Shoulder + Humeral Fractures Flashcards
What is the most common shoulder dislocation?
Anterior (95%)
How does a shoulder dislocation present?
Loss of normal shoulder contour
Squaring of shoulder
Trauma
What imaging views do you get to assess a shoulder dislocation?
X-ray AP, lateral and scapula Y
What is the best radiological image to assess whether a shoulder is anterioly or posteriorly dislocated?
Scapula Y view
What nerve is most at risk in a shoulder dislocation?
How is it assessed?
Axillary nerve
Regimental badge. Region
What usually causes posterior shoulder dislocations?
Seizures
Electrocutions
How does a posterior shoulder dislocation appear on x-ray?
What does the limb look like on examination?
Light bulb sign
Internally rotated upper limb
How do you manage a shoulder dislocation?
Analgesia
Reduce shoulder
Immobilise in a sling
Physio
Take post reduction imaging and re assess neurovascular status
What are some techniques of shoulder relocation?
Kochers
Hippocratic manouvre
What are some complications of shoulder dislocations and relocations?
Bony bankart lesions
Hillsacks lesions
Recurrent dislocations
Axillary nerve palsy
Rotator cuff injury
Adhesive capsulitis
What is a bankart lesion?
Bony and non bony
Bony = Fracture of anteroinferior glenoid
Usually following shoulder relocation
Non bony = avulsion/damage to anterior glenoid labrum
What is a Hillsachs lesion?
H for humeral head
Posterolateral fracture of Humeral Head due to Impaction
What is considered an acute rotator cuff injury?
Less than 3 months
What is considered a chronic rotator cuff injury?
More than 3 months
What are the 4 rotator cuff muscles?
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
What is the function of each of the rotator cuff muscles?
Supraspinatus = abduction
Infraspinatus = external rotation
Teres minor = external rotation and Adduction
Subscapularis = internal rotation
What test assess the function of Supraspinatus?
Empty can test
(Painful arc test for impingement)
What test assess the function of infraspinatus and teres minor?
Arms flexed at 90 degrees with elbow tucked at side and externally rotate against examiner
What test assess the subscapaularis muscle?
Hands behind back and patient pushes against examiners hand
What is the pathophysiology of chronic rotator cuff tears?
Long term progressive micro tears
What are the risk factors for rotator cuff injuries?
Repetitive over the head movements
Old
Trauma
Obesity
Smoking
How do rotator cuff tears present on examination?
Unable to abduct past 90 degrees
Tenderness over greater tuberosity
Sometimes Supraspinatus and Infraspinatus atrophy
What imaging is done if a rotator cuff injury is suspected?
Urgent plain radiograph to exclude bony involvement
Then US to confirm presence and size of tear
MRI also can be used
When are rotator cuffs managed conservatively?
If present within 2 weeks of injury
Not limited by pain or loss of function
Significant co-morbidity
What is the conservative managemtn of rotator cuff tears?
Analgesia
Physio
Activity modification
When are rotator cuff tears managed surgically?
Present after 2 weeks since injury occured
Too painful
Tear to large
Conservative failed
Can be arthroscopic or open repair
What is adhesive capsulitis?
When the Glenohumeral joint capsule becomes adherent to the humeral head causing a frozen shoulder
What causes adhesive capsulitis?
Primary = idiopathic
Secondary = rotator cuff tendinopathy, subacromial impingement, biceps tendinopathy, previous. Surgery or trauma
What is the most common presentation of adhesive capsulitis?
Woman 40-70
Deep constant shoulder pain
Reduced ROM
Deltoid atrophy
Loss of arm swing
What are the 3 stages of adhesive capsulitis?
Freezing
Frozen
Thawing
What is the timeline for the 3 stages of adhesive capsulitis?
Freezing (2-9months)
Frozen (4-12months)
Thawing (12-24months)
What is the presentation at each stage of adhesive capsulitis?
Freezing (constant increasing pain with decreasing movement)
Frozen (extremely painful cant move)
Thawing (pain relieving and movement increasing)
What imaging can be used for adhesive capsulitis?
X-ray to rule out ACJ involvement or atypical fracture presentations
MRI is good however imaging is not actually required since its a clinical diagnosis
What imaging can be used for adhesive capsulitis?
X-ray to rule out ACJ involvement or atypical fracture presentations
MRI is good however imaging is not actually required since its a clinical diagnosis
What diseases is adhesive capsulitis common with so what can you measure when investigating?
Diabetes (HbA1c)
Autoimmune thyroid disease (TSH)
What is the managemtn for adhesive capsulitis?
Physio during thawing phase
Analgesia
Intra-articular corticosteroid injections
Surgical =manuipulation under anaesthesia
What is the subacromial space?
Space between coracoacromial arch/ligament, humeral head and greater tuberosity of the humerus
What causes subacromial impingement syndrome?
Repetitive shoulder movements leading to micro traumas to the rotator cuff tendons
Bursitis
Degenerative tendiopathy
Muscular weakness leading humerus to shift medially
Who does subacromial impingement syndrome occur most commonly in?
Active individuals
Manual professions
How does a subacromial impingement present?
Progressive pain ini anterior superior shoulder
Pain exacerbated by abduction
What test can be used to check for subacromial impingement?
Hawkins test
How do you manage subacromial impingement syndrome?
Analgesia, physio, NSAIDS, corticosteroid joint injections
Surgery
When is subacromial impingement syndrome managed surgically?
What can be done?
If persists 6months after conservative management tried
Direct repair of Muscularis tears
Remove subacromial bursa
Remove section of acromion
How does an ACJ dislocation present?
Pain over the AC joint
Can have skin tenting
What test is positive in ACJ dislocation?
Scarf test
What is the scarf test?
Hand on opposite shoulder and you push the elbow back
How is ACJ dislocation managed?
Briefly immobilise
Want to mobilise again ASAP
ORIF for skin tenting or. Failed conservative management
What are the risk factors of humeral shaft fractures?
Osteoporosis
Increasing age female
Previous fractures
What nerve is at risk in a humeral shaft fracture?
Radial nerve
How can you assess radial nerve damage with humeral shaft fractures?
Finger extension against resistance
Dorsum 1st web space
How do you manage a humeral shaft fracture?
Reduce fracture
Brace
Surgical: ORIF (with plate)
Or IM nail
What age group are supracondylar humeral fractures most common in?
Young children
What is the method of injury that usually leads to a supracondylar fracture?
FOOSH with extended elbow
What nerves and artery are at risk with a supracondylar humeral fracture?
Anterior interosseous nerve of median nerve (most common)
Radial and ulnar nerve
Brachial artery
How does a patient with a supracondylar fracture present?
Pain
Deformity
Bruising
Swelling
Nerve palsy.
What imaging is required to assess a supracondylar fracture?
Plain radiograph AP and lateral
CT may be required if comminuted or Intra articular fractures suspected
What sign is often seen on plain radiograph of supracondylar fractures?
Posterior fat pad sign
Why does the anterior interosseous nerve get damaged in a supracondylar humerus fracture despite itts branch being given off more distal?
The AIN fibres are arranged posteriorly within the the median nerve
How are supracondylar fractures managed?
Immediate closed reduction if NV status compromised
Closed reduction and K wire fixation
Above elbow cast
