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MSK > Shoulder and Elbow Problems > Flashcards

Shoulder and Elbow Problems Flashcards

1
Q

What is frozen shoulder/adhesive capsulitis?

A

Painful condition where the connective tissue surrounding the shoulder capsule becomes inflammed and stiffens, greatly restriciting the ROM and causes chronic pain

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2
Q

What is the pathogenesis of frozen shoulder/adhesive capsulitis?

A

Progressive capsular fibrosis - 3 overlapping clinical phases

  1. Painful phase - Active and passive movements restricted (up to a year)
  2. Frozen Phase - pain usually settles, but shoulder remains stiff (6-12 months)
  3. Thawing phase - shoulder slowly regains ROM (1-3 years)
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3
Q

What is the cause of Frozen shoulder?

A

Unclear cause

Trauma

  • Rotator cuff lesions
  • Following hemiplegia
  • Myocardial infarction

Iatrogenic

  • Chest or breast surgery
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4
Q

How does frozen shoulder present?

A
  • Severe shoulder pain - Constant, worse at night and in cold weather
  • Severely impaired ROM (active and passive) - decreased abduction (<90o), especially external rotation (screened for in REMS)
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5
Q

How would you investigate suspected frozend shoulder/adhesive capsulitis?

A
  • Examination - Can’t carry out simple movements
  • Normal X-ray
  • Consider imaging - look for other soft tissue injury
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6
Q

How would you treat someone diagnosed with frozen shoulder/adhesive capsulitis?

A

Early presentation

  • Physiotherapy
  • Steroid/local anaesthetic injection
  • NSAIDS - High dose

Operative

  • Surgery - arthroscopic release
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7
Q

What is subacromial impingement?

A
  • Syndrome of painful arc due to impingement in the subacromial space
  • Results from any pathology which decreases the volume of the subacromial space or increases the size of the contents
  • Bursa + cuff inflamed ⇒ subacromial impingement syndrome
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8
Q

What are the symptoms of subacromial impingement syndrome?

A

Pain - Radiates to upper arm

  • Painful arc syndrome - Often worse during the middle of the range of abduction (45-120o)
  • Decreased ROM - due to pain, some rotation preserved, unlike frozen shoulder
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9
Q

How would you confirm someone had subacromial impingment syndrome?

A
  • Examination - Painful Arc syndrome
  • X-ray/Ultrasound - only if symptoms are peristent
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10
Q

How would you manage someone with subacromial impingment syndrome?

A

Early presentation

  • Physiotherapy

Specific/empirical

  • Subacromial Steroid injection

Operative

  • Arthroscopic subacromial decompression
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11
Q

What is a rotator cuff tear?

A

Tear in any of the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis). Can be degenerative or traumatic in nature

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12
Q

How are rotator cuff tears described?

A
  • Partial-thickness - Often appear as fraying of an intact tendon.
  • Full-thickness
    • Small pinpoint, larger buttonhole, or involve the majority of the tendon
    • Complete detachment from the humeral head
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13
Q

How do rotator cuff tears present?

A
  • WEAKNESS + PAIN - night pain can be a sign
  • Impaired active abduction of the arm
    • Initiate elevation using the unaffected arm
    • Once elevated, the arm can be held in place by the deltoid muscle
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14
Q

How would you investigate someone who you suspected had a rotator cuff tear?

A
  • Examination
  • X-ray
  • MRI
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15
Q

How would you manage someone diagnosed with a rotator cuff tear?

A

Operative

  • Acute rotator cuff tears = early surgery
  • Chronic degenerative tears = surgery if symptomatic
  • Based on thickness of tear
    • Partial - physiotherapy - opreate if still symptomatic after this
    • Complete - referral for assessment ⇒open/arthroscopic repair
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16
Q

What is Tennis elbow?

A

Also known as lateral epicondylitis, it is an inflammatory process at the forearm extensor origin (ennthesitis) on the humeral lateral supra-condylar ridge

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17
Q

What is Golfer’s Elbow?

A

Also known as medial epicondylitis, it is an inflammatory process at the common forearm flexor origin on the humeral medial supra-condylar ridge

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18
Q

What can cause tennis/golfers elbow?

A
  • Playing racquet sports
  • Throwing sports
  • Manual work
  • Activities that involve fine, repetitive hand and wrist movement
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19
Q

How does tennis elbow present?

A
  • Pain - felt at front of lateral condyle, exacerbated when tendon is most stretched (wrist and finger flexion with hand pronated)
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20
Q

What is the clinical presentation of golfer’s elbow?

