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Musculoskeletal > Shoulder Pathologies and Nerve Compression > Flashcards

Shoulder Pathologies and Nerve Compression Flashcards

1
Q

What are the typical ages of presentation of different shoulder pathologies?

A 
20-30s = instability
30-40s = impingement
40-50s = frozen shoulder
50-60s = cuff tear
>60 = arthritis
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2
Q

What are some features of the shoulder joint?

A

Most mobile joint in the body, made up of 4 joints, 17 muscles attach to scapula

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3
Q

What are the muscles of the shoulder joint?

A 
Intrinsic muscles (rotator cuff) = supraspinatus, infraspinatus, teres minor, subscapularis
Extrinsic muscles = deltoid, trapezium, pectoralis major, latissimus dorsi
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4
Q

What is the common presentation for shoulder instability?

A

Patient teenager-30s, usually sports, mostly traumatic injury

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5
Q

What are the two kinds of dislocations of the shoulder?

A 
Anterior = common (95%), traumatic sports
Posterior = rare (5%), epileptic fit, electrocution
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6
Q

What are the way patients may present to health professionals with shoulder instability?

A

Acute in trauma clinic = ED reduction, painful in sling

Chronic in shoulder clinic = atraumatic laxity/subluxation, not painful, no support

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7
Q

What may be features of a patient’s history with shoulder instability?

A

Traumatic event, mechanisms of injury, ease of dislocation, frequency, general laxity

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8
Q

What are some possible findings of an examination in a patient with shoulder instability?

A 
Look = abnormal shoulder contour, muscle wasting
Feel = tenderness, muscle spasm
Move = good ROM, scapular winging/dyskinesia
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9
Q

What are some special tests that can be done to confirm shoulder instability?

A

RC strength, apprehension, relocation, general laxity

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10
Q

What is the initial management in the ED for a patient with shoulder instability?

A

IV analgesia and sedation, oxygen

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11
Q

What are some methods of reducing a dislocated shoulder by manipulation?

A

Kocher method, Hippocratic method, Stimson method

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12
Q

What is the post reduction treatment for shoulder instability?

A

2-3 weeks in sling, analgesia, gradual early mobilisation, physio

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13
Q

What are some imaging techniques used for shoulder instability?

A

Radiographs = AP shoulder and Garth views (apical oblique)

MRI arthrogram

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14
Q

What are some injuries associated with shoulder instability?

A

Labral lesion (Bankart)
Fractured humeral head (Hill Sachs)
Fracture of glenoid (bony Bankart)
Rotator cuff tear (patients > 40)

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15
Q

What exercises are done in physio for shoulder instability?

A

RC and core strengthening, scapula stabilising

Given to all patients

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16
Q

What is the link between recurrent dislocations and age?

A

Risk of recurrent dislocation decreases with age

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17
Q

What surgery may be needed for an unstable shoulder?

A

Arthroscopic/open stabilisation

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18
Q

How long does recovery take for shoulder instability?

A

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

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19
Q

What are some features of impingement syndrome?

A

Pain originating from subacromial space, common and mostly transient, mostly patients aged 30-40

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20
Q

What are some intrinsic causes of impingement syndrome?

A

Tendon vascularity, watershed area, tendon degeneration, cuff dysfunction

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21
Q

What are some extrinsic causes of impingement syndrome?

A

External pressure = type of acromion, coraco-acromial ligament, clavicular spur/osteophyte

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22
Q

How does the cause of impingement syndrome vary with age?

A 
RC tendonitis/subacromial bursitis = <30s
Calcific tendonitis = 30-40s
Tendinosis/partial RC tears = 40-50s
Cuff tears = 50-60s
Cuff arthroplasty = 70s
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23
Q

What is Neer’s classification for impingement syndrome?

A

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

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24
Q

What are important aspects of the history of a patient with impingement syndrome?

A

Age, dominance, occupation, pain (onset/ location, radiation, night), reach and stretch, painful arc, neurology, neck pain, analgesia, physio, injections

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25
Q

What may be found on examination of a patient with impingement syndrome?

