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Musculoskeletal MBCHB > Shoulder and Upper Arm > Flashcards

Shoulder and Upper Arm Flashcards

1
Q

What is the aetiology of a shoulder dislocation?

A
  • Most common in younger patients (teenage - 30 years)
  • Sporty
  • Mostly traumatic - fall, traction injury
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2
Q

What is the pathophysiology of an anterior shoulder dislocation?

A
  • Humeral head anterior to the glenoid
  • Most common - traumatic, sports
  • Fall with shoulder in external rotation
  • Can result in axillary artery compromise
  • Needs regimental badge area sensory assessment to assess axillary nerve
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3
Q

What is the pathophysiology of a posterior shoulder dislocation?

A
  • Humeral head posterior to the glenoid
  • Fall with shoulder in anterior location
  • Direct blow to anterior shoulder
  • Usually associated with seizures - epileptic fit, electrocution
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4
Q

What is the pathophysiology of a posterior shoulder dislocation?

A
  • Humeral head inferior to glenoid
  • Rare
  • Shoulder forced into hyperabduction
  • Needs prompt neurovascular assessment and reduction due to proximity of brachial plexus
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5
Q

What is the presentation of a shoulder dislocation?

A
  • Severe shoulder pain
  • Inability to move the shoulder
  • Empty glenoid fossa (dent) may be visible
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6
Q

What are the investigations for a shoulder dislocation?

A
  • X-ray - AP shoulder and Garth views (apical oblique)
    • When the humerus dislocates posteriorly, the lack of displacement makes it difficult to appreciate on an AP x-ray
    • Should always obtain an oblique view which will show abnormal humeral displacement posterior to the articular surface of the glenoid
  • MR arthrogram
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7
Q

What is the management of an anterior shoulder dislocation in ED?

A
  • Analgesia and sedation IV
  • O2
  • Reduction by manipulation (closed reduction under sedation or open reduction)
    • Kocher method
    • Hippocratic method
    • Stimson method
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8
Q

What is the management of a shoulder dislocation post reduction?

A
  • Analgesia
  • Stabilisation - 2-3 weeks
  • Rehabilitation - gradually early mobilisation, physio
  • Recurrent instability risk is related to age, risk of recurrence decreases with age
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9
Q

What is shoulder instability?

A

Instability of the shoulder involves painful abnormal translational movement or subluxation and/or recurrent dislocation

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10
Q

What is the aetiology of shoulder instability?

A

Traumatic instability

  • Instability following a traumatic anterior dislocation - patient develops recurrent dislocations and subluxations
  • Age at time of first dislocation predicts the likelihood of further - 80% re‐dislocation rate in under 20s, and 20% re‐dislocation rate in over 30s

Atraumatic instability

  • Patients with generalized ligamentous laxity (idiopathic, Ehlers‐Danlos, Marfan’s) can have pain from recurrent multidirectional (anterior, posterior or inferior) subluxations or dislocations
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11
Q

What is the presentation of shoulder instability?

A
  • Atraumatic laxity/subluxations
  • Not painful
  • Abnormal shoulder contour
  • Muscle wasting
  • Tenderness
  • Muscle spasm
  • Good ROM
  • Scapular winging/dyskinesia
    Tests - sulcus sign, anterior and posterior draw tests, anterior apprehension and relocation test, posterior apprehension test, RC strength, general laxity
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12
Q

What is the management of shoulder instability?

A
  • Traumatic instability - Bankart repair (open or arthroscopic) can stabilize the shoulder to prevent recurrent dislocations
    • Reattaches the labrum and capsule to the anterior glenoid which was torn off in the in the first dislocation
  • Treatment for atraumatic instability is difficult as soft tissue procedures may not work
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13
Q

What is the aetiology of shoulder impingement?

A
  • Impingement occurs most commonly in patients under 25 years, typically in active/athletic individuals or in manual professions
  • Impingement can occur in the older population secondary to degenerative changes or acromioclavicular bony changes
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14
Q

What is the pathophysiology of shoulder impingement?

A
  • Refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion within the shoulderIntrinsic mechanisms
  • Muscular weakness - weakness in rotator cuff muscles can lead to the humerus shifting proximally towards the body
  • Overuse of the shoulder - repetitive microtrauma can result in soft tissue inflammation of the rotator cuff tendons and the subacromial bursa
  • Degenerative tendinopathy - degenerative changes of the acromion can lead to tearing of the rotator cuff, which allows for proximal migration of the humeral head
    Extrinsic mechanisms
  • Anatomical factors - congenital or acquired anatomical variations in the shape and gradient of the acromion
  • Scapular musculature - a reduction in function of the scapular muscles may result in a reduction in the size of the subacromial space
  • Glenohumeral instability - can lead to superior subluxation of the humerus, causing an increased contact between the acromion and subacromial tissues
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15
Q

What is the pathophysiology of rotator cuff tendonitis?