A
  • Pain - exacerbated by pronation and forearm flexion
  • Ulnar neuropathy - Ulnar nerve can occassionally be affected as it runs behind medial epicondyle
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21
Q

How would you treat tennis/golfer’s elbow?

A

General - generally last for 6-24 months

  • Rest + Ice + NSAIDs
  • Physiotherapy

Specific/empirical

  • Corticosteroids
  • PRP injections - short term relief

Surgical

  • Surgical release - May be indicated if persistent problem
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22
Q

What is olecranon bursitis?

A

Traumatic bursitis following pressure on the elbows

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23
Q

How does olecranon bursitis present?

A

Pain and swelling - over the olecranon

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24
Q

What can be a complication of olecranon bursitis?

A

Abscess formation - leading to septic bursitis

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25
Q

How does osteoarthritis of the shoulder present?

A

NOT AS COMMON AS LOWER LIMB OA

  • Pain
  • Decreased ROM of GH joint - globally, but most particularly external rotation.
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26
Q

How does Biceps tendon rupture present?

A
  • Feeling like “something has gone” on lifting something
  • Popeye appearence - ball appearence on flexion of the elbow
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27
Q

What are the signs of subacromial impingement?

A
  • Early scapular rotation
  • Passive elevation - reduces impingement + less painful
  • Painful trapezius spasm
  • Subacromial bursitis
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28
Q

What muscles are involved in flexion of the shoulder?

A
  • Pec major
  • Deltoid anterior 1/3rd
  • Coracobrachialis
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29
Q

What muscles are involved in extension of the shoulder?

A

Primarily Deltoid posterior 1/3rd, but movement initiated by:

  • Latissimus dorsi
  • Pec Major
  • Teres Major
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30
Q

What muscles facilitate abduction at the shoulder?

A

Supraspinatus first 15o, then deltoid

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31
Q

What muscles facilitate Adduction at the shoulder?

A
  • Pec major
  • Latissimus dorsi
  • Teres major
  • Subscapularis
32
Q

What are the muscles of the rotator cuff?

A

SITS

  • Subscapularis
  • Infraspinatus
  • Teres Minor
  • Supraspinatus
33
Q

What muscles are involved in internal rotation at the shoulder?

A
  • Pec Major
  • Deltoid middle 1/3rd
  • Latissimus dorsi
  • Teres major
  • Subscapularis
34
Q

What muscles are involved in lateral rotation of the shoulder?

A
  • Teres minor
  • Infraspinatus
35
Q

What muscles are involved in elevation of the scapula?

A
  • Levator scapulae
  • Trapezius
36
Q

What muscles are involved in depression of the scapula?

A
  • Serratus anterior
  • Pec Minor
37
Q

What muscles are involved in protraction of hte scapula?

A
  • Serratus anterior
  • Pectoralis major
38
Q

What muscles are involved in retraction of the scapula?

A
  • Trapezius
  • Rhomboids
39
Q

What mnemonic can be used to remember the features and treatment of atraumatic shoulder dislocations?

A
  • Atraumatic
  • Multidirectional
  • Bilateral
  • Rehabilitation
  • Inferior capsular shift surgery if rehab fails
40
Q

What is the typical age of rotator cuff tear?

A

>40 years

41
Q

When are results of a rotator cuff repair better?

A

If performed within 3 months of injury

42
Q

What investigationds might you perform in someone with olecranon bursitis?

A

Mainly clinical diagnosis, but can aspirate fluid and send for gram stain, culture and crystal analysis

43
Q

How would you manage olecranon bursitis?

A
  • Non septic - analgesia, consider steroid injection and surgery
  • Septic - Abx and aspiration, analgesia, surgical debridement and lavage
44
Q

What is the following?

A

AC joint separation

45
Q

What are featurs of AC joint dislocation?

A
  • Tender bony prominence - AC joint
  • Scarf test +ve
46
Q

How would you manage someone with AC joint dislocation?

A

X-ray

  • Sling and analgesia followed by early mobilisation
  • Consider surgery in persistent
47
Q

What is the most common cause of proximal humeral fractures?

A

Osteoporosis

48
Q

What nerve is at risk from a humeral shaft frcature?

A

Radial nerve

49
Q

What signs might indicate that damage of local nerves has occured due to humeral shaft fracture?

A

Wrist drop and loss of sensation over 1st dorsal interosseous space - Radial nerve

50
Q

What are signs of anterior shoulder dislocation?

