Shoulder conditions Flashcards by Rebekah Agunede

Most common shoulder dislocation

Anterior (90%) (humerus head anterior to glenoid fossa)

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Signs of shoulder dislocation (visible)

Deformed
Swelling
Bruising

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Why do shoulder dislocations occur?

Glenoid fossa shallow

Weakest on inferior aspect (dislocates anterioinferiorly then displaces anterior)

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Types of anterior dislocation

Subglenoid (30%)

Subcoracoid (60%)

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Actions anterior dislocation

EXTERNAL ROTATION
ABDUCTION

(anterior rotator cuffs lax so rotator cuffs (infraspinatus, supraspinatus and teres minor pull externally)

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How does anterior dislocation occur?

Arm in position of abduction and external rotation (throwing ball, hand behind head)
Force pushes on it posteriorly

OR
Direct posterior blow to shoulder

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What can occur when humeral head is forced out of socket?

Bankart lesion/Labral tear
(glenoid labrum torn off and some bone can be torn off with it)

Hills-Sach lesion

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What is hills sach lesion?

Humerus dislocates anteriorly
Posterior humeral head is pressed against anterior lip of glenoid fossa
Indentation in posterolateral humerus head

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What do Hills-Sach lesions have a risk of?

Increase risk of secondary arthritis in joint

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Posterior shoulder dislocations causes

VERY uncommon 
Epileptic fits
Lightening strike
Electrocution 
Blow to anterior shoulder
Arm flexed, pushed posteriorly (fall on elbow)

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Presentation posterior dislocation

Internally rotated and adducted
Squaring of shoulder
Coracoid process prominent

(posterior rotator cuffs lax so subscapularis pulls internally)

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Sign of posterior dislocation on X ray

Lightbulb humeral head
Glenohumoral distance increased

(Rotated internally so head faces X ray - appears more rounded)

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Inferior dislocation cause

RARE

When arm is fully extended above head forceful traction (HYPERABDUCTION)

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Complications inferior dislocation

Damage to nerves
Rotator cuff tears
Injury to blood vessels

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Complications of all shoulder dislocations

RECURRENT dislocation (damage to stabilising 
factors)

(can lead to OA)

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Damage to neurovascular system shoulder dislocation

Axillary artery 
Axillary nerve (wraps around surgical neck of humerus, supplies deltoid and regimental badge area of skin)

Less common: damage to brachial cords/musculocutaneous nerve

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Test for axillary damage

See if sensation is lost in regimental badge area

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What other damage to structures can occur after shoulder dislocation?

Fractures (clavicle, acromion, head/greater tubercle of humerus)
Rotator cuff tears

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Clavicle fractures: where do they most often occur?

middle third of clavicle (midclavicular)

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Treatment clavicle fractures

Sling BUT surgery if:

Complete displacement
Severe displacement (tenting skin, risk of puncture)
Open fracture
Neurovascular compromise
Floating shoulder (fracture with glenoid neck fracture)

What happens to sections of clavicle when fractured?

Medial end: Sternocleidomastoid elevates

Lateral end: Weight of upper limb exceeds trapezius strength so drops

Arm pulled medially by pectoralis major

Complications of clavicular fracture

non-union/malunion of fracture
Pneumothorax
Suprascapular and supraclavicular nerve damage

Supraclavicular damage means

Paraesthesia over anterior upper chest (c3/C4)

Rotator cuff tears most common

Tendons torn more frequently than muscles

Supraspinatous most at risk

Where does supraspinatus usually tear?

At site of insertion on greater tubercle on humerus (passes under corocacromial arch)

What are most rotator cuff tears a result of?

``` Chronic (poor biomechanics/muscular imbalance) Extended use (lifting/overhead activity - swimming) AGE RELATED degeneration ```

What happens with age to rotator cuffs?

Blood supply decreases with age | Impairs body's ability to repair minor injuries

Theory behind rotator cuff tears

Degenerative-microtrauma model Age related tendon degeneration + microtrauma = partial tendon tears with become full tears

Body's response after tear

Inflammatory cells = Oxidative stress = tenocyte (tendon cell) apoptosis = further degeneration

Common presentation rotator cuff tear

Asymptomatic usually BUT Anterolateral shoulder pain radiating down arm (especially when leaning on arm rest, reaching forward/flexing)

Action weakness rotator cuff injury

Abduction weakness

Management and investigation rotator cuff tears

SOFT TISSUE MRI Ultrasound Conservative or surgical

What is impingement syndrome?

When supraspinatous tendon rubs/catches on corocoacromial arch leading to irritation

Cause of impingement syndrome

Anything that narrows space between humerus and corocoacromial arch eg: Thickening of corocoacromial ligament Inflammation of supraspinatus tendon Subacromial osteophytes Bursitis

When does pain present in impingement syndrome?

When shoulder is abducted or flexed, space is narrowed further so can cause pain and reduced motion

Most common impingement syndrome

Impingement of supraspinatus tendon | Painful arc between 60-120 degrees of abduction

What is calcific supraspinatus tendonopathy?

Macroscopic deposits of hydroxyapatite (calcium phosphate) crystals on supraspinatus tendon

Signs/symptoms calcific supraspinatus tendonopathy

``` Chronic pain (aggrevated by abduction/flexion) Physical appearance of deposit Stiffness Snapping sensation Reduced range of movement ```

Why does calcific tendonopathy occur?

Regional hypoxia = tenocytes --> chondrocytes and lay down cartilage Endochondral ossification produces calcified tendon OR Ectopic bone formation from metaplasia of mesenchymal stem cells

When is most pain caused by calcific tendonpathy?

Reabsoption by phagocytes | Look like toothpaste at this stage (cloudy and less defined on X ray)

Treatment calcific tendonpathy?

Conservative (rest, analgesia) | Surgical if persistent symptoms

Viewing calcific tendonpathy

X ray

What is adhesive capsulitis?

Frozen shoulder Capsule of glenohumoral joint becomes inflamed and stiff Worse in cold, at night and movement

Risk factors adhesive capsulitis

``` Autoimmune initiated by trauma? Female Epilepsy with seizures Diabetes mellitus (glucose binds to capsular collagen) Connective tissue disease Inactivity large periods of time ```

Treatment frozen shoulder

Physio Analgesia Anti-inflammatories Manipulation under analgesia to break up scar tissue/adhesions

What can happen after frozen shoulder?

Can occur in opposite arm | Autoimmune hypothesis

Osteoarthiritis in shoulder usually affects

More common in acromioclavicular joint than glenohumoral

treatment OA shoulder (conservative)

NSAID's Analgesia Viscosupplementation (hyaluronic acid injections to joint) Nutritional supplements (glucosamine/chrondroitin sulfate)

Surgical treatment OA shoulder

Arthroscopy (keyhole) remove loose pieces of damaged cartilage Hemiarthroplasty (humeral head replaced) Or Total shoulder replacement (reverse)