Shoulder and Elbow Problems Flashcards
What is frozen shoulder/adhesive capsulitis?
Painful condition where the connective tissue surrounding the shoulder capsule becomes inflammed and stiffens, greatly restriciting the ROM and causes chronic pain
What is the pathogenesis of frozen shoulder/adhesive capsulitis?
Progressive capsular fibrosis - 3 overlapping clinical phases
- Painful phase - Active and passive movements restricted (up to a year)
- Frozen Phase - pain usually settles, but shoulder remains stiff (6-12 months)
- Thawing phase - shoulder slowly regains ROM (1-3 years)
What is the cause of Frozen shoulder?
Unclear cause
Trauma
- Rotator cuff lesions
- Following hemiplegia
- Myocardial infarction
Iatrogenic
- Chest or breast surgery
How does frozen shoulder present?
- 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)
How would you investigate suspected frozend shoulder/adhesive capsulitis?
- Examination - Can’t carry out simple movements
- Normal X-ray
- Consider imaging - look for other soft tissue injury
How would you treat someone diagnosed with frozen shoulder/adhesive capsulitis?
Early presentation
- Physiotherapy
- Steroid/local anaesthetic injection
- NSAIDS - High dose
Operative
- Surgery - arthroscopic release
What is subacromial impingement?
- 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
What are the symptoms of subacromial impingement syndrome?
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
How would you confirm someone had subacromial impingment syndrome?
- Examination - Painful Arc syndrome
- X-ray/Ultrasound - only if symptoms are peristent
How would you manage someone with subacromial impingment syndrome?
Early presentation
- Physiotherapy
Specific/empirical
- Subacromial Steroid injection
Operative
- Arthroscopic subacromial decompression
What is a rotator cuff tear?
Tear in any of the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis). Can be degenerative or traumatic in nature
How are rotator cuff tears described?
- 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
How do rotator cuff tears present?
- 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
How would you investigate someone who you suspected had a rotator cuff tear?
- Examination
- X-ray
- MRI
How would you manage someone diagnosed with a rotator cuff tear?
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
What is Tennis elbow?
Also known as lateral epicondylitis, it is an inflammatory process at the forearm extensor origin (ennthesitis) on the humeral lateral supra-condylar ridge
What is Golfer’s Elbow?
Also known as medial epicondylitis, it is an inflammatory process at the common forearm flexor origin on the humeral medial supra-condylar ridge
What can cause tennis/golfers elbow?
- Playing racquet sports
- Throwing sports
- Manual work
- Activities that involve fine, repetitive hand and wrist movement
How does tennis elbow present?
- Pain - felt at front of lateral condyle, exacerbated when tendon is most stretched (wrist and finger flexion with hand pronated)
What is the clinical presentation of golfer’s elbow?
- Pain - exacerbated by pronation and forearm flexion
- Ulnar neuropathy - Ulnar nerve can occassionally be affected as it runs behind medial epicondyle
How would you treat tennis/golfer’s elbow?
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
What is olecranon bursitis?
Traumatic bursitis following pressure on the elbows
How does olecranon bursitis present?
Pain and swelling - over the olecranon
What can be a complication of olecranon bursitis?
Abscess formation - leading to septic bursitis
How does osteoarthritis of the shoulder present?
NOT AS COMMON AS LOWER LIMB OA
- Pain
- Decreased ROM of GH joint - globally, but most particularly external rotation.
How does Biceps tendon rupture present?
- Feeling like “something has gone” on lifting something
- Popeye appearence - ball appearence on flexion of the elbow
What are the signs of subacromial impingement?
- Early scapular rotation
- Passive elevation - reduces impingement + less painful
- Painful trapezius spasm
- Subacromial bursitis
What muscles are involved in flexion of the shoulder?
- Pec major
- Deltoid anterior 1/3rd
- Coracobrachialis
What muscles are involved in extension of the shoulder?
Primarily Deltoid posterior 1/3rd, but movement initiated by:
- Latissimus dorsi
- Pec Major
- Teres Major
What muscles facilitate abduction at the shoulder?
Supraspinatus first 15o, then deltoid
What muscles facilitate Adduction at the shoulder?
- Pec major
- Latissimus dorsi
- Teres major
- Subscapularis
What are the muscles of the rotator cuff?
SITS
- Subscapularis
- Infraspinatus
- Teres Minor
- Supraspinatus
What muscles are involved in internal rotation at the shoulder?