A

Repeated impingement results in inflammation or damage of the rotator cuff tendons

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16
Q

What is the pathophysiology of subacromial bursitis?

A
  • In more severe cases of rotator cuff tendonitis, there may be calcification of the tendon, and associated subacromial bursitis → subacromial bursa also becomes inflamed
  • This can then exaggerate the problem, as the now inflamed tendons rub against the acromion, and clavicoaromial joint and ligament
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17
Q

What is Neer’s classification?

A
  1. Inflammation, oedema and haemorrhage (<25 years)
  2. Fibrosis and tendonitis bursa/cuff (25-40 years)
  3. Partial/full thickness tears and degeneration of rotator cuff (>40 years)
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18
Q

What is the presentation of shoulder impingement/rotator cuff tendonitis?

A
  • Progressive pain in the anterior superior shoulder
  • Pain characteristically radiates to the deltoid and upper arm
  • Difficulty sleeping on affected side, reaching overhead and lifting
  • Pain exacerbated by abduction and relieved by rest
  • Tenderness below the lateral edge of the acromion
  • Tests: Hawkins-Kennedy, Jobe’s, painful arc
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19
Q

What are the investigations for shoulder impingement/rotator cuff tendonitis?

A
  • X-ray - AP shoulder and Garth views (apical oblique) or outlet view
    • Generally normal
    • May show a bone spur
    • Rules out AC joint arthritis
  • USS or MRI depending on shoulder mobility
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20
Q

What is the conservative management of shoulder impingement/rotator cuff tendonitis?

A
  • Rest, activity modification
  • Analgesia, NSAIDs
  • Physiotherapy
  • Corticosteroid injections in subacromial space up to 2x
    • Particularly if there is associated subacromial bursitis
  • Resolves in most cases
21
Q

What is the surgical management of shoulder impingement/rotator cuff tendonitis?

A
  • Subacromial decompression should only be considered after a minimum of 6 months non-operative management
  • Other surgical options (cause dependent):
    • Subacromial/subdeltoid bursectomy
    • Release of CA ligaments
    • Release of calcific deposits
    • Excision infraclavicular spur
22
Q

What is the aetiology of a rotator cuff tear?

A
  • Usually occurs in older patients (> 40 years)
  • The tendons of the rotator cuff can tear with minimal or no trauma as a consequence of degenerate changes in the tendons
  • Acute tear - fall on outstretched arm, sudden jerk (e.g. holding a rail on a bus which suddenly stops)
  • Degenerative tear - wearing down over time
    • At least 20% of over 60 year olds have asymptomatic cuff tears due to tendon degeneration
  • Rotator cuff tendons can tear in young patients due to a significant injury (including shoulder dislocation) although this is very uncommon
23
Q

What is the pathophysiology of rotator cuff tears?

A
  • Tears can be partial or full thickness
  • Tears usually involve supraspinatus
  • Large tears can extend into subscapularis and infraspinatus
24
Q

What is the presentation of rotator cuff tear?

A
  • Pain in front of shoulder that radiates down arm
  • Associated weakness
  • Wasting of supraspinatus
  • Tenderness in subdeltoid region
  • Tests: Jobe’s test, infraspinatus, subscapularis
25
Q

What are the investigations of rotator cuff tear?

A
  • X-ray
  • USS if good ROM
  • MRI if reduced ROM
26
Q

What is the management of an acute rotator cuff tear?

A
  • Urgent investigation
  • Early physio, reassessment and surgical intervention
    • Surgery involves an arthroscopic or open repair of rotator cuff
    • Controversial - failure occurs in 1/3 of cases
    • Rehab involves a sling for 6 weeks, 12 weeks no heavy lifting, prolonged physiotherapy and a long recovery time (6-9 months)
27
Q

What is the management of a degenerative rotator cuff tear?

A
  • Physiotherapy - anterior deltoid strengthening
  • Subacromial injections
  • Wait and see approach
28
Q

What are the complications of a rotator cuff tear?

A
  • The torn rotator cuff will mean the deltoid pulls the head of humerus upwards
  • Abnormal forces on glenoid leads to OA
  • Anatomic shoulder replacement will fail - reverse polarity shoulder replacement instead
29
Q

What is adhesive capsulitis?

