Shoulder orthopaedics and trauma

Question 1

What is shoulder impingement syndrome?

Answer 1

The tendons of the rotator cuff, mostly supraspinatus, become compressed in the space in the subacromial space, producing pain on movement

Question 2

What are some of the causes of shoulder impingement?

Answer 2

Tendonitis

Subacromial bursitis

Acromioclavicular OA with inferior osteophyte

A hooked acromion

Rotator cuff tear

Question 3

What are the symptoms of shoulder impingement syndrome?

Answer 3

Constant mild pain in shoulder

Pain when lifting objects or raising arms

Loss of movement

Question 4

What signs on examination would indicate a shoulder impingement?

Answer 4

Tenderness below lateral edge of acromion

Painful arc - pain between 80 to 150 degrees of abduction

Positive Hawkins-Kennedy test

Question 5

What is a common differential diagnosis for shoulder impingement in older patients?

Answer 5

Acromioclavicular osteoarthritis

Question 6

How can shoulder impingement and acromioclavicular OA be distinguished?

Answer 6

Acromioclavicular OA gives a positive scarf test

Question 7

What are differential diagnoses of shoulder impingement?

Answer 7

Frozen shoulder

Rotator cuff tear

Shoulder instability

Question 8

What is the treatment for shoulder impingement?

Answer 8

NSAIDs

Analgesic

Physiotherapy

Subacromial steroid injections

Question 9

How can a shoulder impingement that is not improved successfully with conservative management be treated?

Answer 9

Subacromial decompression surgery

Question 10

What can cause rotator cuff tears?

Answer 10

Impingement

Degeneration of tendons

Vascular problems

Trauma (uncommon)

Question 11

What are the signs and symptoms of a rotator cuff tear?

Answer 11

Muscle weakness

Night pain

Muscle wasting

Positive Jobes test (if supraspinatus affected)

Weakness on rotator cuff muscle tests on examination

Question 12

Which rotator cuff muscle is usually affected by rotator cuff tears?

Answer 12

Supraspinatus

Infraspinatus and subscapularis can also be involved in large tears

Question 13

How can a rotator cuff tear be confirmed?

Answer 13

Ultrasound
MRI

Question 14

What is a frozen shoulder?

Answer 14

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

Question 15

How does adhesive capsulitis present?

Answer 15

Progressive pain and stiffness of the shoulder in patients aged 40-60

Pain is often worse at night and in the cold

Question 16

What is the main indicative sign on examination for adhesive capsulitis?

Answer 16

Loss of external rotation

Question 17

What are the risk factors for developing frozen shoulder?

Answer 17

Diabetes mellitus

Hypercholesterolaemia

Dupuytren’s disease

Question 18

What is the main treatment for frozen shoulder?

Answer 18

Analgesics

Physiotherapy

Intra-articular injections

Question 19

How does calcific tendonitis present?

Answer 19

Acute onset shoulder pain

Question 20

What is calcific tendonitis?

Answer 20

Degenerative calcification of the supraspinatus tendon with calcium deposits just proximal to the greater tuberosity

Question 21

How is calcific tendonitis treated?

Answer 21

Subacromial steroid and local anaesthetic injection

Question 22

What does instability of the shoulder involve?

Answer 22

Painful abnormal translational movement or subluxation and/or recurrent dislocation of the shoulder

Question 23

Is a younger patient more likely to suffer reccurent anterior traumatic dislocations than an older patient?

Answer 23

Yes:

80% recurrence in under 20s

20% recurrence in over 30s

Question 24

How can recurrent shoulder dislocations be improved surgically?

Answer 24

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

Question 25

Which patients might suffer from atraumatic shoulder instability?

Answer 25

Patients with generalized ligamentous laxity (idiopathic, Ehlers‐Danlos, Marfan’s)

Question 26

Which patients suffer from proximal humeral neck fractures?

Answer 26

Those with osteoporosis

Question 27

What is the usual mechanism of a humeral neck fracture?

Answer 27

Osteoporotic bone

Fall onto outstretched hand

Fall directly onto shoulder

Question 28

How does the humeral shaft tend to displace in a fracture of the neck of the humerus?

Answer 28

Medially due to the pull of pectoralis major

Greater and lesser tuberosities may be avusled due to pull of supraspinatus, infraspinatus and teres minor

Question 29

What is the most common pattern of proximal humerus fracture?

Answer 29

Fracture of the surgical neck

Question 30

How are persistently displaced proximal humerus fractures treated?

Answer 30

Internal fixation with plates, screws, wires or intramedullary nails

Question 31

How are head splitting proximal humeral fractures usually treated?

Answer 31

Shoulder replacement unless young patient with good bone quality

Question 32

Which is the more common kind of shoulder dislocation?

Answer 32

Anterior dislocation

Question 33

How do shoulder dislocations occur?

Answer 33

Excessive external rotation force

Fall onto the back of the shoulder

Seizures

Question 34

What is a Bankart lesion and how might it occur?

Answer 34

Detachment of the anterior glenoid labrum

May occur as a result of anterior shoulder dislocation

Question 35

What neurovascular structures are at risk in an anterior shoulder dislocation?

Answer 35

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

Question 36

How might an anterior shoulder dislocation be detected on examination?

Answer 36

Loss of symmetry of shoulders

Patient may be supporting injured arm in an abducted position

Question 37

How can axillary nerve damage be detected clinically?

Answer 37

Loss of sensation in regimental badge area

Question 38

What is the mainstay of treatment in shoulder dislocation?

Answer 38

Closed reduction under anaesthetic

Full neurovascular assessment