Shoulder Pathologies and Nerve Compression Flashcards
What are the typical ages of presentation of different shoulder pathologies?
20-30s = instability 30-40s = impingement 40-50s = frozen shoulder 50-60s = cuff tear >60 = arthritis
What are some features of the shoulder joint?
Most mobile joint in the body, made up of 4 joints, 17 muscles attach to scapula
What are the muscles of the shoulder joint?
Intrinsic muscles (rotator cuff) = supraspinatus, infraspinatus, teres minor, subscapularis Extrinsic muscles = deltoid, trapezium, pectoralis major, latissimus dorsi
What is the common presentation for shoulder instability?
Patient teenager-30s, usually sports, mostly traumatic injury
What are the two kinds of dislocations of the shoulder?
Anterior = common (95%), traumatic sports Posterior = rare (5%), epileptic fit, electrocution
What are the way patients may present to health professionals with shoulder instability?
Acute in trauma clinic = ED reduction, painful in sling
Chronic in shoulder clinic = atraumatic laxity/subluxation, not painful, no support
What may be features of a patient’s history with shoulder instability?
Traumatic event, mechanisms of injury, ease of dislocation, frequency, general laxity
What are some possible findings of an examination in a patient with shoulder instability?
Look = abnormal shoulder contour, muscle wasting Feel = tenderness, muscle spasm Move = good ROM, scapular winging/dyskinesia
What are some special tests that can be done to confirm shoulder instability?
RC strength, apprehension, relocation, general laxity
What is the initial management in the ED for a patient with shoulder instability?
IV analgesia and sedation, oxygen
What are some methods of reducing a dislocated shoulder by manipulation?
Kocher method, Hippocratic method, Stimson method
What is the post reduction treatment for shoulder instability?
2-3 weeks in sling, analgesia, gradual early mobilisation, physio
What are some imaging techniques used for shoulder instability?
Radiographs = AP shoulder and Garth views (apical oblique)
MRI arthrogram
What are some injuries associated with shoulder instability?
Labral lesion (Bankart)
Fractured humeral head (Hill Sachs)
Fracture of glenoid (bony Bankart)
Rotator cuff tear (patients > 40)
What exercises are done in physio for shoulder instability?
RC and core strengthening, scapula stabilising
Given to all patients
What is the link between recurrent dislocations and age?
Risk of recurrent dislocation decreases with age
What surgery may be needed for an unstable shoulder?
Arthroscopic/open stabilisation
How long does recovery take for shoulder instability?
6 weeks in sling, no driving for 8-10 weeks, no heavy lifting for 12 weeks, no non-contact sports before 12 weeks, no contact sports for 6 months
What are some features of impingement syndrome?
Pain originating from subacromial space, common and mostly transient, mostly patients aged 30-40
What are some intrinsic causes of impingement syndrome?
Tendon vascularity, watershed area, tendon degeneration, cuff dysfunction
What are some extrinsic causes of impingement syndrome?
External pressure = type of acromion, coraco-acromial ligament, clavicular spur/osteophyte
How does the cause of impingement syndrome vary with age?
RC tendonitis/subacromial bursitis = <30s Calcific tendonitis = 30-40s Tendinosis/partial RC tears = 40-50s Cuff tears = 50-60s Cuff arthroplasty = 70s
What is Neer’s classification for impingement syndrome?
Inflammation, oedema and haemorrhage = < 25 years
Fibrosis and tendonitis of cuff/bursa = 25-40 years
Partial/full thickness tears and degeneration of RC = >40 years
What are important aspects of the history of a patient with impingement syndrome?
Age, dominance, occupation, pain (onset/ location, radiation, night), reach and stretch, painful arc, neurology, neck pain, analgesia, physio, injections
What may be found on examination of a patient with impingement syndrome?
Look = contour, wasting, scapula position Feel = tenderness of bursa, AC joint Move = ROM, painful arc, RC strength
What are some special tests that can be done to diagnose impingement syndrome?
Hawkins test, Jobe’s test
What imaging can be done to diagnose impingement syndrome?
Radiographs = AP shoulder and Garth views (apical oblique) or Outlet view
USS or MRI depending on ROM
What are some non-operative treatments for impingement syndrome?
Rest, pain relief, physio, corticosteroid injections in subacromial space twice a day
What are some surgical options for impingement syndrome?
Arthroscopic/ open subacromial decompression = subacromial/subdeltoid bursectomy, acromioplasty, release of CA ligament or calcific deposits, excision of infraclavicular spur
What are some features of a cuff tear?
Patients aged 50-60, acute traumatic or chronic attrition, weakness and pain
What are some examination findings in a patient with a cuff tear?
Look = contour, wasting Feel = subdeltoid tenderness Move = ROM active < passive, RC weakness
What are some special tests to assess cuff tears?
Supraspinatus movement, Gerber’s lift off, horn blowers
What imaging modalities can be used for cuff tears?
Radiographs, USS (if good ROM)
What is the treatment for chronic cuff tears?
Rest, analgesia, sling, physio (anterior deltoid strengthening), steroid injections, wait and watch approach
What are the treatments for acute cuff tears?
Rest, analgesia, sling, urgent investigation
Early physio, reassessment and intervention
What is the surgical treatment for cuff tears?
Arthroscopic/open repair
How common are recurrent cuff tears?
20% of patients have recurrent tears
How long is rehabilitation for cuff tears?