A

Inflammation and fibrosis of the joint capsule leading to contracture of the shoulder joint
(Frozen shoulder)

30
Q

What is the aetiology of adhesive capsulitis?

A
  • Age 40s-50s
  • Higher incidence in females
  • Aetiology unclear - sometimes history of a triggering injury but often there is not, may also occur after shoulder surgery
  • Association with diabetes, hypercholesterolaemia and endocrine disease and Dupuytren’s disease
31
Q

What is the pathophysiology of adhesive capsulitis?

A
  1. Freezing or painful stage: minimal synovitis with pain, causing a limitation of motion
  2. Frozen or transitional stage: pain decreases but proliferative synovitis with contraction of the capsule and adhesion of the axillary recess increases
  3. Thawing stage: inflammation decreases, movement slowly improves
32
Q

What is the presentation of adhesive capsulitis?

A
  • Gradual severe pain
    • Pain at night
    • Pain at rest
    • Anterior pain
  • Stiffness
  • Can be bilateral
  • Self-limiting course - pain subsides after around 2-9 months and stiffness will increase for around 4-12 months
  • Global restriction in ROM, especially in external rotation (<50% of normal)
33
Q

What are the investigations of adhesive capsulitis?

A
  • Clinical diagnosis
  • Imaging (x-ray, USS, MRI) may be used to rule out other causes of stiffness and pain
34
Q

What is the conservative management of adhesive capsulitis?

A
  • Self limiting - resolves after 18-24 months
  • Pain will subside and stiffness increases, before stiffness gradually ‘thaws’ out
  • Nearly all patients have some residual stiffness and 15% have residual pain

Conservative

  • Physio and analgesia
  • Intra-articular (glenohumeral) steroid injections can help in the painful phase
  • Fluoroscopic distension
35
Q

What is the surgical management of adhesive capsulitis?

A
  • Once the pain has settled, if the patient cannot tolerate functional loss due to stiffness, recovery can be hastened by manipulation under anaesthetic (MUA which tears the capsule) or surgical capsular release (usually done arthroscopically) which divides the capsule leading to improved motion
  • After capsular release, patient will have a short period in a sling before aggressive physiotherapy
36
Q

What is biceps tendinopathy?

A

Inflammation of the long head of the biceps tendon

37
Q

What is the aetiology of biceps tendinopathy?

A

Overuse, instability, impingement or trauma

38
Q

What is the presentation of biceps tendinopathy?

A
  • Pain anterior shoulder radiating to elbow
  • Aggravated by shoulder flexion, forearm pronation and elbow flexion
  • Snapping with shoulder movements if subluxation
  • Tenderness to palpation of the long head of biceps tendon
  • Tendon tear - ‘Pop-eye’ sign, extensive bruising
39
Q

What is the investigation for biceps tendinopathy?

A

USS

40
Q

What is the management of biceps tendinopathy?

A
  • Conservative - physio, consider corticosteroid injection
  • Surgical repair
    • High risk of neurovascular complications
41
Q

What is the aetiology of proximal humeral fracture?

A
  • Common injury, typically low energy of osteoporotic bone from a fall
  • Usually a surgical neck fracture (rather than anatomical neck)
  • Ranges from simple two part fractures to multiple part fractures involving the humeral head
42
Q

What is the presentation of proximal humeral fracture?

A
  • Pain and swelling
  • Decreased motion
  • Extensive ecchymosis of chest, arm and forearm
  • Neurovascular exam - axillary nerve injury most common
43
Q

What are the investigations of proximal humeral fracture?

A
  • X-ray - AP and lateral
  • CT if needed for pre-op planning
  • MRI rarely indicated but sometimes used to identify associated rotator cuff injury
44
Q

What is the management of a proximal humeral fracture?

A
  • Conservative - collar and cuff
  • Operative - ORIF, replacement
45
Q

What is the aetiology of a humeral shaft fracture?

A
  • Fall resulting in oblique, or spiral fractures if rotational
  • Direct trauma to the arm (e.g. RTC) results in transverse or comminuted fractures
46
Q

What is the presentation of humeral shaft fracture?

A
  • Pain
  • Extremity weakness
  • Preoperative/pre-reduction neurovascular exam is critical
    • Examine and document status of radial nerve pre and post reduction
47
Q

What are the investigations for humeral shaft fracture?

A

X-ray - AP and lateral

48
Q

What is the management of humeral shaft fracture?

A
  • Conservative - humeral brace, U-slab cast
  • Operative - IM nail, ORIF plate fixation

Musculoskeletal MBCHB (21 decks)

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