shoulder & elbow Flashcards
1
Q
ROTATOR CUFF TEAR classification?
A
- either acute (lasting <3 months) or chronic (lasting >3 months) tears.
- They can be either partial thickness or full thickness tears.
- Full thickness tears can be further classified into small (<1cm), medium (1-3cm), large (3-5cm), or massive (>5cm or involves multiple tendons) tears.
2
Q
ROTATOR CUFF TEAR pathophysiology acute?
A
- commonly within tendos w pre-existing degeneration, alone follwoing minimal force
- also occurs in young indiviuals w large force so occur alongside other injuries
3
Q
ROTATOR CUFF TEAR pathophysiology chronic?
A
- occur in pts w degenerative microtears to the tendon - most commonly due to ? seen in what age group?
4
Q
ROTATOR CUFF TEAR risk factors?
A
- age
- trauma
- overuse
- repetitive overheard shoulder motions eg?
- BMI > 25
- smoking
- diabetes
5
Q
ROTATOR CUFF TEAR clinical features?
A
- pain over lateral aspect of shoulder
- inability to abduct arm above 90 degrees
- tears more common in dominant arm
6
Q
ROTATOR CUFF TEAR on examination?
A
- tenderness over greater tuberosity (why?) & subacromial bursa regions
- what 2/4 rotator cuffs can atrophy in massive RC tears?
7
Q
ROTATOR CUFF TEAR specific tests?
A
explain these !!!
- jobe’s test (empty can test) what muscle does this test?
- gerber’s list off test - what muscle does this test?
- posterior cuff test - what muscles does this test?
8
Q
ROTATOR CUFF TEAR differential diagnoses?
A
- fracture
- persistant glenohumeral subluxation
- brachial plexus injury
- radiculopathy
9
Q
ROTATOR CUFF TEAR investigations?
A
- urgent x ray to exclude what?
- most x rays will be unremarkable
- what can you potentially see in chronic tears? x3
- USS to establish presence & size of tear (*** reccomended)
- MRI to detect size. characteristics & location of tear
10
Q
ROTATOR CUFF TEAR conservstive management?
A
- for pts who are not limited by pain or loss of function or those w significant co-morbidities & are unsuitable for surgery
- if pts presents within 2 weeks of injury: analgesia, PT w activity modification, steroid injections in subacromial space
11
Q
ROTATOR CUFF TEAR surgical management?
A
- for pts > 2 wks since injury, remaining symptomatic despite conservative management or large tears
- arthroscopic subacromial decompression - what is this?
12
Q
ROTATOR CUFF TEAR complications?
A
- adhesive capsulitis - leading to stiffness of what joint?
13
Q
FROZEN SHOULDER what is it?
A
aka adhesive capsulitis this is a condition in which the GHJ capsule becomes contracted and adherent to the humeral head
loss in active & passive movement usually in non-dominant unilateral shoulder
14
Q
FROZEN SHOULDER risk factors?
A
- female
- 40-70 yrs old
- usually unilateral but those w it in one shoulder are likely to develop contralateral symptoms
- diabetes mellitus (!!), thyroid disorder, shoulder injury, stroke etc
15
Q
FROZEN SHOULDER pathophysiology?
A
- 1° - idiopathic
- 2°- associated w rotator cuff tendinopathy, impingement, biceps tendinopathy, prev trauma/surgery or known joint arthropathy
- fibrotic/inflammatory contracture of the coracohumeral ligament of the shoulder as well as fibroblast proliferation leading to type 3 collagen deposition -> joint capsule fibrosis causes RROM
16
Q
FROZEN SHOULDER stages?
A
1) initial painful/freezing stage - gradual onset of diffuse pain (6wks-9months)
2) frozen/stiff stage - RROM affecting ADLs (up to 12 months)
3) thawing stage - gradual return to ROM (5-26 months)
* * little evidence to support segregation of these phases - pain due to RROM is thought to be present throughout
17
Q
FROZEN SHOULDER clinical features?
A
- generalised deep & constant pain of shoulder (may radiate to??)
- pain disturbs dleep
- associated symptoms include joint stiffness & reduction in function
18
Q
FROZEN SHOULDER on examination?
A
- loss of arm swing
- atrophy of deltoid
- generalised tenderness on palpation
- pt will have limited ROM prinicpally affected external rotation & flexion of shoulder
19
Q
FROZEN SHOULDER differential diagnosis?
A
- acrmioclavicular pathology
- SAIS
- muscular tear
- AI disease
how would these present? also give examples of each one
20
Q
FROZEN SHOULDER imaging investigations?
A
- x ray - usually unremarkable but can rule out OA or fractures
- MRI reveals thickening of GHJ capsule but also rules out impingement
- HbAC1 & blood glucose - common in diabetics
21
Q
FROZEN SHOULDER conservative management?
