Shoulder Problems - 30/10/18 Flashcards
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In life after love
What are 5 common shoulder pathologies and what ages do these occur?
Instability 20-30 Cuff disease -Impingement 30-40 -Cuff tear 50-60 Frozen shoulder 40-50 Arthritis >60
How many joints are in the shoulder girdle?
4
How many muscles attach to the scapula?
17
What are the extrinsic muscles of the shoulder
Deltoid
Trapezium
Pectoralis major
Latissimus dorsi
What are the intrinsic muscles of the shoulder?
Rotator cuff muscles
What are the characteristics of shoulder instability?
Teenage to 30 years
Young
Sporty
Traumatic
What are the characteristics of shoulder instability?
Teenage to 30 years
Young
Sporty
Traumatic
When can posterior dislocation occur?
Epileptic fits
Electrocution
Alocholic fits
in 5% of cases
What are the characteristics of shoulder instability presentation?
Acute -ED -Painful -In sling Chronic -Atraumatic laxity -Not painful -No support
What are the first things to do in shoulder dislocations?
Give the patient analgesia
Reduce the joint
How does instability present?
Mechanism of injury
Ease of dislocation
Frequency
General laxity
WHat is seen on examination of shoulder instability?
Look - abnormal shoulder contour, muscle wasting
Feel - Tenderness, muscle spasm
Move - Good ROM, scapular winging/dyskkinedia
Tests - RC strength, apprehension, relocation, general laxity
What 2 conditions can cause shoulder laxity?
Marfans
EDS
How is a dislocation reduced?
Manipulation
Kocher method
Hippocratic method
Stimson method - tape a weight to the arm whilst lying face down
What is post reduction treatment?
2-3 weeks sling
Analgesia
Gradual early mobilization
Physiotherapy
What are some investigations for shoulder instability?
X-ray
MRI arthogram
What are some associated injuries with shoulder instability?
Labral lesions (bankart) # humeral head (hill sachs) # glenoid (Bony bankhart) Rotator cuff tear
What are some NON operative treatments for shoulder instability?
Physiotherapy
RC and core strengthening
Scapula stabilising
What patients are most likely to have redislocation?
Younger patients (15-20)
What is the rehab for instability?
6 week sling 8-10 weeks no driving 12 weeks no heavy lifting No contact sports for 12 weeks Training and non contact sports after 6 weeks
What are the characteristics of shoulder impingment?
Pain originating from the sub acromial space
Common and mostly transient
Intrinsic and extrinsic causes
What are the intrinsic and extrinsic causes of impingement?
Intrinsic - Tendon vascularity - Watershed area - Tendon degeneration - Cuff dysfunction Extrinsic - Pressure - Type of acromion - Coraco-acromial ligament - Clavicular spur/osterophyte
What are some types of impingement and who do they occur in?
RC tendonitis/subacromial bursitis - <30s Calcific tendonitis - 30s-40s Tendinosis/partial tears RC - 40s - 50s Cuff tear 50-60s Cuff arthropathy - 70s
Neers classification
1 = Inflammation, oedema, haemorrhage 2 = ??/
WHat is important in the History of impingement?
Age Hand dominance Pain Reach and stretch Painful arch Neurology Neck pain Anaglesia Physio Injections
What may be seen on examination of shoulder impingement?
look - Contour, muscle wasting, scapula position
Feel - Tenderness bursa, ACJ
Move - ROM active/passive, painful arc, RC strength
Tests - Hawkins, Joes
What investigations are used for impingement?
X-ray (Shentens line?) Calcifications USS MRI
What are the treatments for impingement?
Rest Activity modification Pain relief Physiotherapy Cortico-steroid injections in sub acromial space Minimal of 6 month non-operative therapy
What occurs during Arthroscopic/open subacromial decompression?
Subacromial/subdeltoid bursectomy Acromioplasty Release of CA ligament Release of calcific deposits Exision infraclavicular spur
What is the rehab for impingement?
