back

Testing infraspinatus/teres minor

External rotation

Testing supraspinatus

Thumbs up 30d flexion and abduction Push up against resistance

Jobe's test (aka Empty can test)

Thumbs up Shoulder abducted Push up against resistance with thumbs up and then thumbs down if thumb down weaker/more painful Jobe's +ve

Hawkins test

90d flexion and abduction Internally rotate while adducting shoulder Positive in impingement syndrome

Cross-arm (aka scarf) test

Adducting flexed elbow over neck A-C joint pain is +Ve, may indicate OA

Shoulder examination special tests

**Impingement:** Jobe's, Hawkins **OA:** Cross-arm test **Instability:** Laxity, sulcus, apprehension

What is a Bankart lesion?

Avulsion of antero-inferior glenoid labrum during anterior dislocaiton +/- glenoid fracture (bony Bankart)