A
  • Loss of shoulder countour - prominent acromion
  • Anterior bulge - head of humerus
  • Arm in slight abduction
  • Elbow flexed
  • Forearm supported by other hand, pronated
51
Q

What would you want to make sure you check on examination in someone with anterior shoulder dislocation?

A

Before and after reduction - Pulses and nerves - including axillary nerve over badge area

52
Q

What investigations would you consider doing in someone with anterior shoulder dislocation?

A

X-ray - is there a break

53
Q

How would you manage someone with anterior shoulder dislocation?

A
  • Pain relief - entonox, consider strong analgesia
  • Reduction
    • Simple reduction
    • Kocher’s method
54
Q

What would you want to do once you had reduced a dislocated shoulder?

A

Examine pulses and nerves, and X-ray to ensure in the right place

55
Q

What can you see on the following X-ray?

A

Anterior shoulder dislocation

56
Q

What can be seen in the following X-ray?

A

Fractured clavicle

57
Q

What is the risk of using Kocher’s method to relocate someones shoulder?

A

Humeral fracture

58
Q

How would you manage a fracture of the clavicle?

A
  • Broad arm sling
  • Follow-up X-ray - 6 weeks
59
Q

What are potential complications of a clavicular fracture?

A
  • Brachial plexus inkjury
  • Subclavian vessel damage
  • Pneumothorax
60
Q

What is the most common fracture of childhood?

A

Supracondylar fracture

61
Q

What is the most common cause of supracondylar fracture?

A

Hyperextension

62
Q

What is a complication that can occur from a supracondylar fracture?

A

Cubitus varus deformity from malunion

63
Q

How would you manage an olecranon fracture?

A

ORIF

64
Q

What is the most common elbow fracture in adults?

A

Fracture of the radial head

65
Q

What are features of a radial head fracture?

A
  • Swollen and tender over radial head
  • Flexion/extension possible
  • Pronation/supination painful
66
Q

How would you manage a fractured radial head?

A
  • Undisplaced - collar and cuff
  • Displaced - ORIF/removal of radial head
67
Q

What is the most common direction for elbows to dislocate in?

A

Posterior - 90%

68
Q

What are features of an elbow dislocation?

A
  • Posterior ulna displacement
  • Swollen elbow
  • Fixed flexion
69
Q

How would you manage a non-displaced supracondylar fracture?

A

Above elbow back slab + sling

70
Q

How would you manage a supracondylar fracture which is distally angulated?

A

OR under GA

71
Q

How would you manage a posteriorly displaced supracondylar fracture?

A

ORIF + K wires

72
Q

What nerve is threatened in a posteromedial displaced supracondylar fracture?

A

Radial nerve

73
Q

What nerve is threatened in a posterolaterally displaced supracondylar fracture?

A

Median nerve, esp. anterior interosseous

74
Q

How would you test the supraspinatus tendon?

A

Empty Can/Jobe’s Test

  • Upper arm should be passively abducted (∼ 90°) and flexed horizontally with the elbow extended.
  • Internally rotated (thumb pointing downwards)
  • Check the patient’s ability to maintain the arm in this position
  • If the patient is able to maintain this position, the examiner applies pressure to the patient’s arm and the patient is asked to resist.
  • Positive - pain or the inability to maintain the arm’s position against resistance → functional disorder of the supraspinatus muscle (e.g., tendon rupture, tendinopathy, or subacromial bursitis)
75
Q

How would you examine the subscapularis?

A

Lift-off test

  • Hand behind the lower back with the palm facing outwards.
  • Check ability to lift the hand away from the back
  • If the patient is able to perform this movement, the examiner applies resistance to the patient’s palm.
  • The patient is asked to move the hand against resistance applied by the examiner.
  • Check the other arm.
  • Positive lift-off test: pain when returning the hand to the starting position or the inability to move the hand against resistance → functional disorder of the subscapularis tendon (e.g., rupture)
76
Q

How would you assess infraspinatus/teres minor?

A

Infraspinatus test:

  • The test can be performed in two positions:
  • Position 1: The patient’s elbow is bent to 90°.
  • Position 2: The patient’s arm is abducted to 90° and the humerus is medially rotated to 30°
  • The examiner applies resistance against the back of the patient’s hand. The patient is asked to maintain his or her position.
  • Positive infraspinatus test: inability to perform external rotation against resistance → impaired infraspinatus muscle, e.g., in suprascapular nerve lesion

MSK (27 decks)

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