Shoulder Pathology Flashcards
What joint attaches the upper humerus to the shoulder girdle?
What type of joint is this?
Glenohumeral Joint - ball and socket
List 3 features of the GH joint which provide stability?
Bony Congruence
Ligaments
Rotator Cuff and other muscles
Static restraint of the shoulder joint is provided by what 4 things?
- Articular Anatomy
- Labrum
- Negative intra-articular pressure
- Glenohumeral ligaments
Dynamic restraint of the shoulder joint is provided by what 2 things?
- Joint Compression
- Steering effect of cuff muscles
List the ligaments of the GH joint
- Glenohumeral (superior, middle, inferior)
- Coracohumeral
- Coracoclavicular
- Coracoacromial
- Transverse Humeral
What is the purpose of the glenoid labrum and joint capsule?
Labrum – Increases surface area, stability
Capsule – Support, boundary layer
What is the purpose of the rotator cuff muscles?
List/lable these on the image below
Purpose is to depress and stabilise humeral head against glenoid
Supraspinatus, Infraspinatus, Subscapularis, Teres Minor
List the following regarding the Supraspinatus:
- origin
- insertion
- action
- innervation
List the following regarding the Infraspinatus:
- origin
- insertion
- action
- innervation
List the following regarding the Subscapularis:
- origin
- insertion
- action
- innervation
List the following regarding the Teres Minor:
- origin
- insertion
- action
- innervation
State the following regarding ‘other muscles’
- 5 muscles which connect scapula to spine?
- 4 muscles which connect upper limb to thoracic wall?
- 6 muscles act on shoulder joint itself
Revise ‘look, feel, move’ for an shoulder examination
List 4 differentials for shoulder pain
- Dislocation
- Fractures
- Acromio-clavicular OA
- Cervical Radiculitis
- Suprascapular nerve entraptment
- Tendinitis
List 3 features which may indicate vascular damage in a shoulder injury
- absent pulses
- prolonged capillary refill time
- pallor
How do we test the Supraspinatus?
Ie. for Supraspinatus tendinopathy
Jobe’s test (empty can test) ➞ arm abducted to 20, in the plane of the scapula, thumb pointing down
Neer test (full can test)
How do we test the Deltoid muscle?
Resisted abduction at 90o
How do we test the Infraspinatus muscle?
Resisted External Rotation
How do we test the Subscapularis muscle? (2)
- Gerber’s Lift of test
- Resisted Internal Rotation
How do we test the Long Head of Biceps?
Rupture of the LHB tendon will show what deformity?
Resisted elbow flexion – ‘popeye’ sign
What is Hawkin’s test and how is it performed?
Test to identify subacromial impingement syndrome
Flexion to 90o + internal rotation will cause pain
What is the scarf test used to test
How is it performed?
Test for ACJ pathologies ie. AC joint arthritis
Forced cross body adduction in 90o flexion (+) pain at the extreme of motion
What is the Sulcus Test?
To assess the GH joint for inferior instability
(+) = sulcus sign, when downward force applied to arm by patients side in neutral rotation
Sulcus = hollow under acromion
What is the Apprehension test and how is it performed?
To assess for shoulder instability, specifically in the anterior direction
- Shoulder abducted to 90o, elbow flexed to 90o
- Slow ER of the shoulder
- (+) test → At ~ 90o of ER, patient is anxious/apprehensive that shoulder will dislocate (no a/w pain)
When may the apprehension test be positive?
After previous anterior dislocation or subluxation of the shoulder
Test may be performed after recovery from any acute injuries
What is the Jobe Relocation Test and how is it performed?
Also known as the ‘Fowler Sign’ - used to test for anterior instability of the GH joint
- Shoulder abducted to 90o, elbow flexed to 90o, Slow ER of the shoulder, patient apprehensive = (+) apprehension test
- At this point, a posterior force is applied to shoulder
- If apprehension is reduced = (+) Jobes
What 3 views of the shoulder are shown on the MRI below?
What may be done for diagnostic and/or therapeutic intervention for shoulder problems?
Shoulder Arthroscopy
List 4 complications of Shoulder Arthroscopy
- fluid extravasation
- articular cartilage damage
- infection
- musculocutaneous nerve palsy
What is arthritis of the GH joint?
List 4 causes
Destruction articular surface of GH joint resulting in pain and loss of motion
Causes: RA, OA, Post traumatic, Cuff Arthropathy, AVN
Compare the x-ray of RA vs OA
RA: significanrt errosion of the bone of the glenoid and loss of joint space
OA: loss of joint space, sclerosis, osteophytes, cysts
Arthroplasty indication for shoulder arthritis?
What are the 2 types and explain each?
Indication ➞ pain
Hemiarthroplasty ➞ replace humeral head, glenoid remains
TSR ➞ Controversy due to problems with glenoid loosening
Pathology of Subacromial impingement
Abrasion of the rotator cuff due to narrowing of the bony tunnel through which the tendon passes
Image shows how morphological changes in anterior aspect of the acromion can predispose an individual to impingement
What is the typical Presentation of impingement? (4)
- 40-50 years
- Pain over greater tuberosity
- Difficulty sleeping on affected side
- Painful arc of abduction 60-120 degrees
What X-ray sign may be seen in Impingement?