- Pec Major
- Deltoid middle 1/3rd
- Latissimus dorsi
- Teres major
- Subscapularis
What muscles are involved in lateral rotation of the shoulder?
- Teres minor
- Infraspinatus
What muscles are involved in elevation of the scapula?
- Levator scapulae
- Trapezius
What muscles are involved in depression of the scapula?
- Serratus anterior
- Pec Minor
What muscles are involved in protraction of hte scapula?
- Serratus anterior
- Pectoralis major
What muscles are involved in retraction of the scapula?
- Trapezius
- Rhomboids
What mnemonic can be used to remember the features and treatment of atraumatic shoulder dislocations?
- Atraumatic
- Multidirectional
- Bilateral
- Rehabilitation
- Inferior capsular shift surgery if rehab fails
What is the typical age of rotator cuff tear?
>40 years
When are results of a rotator cuff repair better?
If performed within 3 months of injury
What investigationds might you perform in someone with olecranon bursitis?
Mainly clinical diagnosis, but can aspirate fluid and send for gram stain, culture and crystal analysis
How would you manage olecranon bursitis?
- Non septic - analgesia, consider steroid injection and surgery
- Septic - Abx and aspiration, analgesia, surgical debridement and lavage
What is the following?
AC joint separation
What are featurs of AC joint dislocation?
- Tender bony prominence - AC joint
- Scarf test +ve
How would you manage someone with AC joint dislocation?
X-ray
- Sling and analgesia followed by early mobilisation
- Consider surgery in persistent
What is the most common cause of proximal humeral fractures?
Osteoporosis
What nerve is at risk from a humeral shaft frcature?
Radial nerve
What signs might indicate that damage of local nerves has occured due to humeral shaft fracture?
Wrist drop and loss of sensation over 1st dorsal interosseous space - Radial nerve
What are signs of anterior shoulder dislocation?
- Loss of shoulder countour - prominent acromion
- Anterior bulge - head of humerus
- Arm in slight abduction
- Elbow flexed
- Forearm supported by other hand, pronated
What would you want to make sure you check on examination in someone with anterior shoulder dislocation?
Before and after reduction - Pulses and nerves - including axillary nerve over badge area
What investigations would you consider doing in someone with anterior shoulder dislocation?
X-ray - is there a break
How would you manage someone with anterior shoulder dislocation?
- Pain relief - entonox, consider strong analgesia
-
Reduction
- Simple reduction
- Kocher’s method
What would you want to do once you had reduced a dislocated shoulder?
Examine pulses and nerves, and X-ray to ensure in the right place
What can you see on the following X-ray?
Anterior shoulder dislocation
What can be seen in the following X-ray?
Fractured clavicle
What is the risk of using Kocher’s method to relocate someones shoulder?
Humeral fracture
How would you manage a fracture of the clavicle?
- Broad arm sling
- Follow-up X-ray - 6 weeks
What are potential complications of a clavicular fracture?
- Brachial plexus inkjury
- Subclavian vessel damage
- Pneumothorax
What is the most common fracture of childhood?
Supracondylar fracture
What is the most common cause of supracondylar fracture?
Hyperextension
What is a complication that can occur from a supracondylar fracture?
Cubitus varus deformity from malunion
How would you manage an olecranon fracture?
ORIF
What is the most common elbow fracture in adults?
Fracture of the radial head
What are features of a radial head fracture?
- Swollen and tender over radial head
- Flexion/extension possible
- Pronation/supination painful
How would you manage a fractured radial head?
- Undisplaced - collar and cuff
- Displaced - ORIF/removal of radial head
What is the most common direction for elbows to dislocate in?
Posterior - 90%
What are features of an elbow dislocation?
- Posterior ulna displacement
- Swollen elbow
- Fixed flexion
How would you manage a non-displaced supracondylar fracture?
Above elbow back slab + sling
How would you manage a supracondylar fracture which is distally angulated?
OR under GA
How would you manage a posteriorly displaced supracondylar fracture?
ORIF + K wires
What nerve is threatened in a posteromedial displaced supracondylar fracture?
Radial nerve
What nerve is threatened in a posterolaterally displaced supracondylar fracture?
Median nerve, esp. anterior interosseous
How would you test the supraspinatus tendon?
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)
How would you examine the subscapularis?
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)
How would you assess infraspinatus/teres minor?
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