Painful
Sling 1-2 weeks
Early physio and ROM movements
RC strengthening
How long does shoulder impingement surgery take to recover?
3-4 months
How do cuff tears present?
50-60yo Grey hair - cuff tear Acute traumatic Chronic attrition Weakness Pain
What is seen on cuff tear examination?
L - Contour, wasting
F - Tenderness subdeltoid region
M - ROM active
How are cuff tears investigated?
Radiographs
MRI if stiff
How are chronic cuff tears treated?
Rest analgesia Sling Physiotherapy Steroids Weait and watch
How are acture cuff tears treated?
Urgent investigation
Early physio
Early reassessment
Early intervention
What is cuff tear rehabilitation?
Sling 6 weeks No driving for 6-8 weeks 12 weeks no heavy lifting Prolonged physiotherapy Prolonged recovery 6-9 months
What are the frozen shoulder presentation?
Females 40-50 Can be bilateral Gradual severe pain Associated with Diabetes, lipid and endocrine disease and dupuytren's
What is frozen shoulder
Contracture and thickening of coracohumeral ligament in the rotator interval and axillary fold
Decrease in joint volume
What are the three phases of frozen shoulder?
Freezing
Frozen
Thawing
How long does frozen shoulder take to recover?
3-4 years
What is seen on frozen shoudler history?
Pain at rest
At night
Anterior
Stiffness
Examination
Global restriction
Differentials of frozen shoulder
Locked posterior dislocation
Arthritis
How is frozen shoulder treated?
NO - Gentle movements, analgesia, Physio, gleno-humeral injections, Fluerescence?
O - Manipulation under anaesthetic, Arthroscopic capsular releaase
What is frozen shoulder rehab?
Short period in sling
Pain control
Physiotherapy
WHat is GH OA presentation?
Over 60 Uncommon location OA RA Gradual onset Intermittent exacerbations
What are the history features in GHOA?
Gradual onset Pain at rest and at night Stiffness Intermittent Functional difficulties
What is the treatment for GHOA?
Analgesia Physio Steroid Shoulder replacement Resurfacing Total shoulder arthroplasty Reverse polarity shoulder replacement
What is the Post arthroplasty rehabilitation?
Sling
Physio
No driving
What is the Post arthroplasty rehabilitation?
Sling
Physio
No driving
Carpal tunnel syndrome?
>30s Common Female Pregnancy Hypothyroidism Diabetes Obesity RA
What happens to the blood supply in CTS?
Reduced blood supply
What nerve is compressed in carpal tunnel syndrome?
Median nerve
What muscles are innervated by the median nerve?
LOAF muscles Lumbricals IF and MF Opponens Abductor pollicus brevis Flexor polllicus brevis
What are the symptoms of carpal tunnel syndrome?
Pins and needles Pain Clumsiness Numbness Weakness Early morning wakening worse when: Driving Phone use Reading
SIgns of CTS?
Thenar atrophy
Altered sensation
Weakness APB
What are 3 tests for CTS?
Durkings test - compression
Tinnels test - tapping
Phalens test - volar flexion
What are CTS investigations?
Carpal tunnel questionsaire
Nerve conduction studies
What is the treatment for CTS?
Splintage Physiotherapy Steroid injections Carpal tunnel Decompression surgery -Day surgery -Local anaesthetic -Division transverse carpal ligament -Anatomical variation
CTS rehab?
2 days reduce dressings
5 days keep dry
???
CBTS?
>30s 2nd most comon More males Post trauma Direct pressure Arthritis
Revise the ulnar nerve anatomy and Cubital tunnel
XOXO gossip girl
Symptoms of CBTS?
Ulnar pins and needles Pain CLumsiness Numbness weakness Leaning pain Night pain
CBTS tests?
Tinnels test
Modified phalens test
Froments test
CBTS investigations?
Clinical examination
Nerve conduction studies
Treatment of CBTS?
Elbow splintage Physio NSAIDs Ulnar nerve decompression -Day surgery -Local