A 
Look = contour, wasting, scapula position
Feel = tenderness of bursa, AC joint
Move = ROM, painful arc, RC strength
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26
Q

What are some special tests that can be done to diagnose impingement syndrome?

A

Hawkins test, Jobe’s test

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27
Q

What imaging can be done to diagnose impingement syndrome?

A

Radiographs = AP shoulder and Garth views (apical oblique) or Outlet view
USS or MRI depending on ROM

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28
Q

What are some non-operative treatments for impingement syndrome?

A

Rest, pain relief, physio, corticosteroid injections in subacromial space twice a day

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29
Q

What are some surgical options for impingement syndrome?

A

Arthroscopic/ open subacromial decompression = subacromial/subdeltoid bursectomy, acromioplasty, release of CA ligament or calcific deposits, excision of infraclavicular spur

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30
Q

What are some features of a cuff tear?

A

Patients aged 50-60, acute traumatic or chronic attrition, weakness and pain

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31
Q

What are some examination findings in a patient with a cuff tear?

A 
Look = contour, wasting
Feel = subdeltoid tenderness
Move = ROM active < passive, RC weakness
32
Q

What are some special tests to assess cuff tears?

A

Supraspinatus movement, Gerber’s lift off, horn blowers

33
Q

What imaging modalities can be used for cuff tears?

A

Radiographs, USS (if good ROM)

34
Q

What is the treatment for chronic cuff tears?

A

Rest, analgesia, sling, physio (anterior deltoid strengthening), steroid injections, wait and watch approach

35
Q

What are the treatments for acute cuff tears?

A

Rest, analgesia, sling, urgent investigation

Early physio, reassessment and intervention

36
Q

What is the surgical treatment for cuff tears?

A

Arthroscopic/open repair

37
Q

How common are recurrent cuff tears?

A

20% of patients have recurrent tears

38
Q

How long is rehabilitation for cuff tears?

A

Sling for 6 weeks. no driving for 8-10 weeks, 12 weeks before heavy lifting, prolonged physio, 6-9 month recovery

39
Q

What are some features of frozen shoulder?

A

Patients aged 40-50, more common in females, often bilateral but not simultaneous, gradual severe pain

40
Q

What are some associations of frozen shoulder?

A

Diabetes, lipid/endocrine disorders, Dupuytren’s

41
Q

What occurs in frozen shoulder?

A

Contracture and thickening of coraco-humeral ligament, rotator interval and axillary fold
Decrease in joint volume

42
Q

What are the stages of frozen shoulder?

A

Freezing, frozen and thawing

Self limiting and process can take 3-4 years, nearly all patients have residual stiffness

43
Q

What are the differentials for a lack of passive ER in the shoulder?

A

Locked posterior dislocation, glenohumeral arthritis, frozen shoulder

44
Q

What is the non-operative treatment for frozen shoulder?

A

Gentle movements, analgesia, physio, glenohumeral steroid injections, fluoroscopic distension

45
Q

What is the history of a patient with frozen shoulder?

A

Pain at night, pain at rest, anterior pain, stiffness

46
Q

What would an examination of a frozen shoulder show?

A

Global restriction in ROM, external rotation < 50% of normal

47
Q

What are operations that can be done on a frozen shoulder?

A

Manipulation under anaesthesia, arthroscopic capsular release (arthrolysis)

48
Q

What is the rehabilitation for frozen shoulder like?

A

Short period in sling, excellent pain control, aggressive physio

49
Q

What are some features of glenohumeral arthritis?

A

Occurs in patients over 60, uncommon location

Maybe be due to osteoarthritis, rheumatoid arthritis or post-traumatic arthritis

50
Q

What is the history of a patient with glenohumeral arthritis?

A

Gradual onset, pain at rest and night, stiffness, intermittent exacerbations, functional difficulties

51
Q

What would the examination results be for a patient with glenohumeral arthritis?

A

Asymmetry, wasting, limitation of external rotation, global restriction in movement, pain throughout ROM

52
Q

What imaging modality is used for glenohumeral arthritis?