A
- self limiting
- education & reassurance
- analgesia
- aggressive PT
- GHJ steroid injections
22
Q
FROZEN SHOULDER surgical management?
A
- MUA (manipulation under anesthetic) - what does this do?
- Arthrographic distension - fluid (saline or steroids) injected into shoulder joint which stretches & reduced inflammation here
- Surgical release of GHJ capsule
23
Q
FROZEN SHOULDER complications?
A
- small proportion don’t regain full range of motion
- may persist >2/3 yrs
- happens in contralateral shoulder
24
Q
SAIS what is it and what pathology does it encompass?
A
- inflammation & irritation of the rotator cuff tendons as they pass through the subacromial space resulting in pain, weakness & RROM
- pathology includes rotator cuff tendinosis, subacromial bursitis & calcific tendinitis –» Combination of extrinsic compression and internal degeneration causing narrowing and irritation to subacromial space
25
SAIS intrinsic mechanisms pathophysiology?
intrinsic mechanisms incolve pathologies of the rotator cuff tendons due to tension, including:
- muscular weakness - weakness in the RC muscles can lead to muscle imbalances so the humerus shifts ??
- overuse of shoulder - repetitive microtrauma can result in soft tissue inflammation of the RC tendons & subacromial bursa leading to friction between the tendons & the coracoacromial arch
- degenerative tendinopathy - degenerative changes of the afro ion can lead to tearing of the rotator cuff which allows for ? migration of the humeral head
26
SAIS pathophysiology extrinsic mechanisms?
involve pathologies of the RC tendons due to external compression such as:
- anatomical factors - congenital or acquired anatomical variations in shape & gradient of the acromion
- scapular musculature - a reduction in function of thr scapular muscles (particularly? x2). these muscles allow the humerus to move past the acromion on what?? reduced function may result in a reduction in the size of the subacromial space
- GH instability - abnormality in GHJ/ weak RC muscles can lead to subluxation of the humerus therefore inc contact between the acromion & subacromial tissues
27
SAIS clinical features?
- progressive pain in anterior superior shoulder
- exacerbated by?
- relieved by?
- associated w weakness & stiffness secondary to the pain
28
SAIS examination signs that can be elicited?
- neers impingement test - what is this? it works as it narrows the subacromial space so pinching RC tendons
- hawkins test - what is this? it works as it drives the greater tuberosity under the coracoacromial arch impinging the supraspinatus tendon
29
SAIS differential diagnoses?
- muscular tear (eg what muscles?) - but weakness persists despite shoulder pain being relieved
- neurological pain (eg ? x3) - any weakness associated w paraesthesia +- pain but the weakness will persist despite the shoulder pain being relieved
- frozen shoulder - stiffness persists even if pains relieved
- acromioclavicular pathology (eg? x2) - presents w generalised pain and weakness & stiffness related to the pain
30
SAIS imaging investigations?
- diagnosis is clinical but confirmed w imaging
- MRI - what features can be seen? x5
( painful arc - 60-120 degrees abduction )
31
SAIS conservative management?
- analgesia eg NSAIDs
- regular PT including postural, stability, mobility, stretching & strength exercises
- corticosteroid injections in the subacromial space
- pts should be educated w adequate warm up techniques & monitoring for early signs of worsening impingement
32
SAIS surgical management?
- how many months after no response to conservative treatment is surgical treatment recommended?
- its particularly useful in pts w RROM & is normally arthroscopic. surgical techniques:
>> surgical repair of muscle tears - what muscles are most commonly fixed? x2. improves ROM
>> surgical removal of subacromial bursa ie bursectomy inc subacromial space & reduces pain
>> surgical removal of a section of the acromion ie acriomioplasty inc subacromial space & reduces pain
33
SAIS complications?
- RC degeneration & tear
- frozen shoulder
- cuff tear arthropathy
- complex regional pain syndrome
34
SHOULDER FRACTURE what type of injuries cause this?
- low energy injuries in elderly from FOOSH from standing. primarily due to osteoporosis
- less commonly in younger pts in high energy traumatic injuries w associated soft tissue/neurovascular injuries
35
SHOULDER FRACTURE risk factors?
comparable to other osteoporotic fractures including:
- female (why?)
- early menopause
- prolonged steroid use
- recurrent falls
- frailty
36
SHOULDER FRACTURE clinical features?
- pain - specifically where?
- RROM
- inability to abduct arm
37
SHOULDER FRACTURE on examination?
- significant swelling & bruising of shoulder which spread to chest & down arm
- there is a close relationship w ? nerve & ? vessels so you should check the neurovascular status of the arm. damage to the ? nerve can result to loss of sensation in the lateral shoulder (“? area”) and loss of power to ? muscle
38
SHOULDER FRACTURE investigations?
trauma?