Sourcil Sign - sclerosis on undersurface of acromion
List and explain 2 conservative managements for Impingement
- Subacromial injection:
- steroid and local anaesthetic
- reducing inflammation
- repeat up to 3 injections in total
- Physiotherapy
- strengthening exercises to rotator cuff
- theraband
- centering of the head, reducing impingement
When is surgery recommended for Impingement?
What is the procedure
Failure to respond to conservative measures despite an improvement immediately after subacromial injection
Procedure: Sub acromial decompression
What is Arthroscopic subacromial decompression?
Shave off attachment of coracoacromial ligament , burr down anterior margin acromion (80% success)
Incidence of Rotator Cuff Tears increase with what?
Age - over 80 =70%
Management of Rotator cuff tears
- Conservative – Physio, NSAIDS, Injection
- Acromioplasty
- Cuff Repair – open vs arthroscopic
- Shoulder Hemiarthroplasty
What is meant by cuff tear arthropathy?
Arthritis secondary to patients with chronic rotator cuff pathology
Commonly affects patients 70-80 yrs
List 2 X-ray changes associated with cuff tear arthropathy
- Subluxation of humerus superiorly
- Glenoid arthritis - arthritic humeral head articulating with acromion
Calcific Tendonitis usually involves the _______ muscle and is often associated with _______
supraspinatus, tendon degeneration
How does Calcific Tendonitis present?
Severe crescendo pain in shoulder with spontaneous onset
What X-ray change is seen in Calcific Tendonitis
Characteristic calcification within tendon
Management of Calcific Tendonitis
- Physio
- Corticosteriod Injections
- Operative decompression
Adhesive Capsulitis is also known as what?
What age and gender is most commonly affected?
Known as Frozen Shoulder
Age 56 years, F=M
Main risk factor for adhesive capsulitis?
Diabetics
+ Dupuytrens, minor trauma, epileptics
What are the 3 phases of symptoms in adhesive capsulitis?
PAINFUL ➞ gradual onset diffuse pain
STIFF ➞ stiffness and decreased ROM (ER most affected)
THAWING ➞ gradual improvement of motion
Pathophysiology of Adhesive Capsulitis
Fibromatosis
- Inflammation and fibrosis in joint capsule lead to adhesions
- These bind the capsule and cause contracture of the CH ligament
- Restricts movement in the joint
How long does adhesive capsulitis take to resolve?
Entire illness lasts 1-3 years (~6 months in each phase)
However, a large number of patients have persistent symptoms
Diagnosis of Adhesive capsulitis?
Clinical diagnosis, based on history, exam and excluding other ddx
X-rays are usually normal, but useful to rule out ddx ie. osteoarthritis
Non-surgical management of adhesive capsulitis
- Analgesia (eg. NSAIDs)
- Physiotherapy
- Intra-articular steroid injections
- Hydrodilation (injecting fluid into joint to stretch the capsule)
Surgical management of adhesive capsulitis
For resistant or severe cases, options are:
- MUA
- Arthroscopy
How does a shoulder dislocation present?
- Present after an acute injury
- Arm held at the side of their body
- Flattened deltoid
- Bulging at the head of the humerus, which is palpable at the front of the shoulder
In which direction is shoulder dislocation most common?
Anterior Dislocation (95%)
Mechanism of an anterior shoulder dislocation?
Force applied to an ER +/- Hyperextension in abducted arm
What fracture is often associated with an anterior shoulder dislocation?
Greater tuberosity fracture
What nerve damage is commonly associated with anterior dislocations?
How does this present?
Axillary nerve (C5-C6)
- loss of sensation over “regimental badge” area
- motor weakness in the deltoid and teres minor
Mechanism of a posterior shoulder dislocation?
Indirect force to flexed, adducted & IR arm
Posterior shoulder dislocations are associated with what 2 things?
electric shocks and seizures
What fracture is often associated with a posterior shoulder dislocation?
lesser tuberosity fracture
Investigation in the acute in presentation to confirm a dislocation and exclude fractures?
X-ray
Not always required before reduction, depends on clinical findings and fracture risk
Acute management of a shoulder dislocation?
- Analgesia, muscle relaxants and sedation
- Broad arm sling to support the arm
- Closed reduction (after excl fracture)
- If a/w a fracture, may require surgery
- Post-reduction x-rays
- Immobilisation
What does TUBS and AMBRI stand for?
TUBS ➞ Traumatic Unilateral Bankart lesion often require Surgery (‘Torn Loose’)
AMBRI ➞ Atraumatic Multidirectional Bilateral Rehabilitation (sometimes Inferior capsular shift (‘Born Loose’))
Ongoing management for shoulder instability or following dislocation?
- Physiotherapy (minimum one year before considering surgery)
- Consider shoulder stabilisation surgery
List 4 injuries/damage associated with a shoulder dislocation
- Bankart lesion
- Hill-Sachs lesions
- Fractures (humeral head, greater/lesser tuberosity, acromion, clavicle)
- Axillary nerve damage
What is a Bankart Lesion?
Treatment?
Detachment of anterior labrum from glenoid
Treatment ➞ arthroscopic reattachment
What is a Hill Sachs Lesion?
Osteochondral depression fracture ➞ Infra-spinatus inserted into defect
Makes shoulder less stable and at risk of further dislocations
Imaging to diagnose Bankart and/or Hill-Sachs lesions?
Magnetic resonance arthrography
An MRI with a contrast injected into the shoulder joint
