Shoulder joint Flashcards
Differentials for painful shoulder
Referred pain
- cervical spondylosis
- mediastinal pathology
- CARDIAC ISCHAEMIA
Joint disorders
- glenohumeral arthritis
- acromioclavicular arthritis
Rotator cuff disorders
- Tendinitis
- Tendon rupture
- Frozen shoulder
Shoulder dislocation (anterior/posterior)
What does shoulder stiffness point towards?
Frozen shoulder
How is loss of function expressed?
Inability to reach behind back - difficulty dressing or combing hair for some patients
General points of shoulder exam
Look
Feel
Move
Neck exam
What are you looking for?
Skin - scars, sinuses
Shape - asymmetry of shoulders, winging of scapula, deltoid wasting, joint swelling
Don’t forget the axilla
What are sinuses and what do they indicate?
Areas where there is discharge and pus, indicative of osteomyelitis.
What are you feeling for?
Soft tissue for swelling
Joint temperature
Bony landmarks - sternoclavicular joint, clavicle, acromioclavicular joint, acromion, scapula
What active movements do you test?
Abduction, adduction
Flexion, extension
Internal and external rotation
What does pain on abduction indicate?
Mid-range pain - rotator cuff tear/supraspinatus tendinitis
End pain - acromioclavicular arthritis
How do we test passive movements?
Same movements as active but do it for patient with hand on shoulder feeling for crepitus
What special tests do we do?
Empty beer cans - tests supraspinatus against resistance
Get patient to reach high behind back and push out - tests infraspinatus against resistance
Look for winging of scapula (long thoracic nerve injury)
Painful arc - abduct patients shoulder and let them bring it down slowly
Feel for movement of scapula - should rotate at 90 degrees of abduction
What imaging modalities can we use?
XR shoulder - AP view, lateral view
CT
MRI
Arthroscopy
What is the lateral view X-Ray good for?
Showing direction of dislocation
Looking at narrowing of joint space
What are CT and MRI scans good for?
Looking for rotator cuff tears
What are the 4 rotator cuffs and what do they form?
Subscapularis, supraspinatus, infraspinatus, teres minor
Form conjoint tendons stabilising the shoulder capsule
5 syndromes involving the rotator cuff muscles?
Acute calcific tendinitis
Chronic tendinitis (impingement syndrome)
Rotator cuff tears
Adhesive capsulitis (frozen shoulder)
Biceps tendon lesions
What is acute calcific tendinitis and what are the X-Ray findings?
Calcification (fibrosis) of the supraspinatus tendon which is seen just above the greater tubercle
Acute tendinitis management
Arm sling
NSAIDs - pain relief and reduce inflammation
Methylprednisolone 40mg and lignocaine 1% for severe pain (temporary)
Arthroscopic removal of calcifications if recurrent symptoms
What is chronic tendinitis/impingement syndrome?
Who does it typically affect?
Impingement of rotator cuff against coraco-acromial arch during abduction
People between 40-60 years of age
Symptoms of chronic tendinitis
Shoulder pain and tenderness just below anterior edge of acromion
Signs of chronic tendinitis
Painful arc (between 60 and 120 degrees of abduction) - pathognomonic finding
Restriction of abduction and external rotation due to muscle wasting
Treatment of chronic tendinitis
Conservative - heat compresses, analgesia, physiotherapy and active mobilisation
Recurring cases - arthroscopic decompression of rotator cuff by dividing the coracoacromial ligament
Causes of rotator cuff tear
Who does it typically affect?
Partial/complete tear due to sudden strain on top of chronic tendinitis
People between 45-75 years of age
How to distinguish between partial and complete tear?
Inject local anaesthetic and if abduction is possible then tear is partial
What sign is seen in rotator cuff tears?
Drop-arm sign - arms suddenly drop when attempting to lower them after abduction
Treatment of rotator cuff
Acute phase - conservative (heat exercises and use of LA injections)
After 3 weeks - complete tears should be repaired operatively
Surgery contraindicated in old and/or sedentary individuals
What is adhesive capsulitis/frozen shoulder and who does it typically affect?
Thickening and inflammation of the joint capsule
People between 40-60 years of age
How does adhesive capsulitis/frozen shoulder present?
Progressive pain and stiffness which spontaneously resolves after 18 months
Progressive pain stops patient from sleeping on affected side
Movement may be regained but may not return to normal
Differentials for frozen shoulder
Post-traumatic stiffness
Disuse stiffness
Regional pain syndrome - happens after prolonged immobilisation
Treatment for adhesive capsulitis/frozen sholder
Manipulation under anaesthesia
Active exercises
Treatment for adhesive capsulitis/frozen shoulder
Manipulation under anaesthesia
Active exercises
Arthroscopic release
What can bicipital tendinitis/long head bicep tendon rupture be caused by?
Impingement syndrome as the tendon lies adjacent to the rotator cuff tendons.
What is the sign for a complete tendon rupture?
A prominent lump upon flexion of the elbow
Treatment for bicipital tendinitis/long head tendon rupture
None, function is hardly disturbed (short head)
Cause of anterior dislocation
TRAUMA
FOOSH back-wards, forced abduction and external rotation
Sign of anterior dislocation
Severe pain, patient sitting very still
Overlap of humeral head and glenoid fossa (head is medial and below socket)
Loss of shoulder curvature
Treatment of anterior dislocation
MUA & reduction (Kocher’s method)
X-Ray repeated to confirm reduction and exclude fracture
Sling for 2 weeks then active movement
What is Kocher’s method
Method of shoulder dislocation reduction done under GA
Elbow bent to 90 and held close to body
Shoulder slowly laterally rotated by 75
Elbow is lifted forwards and adducted
Rotated arm medially
Complications of anterior dislocation
Rotator cuff tear
Nerve injury (axillary)
Axillary artery injury
Fracture dislocation requiring ORIF
Recurrent dislocation
Cause of posterior dislocation
Forced internal rotation of abducted arm
Direct blow to front of shoulder (epileptic fit or severe electric shock)
Signs of posterior dislocation
Arm held in medial rotation and locked in that position
Lateral X-Ray shows posterior subluxation and light bulb sign
Management of posterior dislocation
That of anterior dislocation
When can recurrent dislocation occur?
When arm is lifted into abduction and lateral rotation (when swimming or dressing)
Patients learn to reduce themselves
What lesions can be caused by recurrent dislocations?
Hill-sachs
Bankarts
What is a Hill-Sachs lesion?
Defect or art missing from the humeral head (dips down) seen on X-Ray
What is a Bankart lesion?
Damage or tear in the glenoid labrum seen on CT
Treatment for Hill-Sachs and Bankart lesions
Capsular reconstruction and bone operation to block abnormal movement at back of shoulder
