Shoulder pathology

Question 1

Shoulder: Anterior dislocation

Answer 1

Falls from heights/sports

Presents with pain and inability to move arm, humeral head bulging anteriorly

Question 2

Investigations

Answer 2

X-Rays

Need 2 - Lateral and Anterior view

Question 3

Management

Answer 3

Conservative - closed reduction whilst awake/sedated + muscle relaxant (ketamine)
Reduce, POST-REDUCTION X-Ray, recheck neuromuscular status and use sling for comfort

Surgical - rarely required unless continually dislocating
*associated with Hills-Sachs fractures

Question 4

Shoulder: Posterior dislocation

Answer 4

Much rarer than anterior

Occurs in epileptics during seizures, struck by lightning, elderly, electric shock victims

Question 5

Investigations

Answer 5

X-Ray - lightbulb sign (away from the ribs)

Question 6

Management

Answer 6

Closed reduction as per anterior

More likely to get Bankart or Hill-Sachs fractures (can require CT)

Question 7

Acromio-clavicular joint separation

Answer 7

Joint disruption due to direct blow, athletes playing contact sports

Question 8

Clinical presentation

Answer 8

Pain and swelling over ACJ, can be mild

Exclude C-spine injury

Question 9

Investigations

Answer 9

X ray with stress views - ask patient to hold onto a weight and x ray

Get normal CXR to compare both ACJ to eachother

Question 10

Management

Answer 10

Depends on patient baseline (young or old)

Conservative - if displacement up to 200%, 1 week of rest in sling

Surgical - >200% displacement or posterior displaced

Question 11

Clavicle fracture

Answer 11

Direct blow, fracture middle third, proximal fragment pulled upwards by SCM
EXCLUDE PNEUMOTHORAX
Check neuromuscular status

Question 12

Investigations

Answer 12

X ray

Question 13

Management

Answer 13

Conservative - if < 100% displacement - broad arm sling

Surgical - >100% displacement and for active adults (leads to better function)

Question 14

Biceps tendon rupture

Answer 14

Ruptures in dominant elbow

Bruising, pop eye sign, painful pop

Question 15

Investigations

Answer 15

X ray, MRI to see partial and complete tears

Question 16

Management

Answer 16

Older - pain relief and physio

young - repair within a few weeks

Question 17

Rotator Cuff pathology

Answer 17

SITS muscles
Supraspinatous 
Infraspinatoous
Teres minor
Subscapularis

Continuim of disease

• impingement and burtitis
• partial tear
• full thickness tear
• rotator cuff tear arthropathy

Question 18

Impingement / subacromical bursisits

Answer 18

Can be due to extrinsic compression (of cuff between the joint bones) or intrinsic degeneration of supraspinatous

Question 19

Presentation

Answer 19

Insidious onset pain, worsened by overhead activity, night pain

Positive Jobe’s test, painful arc between 60-120 degrees, positive internal impingement test

Question 20

Investigations

Answer 20

X rays, MRI

Question 21

Management

Answer 21

Conservative - physio, NSAID

Surgical if not worked -

Question 22

Rotator cuff tear

Answer 22

Supraspinatous most common
Full or partial thickness
> 50 years old, low energy trauma OR young high energy

Presentation
Pain, localised tenderness, loss of function (unable to high arc/lift arm above shoulder)
History of preceding impingement

ABduction limited to 30degrees

Ix - Xray, US, MRI

Mx
Conservative - if partial thickness or not for surgery - NSAIDs, physio
Surgery - subacromial decompression, reattachment: for active patients or full thickness tears

Question 23

Adhesive capsulitis

Answer 23

Frozen shoulder

1 - initial pain
2- decreased ROM
3 - gradual recovery over months / years

MUST have had a painful shoulder with restrictive active AND passive AND resistive movement for at least 1 month not getting better, pain worse at night

Investigations
X ray to rule out other causes

Managenet
Freezing stage - analgesia, gentle active ROM
Frozen stage - limited ROM can be improved with physio or maniplulation under anaesthesia and intra articular steroid

Question 24

Shoulder OA

Answer 24

Acromioclavicular joint -

Glenohumeral joint - pain felt deep in the shoulder and lateral aspect of arm, may be stiff, may have reduced ROM due to osteophytes blocking, crepitus

Ix - Xray

Question 25

Management

Answer 25

ACJ - conservative with NSAID, steroid injections
Surgical if does not get better

GHJ - NSAIDs, physio, hydrotherapy to retain ROM
Surgical if worsens - reverse arthroplasty only if deltoid works

Question 26

Biceps tendonopathy

Answer 26

inflammation of the biceps tendon, usually long head (proximal) - goes through shoulder joint

Swimmings, baseball, weight lifting

Anterior shoulder pain, worsen on overhead lifting

Investigation
X-ray, USS, MRI

Mx
Conservative - rest, ice, NSAID