A

Radiographs = show loss of articular cartilage, osteophytes, subchondral sclerosis and cysts

53
Q

What are the non-operative treatments for glenohumeral arthritis?

A

Analgesia, physio, GH steroid injections

54
Q

What are some operations that can be done for glenohumeral arthritis?

A

Shoulder replacement = resurfacing, total shoulder arthroplasty, reverse polarity shoulder arthroplasty

55
Q

What are some features of carpal tunnel syndrome?

A

Patients >30, common, more common in females, influenced by hormonal fluctuations

56
Q

What are some associations of carpal tunnel syndrome?

A

Hypothyroidism, diabetes, pregnancy, obesity, rheumatoid arthritis

57
Q

What may occur as a result of carpal tunnel syndrome?

A

Relative reduction in blood supply

58
Q

What are some features of the anatomy of the carpal tunnel?

A

Radial aspect = scaphoid tubercle, trapezium
Ulnar aspect = hook of hamate, pisiform
Superficially = transverse carpal ligament
Deep = bony carpus

59
Q

What are the contents of the carpal tunnel?

A

9 flexor tendons, median nerve

60
Q

Where does the median nerve innervate?

A

Lumbricals IF and MF, opponens, abductor pollicis brevis, flexor pollicis brevis

61
Q

What are the symptoms of carpal tunnel syndrome?

A 
Early = pins and needles, pain, clumsiness
Functional = early morning waking, triggers include driving, phone use and reading
Late = numbness, weakness
62
Q

What are some signs of carpal tunnel syndrome?

A

Thenar atrophy, altered sensation, weakened abductor pollicis brevis

63
Q

What are some special tests that can be done for carpal tunnel syndrome?

A

Durkin’s (compression), Tinnel’s (tapping), Phalen’s (volar flexion)

64
Q

What investigations can be done for carpal tunnel syndrome?

A

Carpal tunnel questionnaire = Kamath and Stothard
Nerve conduction studies
Electromyogram

65
Q

What are the treatments for mild/moderate carpal tunnel syndrome?

A

Splintage, physio, steroid injections

66
Q

What is the treatment for severe carpal tunnel syndrome?

A

Carpal tunnel decompression = day surgery, local anaesthetic, division of transverse carpal ligament

67
Q

What are the aims of surgery for nerve compressions?

A

Prevent progression and reduce symptoms

68
Q

What is the rehabilitation for carpal tunnel syndrome like?

A

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

69
Q

What are some features of cubital tunnel syndrome?

A

Occurs in patients > 30, more common in men

May be caused by trauma, direct pressure (tumours) or arthritis

70
Q

Where does the ulnar nerve innervate?

A

Ulnar two lumbricals, all hypothenar muscles, deep head of flexor pollicis brevis, adductor pollicis, forearm flexors

71
Q

What are the symptoms of cubital tunnel syndrome?

A 
Early = ulnar pins and needles, pain, clumsiness
Functional = night pain, pain on leaning
Late = numbness, waekness
72
Q

What are some signs of cubital tunnel syndrome?

A

Hypothenar and interosseous atrophy, clawing of ring and little finger, altered sensation, weakness of abductor digiti minimi, weakness of grasp and pinch

73
Q

What is Wartenberg’s sign?

A

Abducted little finger = positive in cubital tunnel syndrome

74
Q

What are some special tests for cubital tunnel syndrome?

A

Tinnel’s (tapping), modified Phalen’s (elbow flexion), Froment’s (thumb flexion during key grip)

75
Q

What are some investigations suitable for cubital tunnel syndrome?

A

Nerve conduction studies and electromyograms

76
Q

What is the treatment for mild/moderate cubital tunnel syndrome?

A

Elbow splintage, physio (nerve gliding), NSAIDs

77
Q

What is the treatment for severe cubital tunnel syndrome?

A

Ulnar nerve decompression = day surgery, local/regional general anaesthetic, release nerve from arcade struthers to head of FCU

Musculoskeletal (57 decks)

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