Sling for 6 weeks. no driving for 8-10 weeks, 12 weeks before heavy lifting, prolonged physio, 6-9 month recovery
What are some features of frozen shoulder?
Patients aged 40-50, more common in females, often bilateral but not simultaneous, gradual severe pain
What are some associations of frozen shoulder?
Diabetes, lipid/endocrine disorders, Dupuytren’s
What occurs in frozen shoulder?
Contracture and thickening of coraco-humeral ligament, rotator interval and axillary fold
Decrease in joint volume
What are the stages of frozen shoulder?
Freezing, frozen and thawing
Self limiting and process can take 3-4 years, nearly all patients have residual stiffness
What are the differentials for a lack of passive ER in the shoulder?
Locked posterior dislocation, glenohumeral arthritis, frozen shoulder
What is the non-operative treatment for frozen shoulder?
Gentle movements, analgesia, physio, glenohumeral steroid injections, fluoroscopic distension
What is the history of a patient with frozen shoulder?
Pain at night, pain at rest, anterior pain, stiffness
What would an examination of a frozen shoulder show?
Global restriction in ROM, external rotation < 50% of normal
What are operations that can be done on a frozen shoulder?
Manipulation under anaesthesia, arthroscopic capsular release (arthrolysis)
What is the rehabilitation for frozen shoulder like?
Short period in sling, excellent pain control, aggressive physio
What are some features of glenohumeral arthritis?
Occurs in patients over 60, uncommon location
Maybe be due to osteoarthritis, rheumatoid arthritis or post-traumatic arthritis
What is the history of a patient with glenohumeral arthritis?
Gradual onset, pain at rest and night, stiffness, intermittent exacerbations, functional difficulties
What would the examination results be for a patient with glenohumeral arthritis?
Asymmetry, wasting, limitation of external rotation, global restriction in movement, pain throughout ROM
What imaging modality is used for glenohumeral arthritis?
Radiographs = show loss of articular cartilage, osteophytes, subchondral sclerosis and cysts
What are the non-operative treatments for glenohumeral arthritis?
Analgesia, physio, GH steroid injections
What are some operations that can be done for glenohumeral arthritis?
Shoulder replacement = resurfacing, total shoulder arthroplasty, reverse polarity shoulder arthroplasty
What are some features of carpal tunnel syndrome?
Patients >30, common, more common in females, influenced by hormonal fluctuations
What are some associations of carpal tunnel syndrome?
Hypothyroidism, diabetes, pregnancy, obesity, rheumatoid arthritis
What may occur as a result of carpal tunnel syndrome?
Relative reduction in blood supply
What are some features of the anatomy of the carpal tunnel?
Radial aspect = scaphoid tubercle, trapezium
Ulnar aspect = hook of hamate, pisiform
Superficially = transverse carpal ligament
Deep = bony carpus
What are the contents of the carpal tunnel?
9 flexor tendons, median nerve
Where does the median nerve innervate?
Lumbricals IF and MF, opponens, abductor pollicis brevis, flexor pollicis brevis
What are the symptoms of carpal tunnel syndrome?
Early = pins and needles, pain, clumsiness Functional = early morning waking, triggers include driving, phone use and reading Late = numbness, weakness
What are some signs of carpal tunnel syndrome?
Thenar atrophy, altered sensation, weakened abductor pollicis brevis
What are some special tests that can be done for carpal tunnel syndrome?
Durkin’s (compression), Tinnel’s (tapping), Phalen’s (volar flexion)
What investigations can be done for carpal tunnel syndrome?
Carpal tunnel questionnaire = Kamath and Stothard
Nerve conduction studies
Electromyogram
What are the treatments for mild/moderate carpal tunnel syndrome?
Splintage, physio, steroid injections
What is the treatment for severe carpal tunnel syndrome?
Carpal tunnel decompression = day surgery, local anaesthetic, division of transverse carpal ligament
What are the aims of surgery for nerve compressions?
Prevent progression and reduce symptoms
What is the rehabilitation for carpal tunnel syndrome like?
Reduce dressings after 2 days, keep dry for 5 days, remove sutures after 10 days, pincher grip should return after 6 weeks, grip strength should return after 12 weeks
What are some features of cubital tunnel syndrome?
Occurs in patients > 30, more common in men
May be caused by trauma, direct pressure (tumours) or arthritis
Where does the ulnar nerve innervate?
Ulnar two lumbricals, all hypothenar muscles, deep head of flexor pollicis brevis, adductor pollicis, forearm flexors
What are the symptoms of cubital tunnel syndrome?
Early = ulnar pins and needles, pain, clumsiness Functional = night pain, pain on leaning Late = numbness, waekness
What are some signs of cubital tunnel syndrome?
Hypothenar and interosseous atrophy, clawing of ring and little finger, altered sensation, weakness of abductor digiti minimi, weakness of grasp and pinch
What is Wartenberg’s sign?
Abducted little finger = positive in cubital tunnel syndrome
What are some special tests for cubital tunnel syndrome?
Tinnel’s (tapping), modified Phalen’s (elbow flexion), Froment’s (thumb flexion during key grip)
What are some investigations suitable for cubital tunnel syndrome?
Nerve conduction studies and electromyograms
What is the treatment for mild/moderate cubital tunnel syndrome?
Elbow splintage, physio (nerve gliding), NSAIDs
What is the treatment for severe cubital tunnel syndrome?
Ulnar nerve decompression = day surgery, local/regional general anaesthetic, release nerve from arcade struthers to head of FCU
