Shoulder orthopaedics and trauma Flashcards
What is shoulder impingement syndrome?
The tendons of the rotator cuff, mostly supraspinatus, become compressed in the space in the subacromial space, producing pain on movement
What are some of the causes of shoulder impingement?
Tendonitis
Subacromial bursitis
Acromioclavicular OA with inferior osteophyte
A hooked acromion
Rotator cuff tear
What are the symptoms of shoulder impingement syndrome?
Constant mild pain in shoulder
Pain when lifting objects or raising arms
Loss of movement
What signs on examination would indicate a shoulder impingement?
Tenderness below lateral edge of acromion
Painful arc - pain between 80 to 150 degrees of abduction
Positive Hawkins-Kennedy test
What is a common differential diagnosis for shoulder impingement in older patients?
Acromioclavicular osteoarthritis
How can shoulder impingement and acromioclavicular OA be distinguished?
Acromioclavicular OA gives a positive scarf test
What are differential diagnoses of shoulder impingement?
Frozen shoulder
Rotator cuff tear
Shoulder instability
What is the treatment for shoulder impingement?
NSAIDs
Analgesic
Physiotherapy
Subacromial steroid injections
How can a shoulder impingement that is not improved successfully with conservative management be treated?
Subacromial decompression surgery
What can cause rotator cuff tears?
Impingement
Degeneration of tendons
Vascular problems
Trauma (uncommon)
What are the signs and symptoms of a rotator cuff tear?
Muscle weakness
Night pain
Muscle wasting
Positive Jobes test (if supraspinatus affected)
Weakness on rotator cuff muscle tests on examination
Which rotator cuff muscle is usually affected by rotator cuff tears?
Supraspinatus
Infraspinatus and subscapularis can also be involved in large tears
How can a rotator cuff tear be confirmed?
Ultrasound
MRI
What is a frozen shoulder?
Adhesive capsulitis - the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain
How does adhesive capsulitis present?
Progressive pain and stiffness of the shoulder in patients aged 40-60
Pain is often worse at night and in the cold
What is the main indicative sign on examination for adhesive capsulitis?
Loss of external rotation
What are the risk factors for developing frozen shoulder?
Diabetes mellitus
Hypercholesterolaemia
Dupuytren’s disease
What is the main treatment for frozen shoulder?
Analgesics
Physiotherapy
Intra-articular injections
How does calcific tendonitis present?
Acute onset shoulder pain
What is calcific tendonitis?
Degenerative calcification of the supraspinatus tendon with calcium deposits just proximal to the greater tuberosity
How is calcific tendonitis treated?
Subacromial steroid and local anaesthetic injection
What does instability of the shoulder involve?
Painful abnormal translational movement or subluxation and/or recurrent dislocation of the shoulder
Is a younger patient more likely to suffer reccurent anterior traumatic dislocations than an older patient?
Yes:
80% recurrence in under 20s
20% recurrence in over 30s
How can recurrent shoulder dislocations be improved surgically?
A Bankart repair (open or arthroscopic) can stabilize the shoulder by reattaching the labrum and capsule to the anterior glenoid which was torn off in the first dislocation
Which patients might suffer from atraumatic shoulder instability?
Patients with generalized ligamentous laxity (idiopathic, Ehlers‐Danlos, Marfan’s)
Which patients suffer from proximal humeral neck fractures?
Those with osteoporosis
What is the usual mechanism of a humeral neck fracture?
Osteoporotic bone
Fall onto outstretched hand
Fall directly onto shoulder
How does the humeral shaft tend to displace in a fracture of the neck of the humerus?
Medially due to the pull of pectoralis major
Greater and lesser tuberosities may be avusled due to pull of supraspinatus, infraspinatus and teres minor
What is the most common pattern of proximal humerus fracture?
Fracture of the surgical neck
How are persistently displaced proximal humerus fractures treated?
Internal fixation with plates, screws, wires or intramedullary nails
How are head splitting proximal humeral fractures usually treated?
Shoulder replacement unless young patient with good bone quality
Which is the more common kind of shoulder dislocation?
Anterior dislocation
How do shoulder dislocations occur?
Excessive external rotation force
Fall onto the back of the shoulder
Seizures
What is a Bankart lesion and how might it occur?
Detachment of the anterior glenoid labrum
May occur as a result of anterior shoulder dislocation
What neurovascular structures are at risk in an anterior shoulder dislocation?
The axillary nerve can be stretched as it passes through the quadrilateral space whilst other nerves of the brachial plexus as well as the axillary artery can be stretched or compressed
How might an anterior shoulder dislocation be detected on examination?
Loss of symmetry of shoulders
Patient may be supporting injured arm in an abducted position
How can axillary nerve damage be detected clinically?
Loss of sensation in regimental badge area
What is the mainstay of treatment in shoulder dislocation?
Closed reduction under anaesthetic
Full neurovascular assessment