- ABCDE
- urgent bloods inc coag, g&s
pathological cause suspected?
- further work up blood inc serum calcium & myeloma screen
39
SHOULDER FRACTURE imaging?
- plain film radiograph - what views x3 to classify a proximal humerus fracture?
- further imaging CT scan for pre op planning or if humeral segments position is unclear
40
SHOULDER FRACTURE classification?
the neer classification system is used to characterise proximal humeral fractures based on the relationship between the 4 main segments of the proximal humerus - which are??
-> these segments are considered separate if there is displacement >1 cm between them or at least 45 degrees of angulation. it categorises injuries into either minimal displacement or 2 or 4 part part injuries - dependent on the no of separate segments present
41
SHOULDER FRACTURE conservative management?
- most can be managed this way especially those minimally displaced w/o neurovascular compromise
- immobilisation initially
- early mobilisation including pendulum exercises 2-4 wks post injury
* pts must have a correctly applied polysling that allows their arm to hang; the effect of gravity on the arm will aid the reduction of the fragments
42
SHOULDER FRACTURE surgical management?
indicated in pts w displaced, open or neurovascularly compromised fractures
- multiple segment injuries? ORIF (preferred in what specific fracture?) or intramedullary nailing (preferred when the fracture involves ?/ combined w what other fracture?)
- hemiarthroplasty; only in a small no of pts - when is it indicated?
- reverse shoulder arthroplasty (RSA) - when is it indicated? ball & socket portions are switched
43
SHOULDER FRACTURE complications?
- RROM so extensive PT to regain full function & reduce pain. how long is rehab time?
- risk of avascular necrosis due to disruption of blood supply from which vessels? hemiarthroplasty/rsa may be required
- axillary nerve injury
44
SHOULDER DISLOCATION aetiology?
- most common: anterior. also have posterior and inferior
- > anterior classically causes by a force being applied to an extended, abducted & externally rotated humerus
- > posterior dislocation typically caused by seizures or electrocution but can also occur through trauma ( a direct blow to the anterior shoulder or force through a flexed adducted arm) ** posterior usually missed as subtle on xray
45
SHOULDER DISLOCATION clinical features?
- painful shoulder, reduced mobility & a feeling of instability.
- pts reluctant to move affected limb
46
SHOULDER DISLOCATION on examination?
- asymmetry
- loss of shoulder contours ( ie flattened ?)
- anterior bulge from head of humerus
- examine neurovasucular status of arm - what nerves specifically ?
47
SHOULDER DISLOCATION associated injuries?
bony:
- bony bankart lesions - ??. most commonly in those w recurrent dislocations
- hill-sachs ?? in most traumatic dislocations
- fractures of greater tuberosity & surgical neck
labral, ligamentous & RC:
- soft bankart - avulsions of ??
- GH ligament avulsion
- RC injuries freq in anterior dislocations especially young pts
48
SHOULDER DISLOCATIONS investigations imaging?
- plain radiograph in acute setting -> trauma shoulder series w what views? x3
- what indicates an anterior dislocation on AP/Y-scapular view?
- what sign suggests posterior dislocation on AP film due to the humerus being fixed in internal rotation?
* ** Y scapular view is best to differentiate between anterior & posterior
- labral or RC injuries suspected? MRI
49
SHOULDER DISLOCATION management?
- ABCDE
- analgesia
- reduction (closed), immobilisation (broad arm sling, 2 wks - longer for posterior) & rehabilitation (PT to restore ROM, strengthen RC & pericapsular musculature)
- assess neurovascular status pre & post reduction
* failed reduction? MUA
* ongoing future shoulder pain? joint instability? large hill sachs or bony bankarts? >> surgical treatment
50
SHOULDER DISLOCATION complications?
- chronic pain
- limited mobility
- stiffness
- recurrence
- frozen shoulder
- nerve damage
- RC injury
- degenerative joint disease
51
OLECRANON FRAC causes
the olecranon has no protection w muscle etc and just a thin layer of skin so is very susceptible to injury
causes:
- direct fall onto elbow
- direct blow to elbow eg cricket bat, dashboard
- FOOSH w elbow held tightly -> triceps pulls bone off ulna (its attached @ olecranon)
52
OLECRANON FRAC sx?
- sudden, intense pain. ↓ movement
- swelling @ elbow tip
- bruising
- nerve damage? numbeness in fingers
53
OLECRANON FRAC non-surgical management?
non displaced frac? splint for 6 wks + analgesia
54
OLECRANON FRAC surgical management?
displaced or open frac? ORIF, bone graft, frac fragment removal
