Shoulder and elbow Flashcards
Presentation of rotator cuff tear
Older patient
Weakness
Diffuse lateral shoulder pain
After trauma if younger
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)
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)
Pathophysiology of rotator cuff impingement
Tendinopathy with disordered collagen, inflammation
Beaking of acromion process with age
Presentation of rotator cuff impingement
Painful arc (45-160 degrees)
40s-60s
Only on active movement, passive if acromion pressed
Special tests for rotator cuff impingement
Empty can test (thumbs down for supraspinatus)
Hawkins-Kennedy test
Management of impingement syndrome
Analgesia, physio, subacromial injections
Calcifying tendinopathy –> aspiration
‘Beaking’ of acromion –> surgical decompression
NSAIDs if calcifuing tendinopathy/AC osteoarthritis
Special test for A-C joint dysfunction
Scarf test –> pain over acromioclavicular joint
Management of shoulder arthritis
A-C joint: excision
G-H joint: fusion or replacement
For both: analgesia, physio
Radiographic features of osteoarthritis
Joint space loss
Osteophytes
Subchondral sclerosis
cyst formation
Presentation of shoulder arthritis
Pain, stiffness, loss of movement/function (esp external rotation)
Always consider referred neck pain!
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
Investigation of rotator cuff tears
LA injection + ultrasonography
Pathophysiology of frozen shoulder
Immobilisation, diabetes, thyroid disorders –> fibrosis and thickening of joint capsule restricting movement
Self-limiting condition, hydrodilatation may help (+ physio)
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
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
Presentation of SCJ dislocation
Dyspnoea/dysphagia
Mediastinal compression
Upper limb paraesthesia
Follows high-energy trauma, investigated with CT, managed by thoracic surgeons
History suggesting posterior shoulder dislocation
Electric shock
High-energy trauma
Epileptic fits
Forcible restraint
Need axillary/oblique views!
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)
Presentation of scapulothoracic dissociation
Laterally displaced scapula + swelling + bruising
Neurovascular compromise in upper limb
Hx of high-energy trauma
Causes of secondary elbow OA
Much more common than primary
Haemoglobinopathies
RA
synovial proliferative disorders (e.g. chondromatosis)
Trauma
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
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)
