Shoulder joint Flashcards by Haydn Cooper

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)

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What does shoulder stiffness point towards?

Frozen shoulder

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How is loss of function expressed?

Inability to reach behind back - difficulty dressing or combing hair for some patients

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General points of shoulder exam

Look
Feel
Move
Neck exam

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What are you looking for?

Skin - scars, sinuses
Shape - asymmetry of shoulders, winging of scapula, deltoid wasting, joint swelling

Don’t forget the axilla

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What are sinuses and what do they indicate?

Areas where there is discharge and pus, indicative of osteomyelitis.

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What are you feeling for?

Soft tissue for swelling
Joint temperature
Bony landmarks - sternoclavicular joint, clavicle, acromioclavicular joint, acromion, scapula

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What active movements do you test?

Abduction, adduction
Flexion, extension
Internal and external rotation

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What does pain on abduction indicate?

Mid-range pain - rotator cuff tear/supraspinatus tendinitis
End pain - acromioclavicular arthritis

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How do we test passive movements?

Same movements as active but do it for patient with hand on shoulder feeling for crepitus

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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

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What imaging modalities can we use?

XR shoulder - AP view, lateral view
CT
MRI
Arthroscopy

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What is the lateral view X-Ray good for?

Showing direction of dislocation
Looking at narrowing of joint space

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What are CT and MRI scans good for?

Looking for rotator cuff tears

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What are the 4 rotator cuffs and what do they form?

Subscapularis, supraspinatus, infraspinatus, teres minor

Form conjoint tendons stabilising the shoulder capsule

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5 syndromes involving the rotator cuff muscles?

Acute calcific tendinitis
Chronic tendinitis (impingement syndrome)
Rotator cuff tears
Adhesive capsulitis (frozen shoulder)
Biceps tendon lesions

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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

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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

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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