Shoulder + elbow pathology Flashcards
Why is the shoulder the most commonly dislocated joint?
The shoulder is a highly mobile joint which sacrifices stability for an increased range of movement.
What are the different types of shoulder dislocation?
- Anteriorinferior dislocation (anterior) - 95% of shoulder dislocations
- Posterior dislocation - typically caused by seizures or electrocution
- Inferior dislocation
Symptoms of a dislocated shoulder
- Pain
- Reduced mobility
- Feeling of instability
Dislocated shoulder - on examination
- Often asymmetry with the contralateral side - loss of shoulder contours and an anterior bulge from the head of the humerus
- Assess the neurovascular status of the arm (pre and post reduction)
Investigations for dislocated shoulder
- Plain radiographs are usually adequate in the acute setting
- Trauma shoulder series is required, comprising anterior-posterior, Y scapular and axial views
Management of shoulder dislocation
- Appropriate analgesia
- Reduction, immobilisation and rehabilitation
- Closed reduction (Hippocratic method)
- Broad arm sling - typically 2 weeks
- Physiotherapy
The rotator cuff is composed of 4 muscles:
- Supraspinatus - Abduction
- Infraspinatus - External rotation
- Teres minor - External rotation
- Subscapularis - Internal rotation
Risk factors for rotator cuff tears
- Increasing age
- Trauma
- Overuse
- Repetitive overhead shoulder motions
Symptoms of rotator cuff tear
- Pain over the lateral aspect of the shoulder
- Inability to abduct the arm above 90 degrees
Rotator cuff tear - on examination:
- Tenderness over the greater tuberosity
- Supraspinatus and infraspinatus muscle wasting can be seen in massive rotator cuff tears
Investigations for rotator cuff tear
- Urgent plain film radiograph to exclude a fracture
- Ultrasound to establish the presence of a tear
- MRI imaging to detect the size, characteristics and location of any tear
Which patients should receive surgical management for a rotator cuff injury?
- Presenting 2 weeks after the injury
- Remaining symptomatic despite conservative management
- Large and massive tears
Conservative management of rotator cuff tears
- Analgesia
- Physiotherapy
- Corticosteroid injections into the subacromial space
Complications of rotator cuff tear
The main complication is adhesive capsulitis, leading to stiffness of the glenohumeral joint.
What is adhesive capsulitis?
Adhesive capsulitis is a condition in which the glenohumeral join capsule becomes contracted and adherent to the humeral head.
Symptoms of adhesive capsulitis
- Generalised deep and constant pain of the shoulder
- Joint stiffness and a reduction in function
Adhesive capsulitis - on examination:
- Loss of arm swing
- Atrophy of the deltoid muscle
- Generalised tenderness on palpation
- Limited range of motion
Management of adhesive capsulitis
Adhesive capsulitis is a self limiting condition, recovery occurs over months to years.
- Physiotherapy
- Simple analgesics
Pathophysiology of epicondylitis
Epicondylitis is an overuse syndrome in the elbow, caused by micro tears in the tendons attaching to the epicondyles of the elbow following repetitive injury.
There are two common types of epicondylitis:
- Lateral epicondylitis (“Tennis elbow”)
- Medial epicondylitis (“Golfer’s elbow”)
Clinical features of lateral epicondylitis
- Pain affecting the elbow and radiating down the forearm
- Typically worsens over weeks to months
- Most often affects the dominant arm
- On examination: local tenderness on palpation
- Full range of movement at elbow and wrist
Investigations for lateral epicondylitis
Clinical diagnosis
Sometimes USS or MRI
Management of lateral epicondylitis
- Analgesia
- Lifestyle modification
- Physiotherapy
How are elbow dislocations classified?
- Simple
- Complex (associated with a concomitant fracture)
How does a elbow dislocation present?
- Following a high energy fall
- Elbow will be painful, deformed with associated swelling and decreased function
Dislocated elbow examination
A complete neurovascular examination of the upper limb is essential
- A deficit is often found in the territory of the ulnar nerve as neuropraxia of this nerve is common
- Any concern over the pulse of the limb will warrant a Doppler ultrasound for further assessment
Investigations for dislocated elbow
Plain film radiograph - both AP and lateral
