Shoulder Problems Flashcards
give 4 shoulder problems
instability cuff disease - impingement - cuff tear frozen shoulder arthritis
at what age is each problem most likely?
instability = 20-30 impingement = 30-40s frozen shoulder = 40-50s cuff tears = 50-60s arthritis = >60
how many joints are in the shoulder girdle?
4
how many muscles attach to the scapula?
17
coracohumeral ligament is thickened in what disease?
frozen shoulder
what are the 4 important extrinsic muscles?
deltoid
trapezium
pectoralis major
latissimus dorsi
what are the intrinsic muscles?
rotator cuff muscles
- supraspinatous
- infraspinatous
- teres minor
- subscapularis
who does shoulder instability usually affect?
teenage - 30s
young sporty people
usually traumatic
where does the shoulder usually dislocate?
anteriorly
what can indicate whether anterior or posterior dslocation?
subtle dislocation = posterior
gross = anterior
what is more likely to cause a posterior dislocation?
epileptic fit
alcohol?
electrocution
first thing you do in an acute shoulder dislocation due to trauma?
analgesia
then reduce the joint
how does a more chronic instability of the shoulder present?
atraumatic
not painful
no support
important aspects of history in shoulder dislocation?
mechanism of injury
ease of dislocation
has it happened before
what is seen on examination of shoulder instability?
abnormal shoulder contour muscle wasting tenderness spasm good ROM scapular winging/dyskinesia
give 2 conditions associated with hyperlaxity?
marfans
ehlers danlos syndrome
how is a shoulder reduced by manipulation?
Kocher method
can give IV analgesia, O2 or IV sedation
Hippocratic method (large muscly people)
Stimson method (multiple dislocations)
post reduction treatment?
2-3 weeks sling for pain relief
analgesia
gradual early mobilisation
physiotherapy
investigations for shoulder dislocations?
imaging (X rays etc) MRI angiogram (if multiple dislocations have occurred)
give for injuries associated with shoulder instability
Labral lesion (Bankart) = most important
fracture humeral head (Hill Sachs)
Fracture of glenoid (Bony bankart)
Rotator cuff tear
what do all shoulder dislocations get?
physio (RC and core strengthening, scapula stability)
what causes an increased risk of recurrence of dislocation?
younger age at first dislocation
surgical treatment?
arthroscopic/open stabilisation
instability rehab?
6 weeks 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 is impingement syndrome?
pain originating from t he sub acromial space ………..
intrinsic impingement syndrome?
tendon vascularity
watershed area
tendon degeneration
cuff dysfunction
extrinsic impingement syndrome?
external pressure due to
- type of acromion
- coraco acromial ligament
- clavicular spur/osteophyte
what type of impingment is most likely to occur at which age?
<30s = RC tendonitis/subacromial bursitis calcific tendonitis = 30-40s tendinosis/partial tears RC = 40-50s cuff tear = 50-60s cuff arthropathy (due to really bad cuff tear) = 70s
how is impingement syndrome classified?
Neers classification
1 = inflammation, oedema and haemorrhage (reversible)
2 = …..
important aspects of history in impingement?
age hand dominance occupation pain (SOCRATES) reach and stretch ability painful arc neurology (pins and needles etc) neck pain (can be related to shoulder cause) analgesia, physio, injections (any previous treatment)
features of impingement examination?
contour wasting scapula positioning tenderness bursa loss of active ROM? Hawkins Joes test
X ray signs?
calcification (fluffy dots) in muscles
sclerosis on underside of acromion
other shoulder impingement investigations?
US
MRI
depending on mobility
how is impingement treated?
rest pain relief physiotherapy cortico-steroid injections in subacromial space (X2 or 3) surgery = last resort
how long must non operative treatment be used before surgery?
6 months
surgical treatment for impingement?
arthroscopic/subacromial decompression
how can decompression surgery be used?
….
impingement rehab?
painful sling for 1-2 weeks early physio and ROM exercise RC strengthening recovery time longer than expected - 3 or 4 months
classic examination feature of impingement?
painful arc
who does cuff tear normally affect?
age 50-60s
most commonly chronic but can be acute trauma
how does cuff tear present?
weakness
pain
where does cuff tear usually start>
articular surface, not on bursa side
examination findings of cuff tear?
muscle wasting = main sign
subdeltoid tenderness
…..
cuff tear investigations? when is each used?
X ray (reduced subacromial space, some sclerosis, rounding of shoulder, humeral head can move upwards)
US if good ROM
MRI if very stiff
treatment of chronic cuff tear?
physio (anterior deltoid strengthening)
steroid injections
wait and see
acute cuff tear treatment?
urgent investigation
early physio
early reassessment
early intervention (good response to surgery)
cuff tear surgery?
arthroscopic or open repair of RC
cuff repair rehab?
sling 6 weeks no driving 8-10 weeks 12 weeks no heavy lifting prolonged physio 6-9 months recovery 2-40% recurrence rate at 1 year
who does frozen shoulder affect?
40-50s females
diabetes, lipid and endocrine disease and dupuytrens
how does frozen shoulder present?
gradual severe pain
can be bilateral (but not always simultaneous)
what is a frozen shoulder?
contracture and thickening of coracohumeral ligament, rotator interval, axillary fold
decrease in joint volume
NO ADHESION
3 phases of frozen shoulder?
freezing
frozen
thawing
self limiting but can take 3-4 years
does frozen shoulder always completely resolve?
often have residual pain
examination of frozen shoulder?
global restriction……
differential diagnoses with frozen shoulder?
locked posterior ……
how is frozen shoulder diagnosed and differentiated from other things?
normal radiographs
non opeative treatment for frozen shoulder?
gentle movements analgesia physio gleno-humeral injections? flouresence?
operative treatment of frozen shoulder?
manipulation under anaesthetic
arthroscopic capsular release
frozen shoulder rehab?
short time in sling
quick physio
arthritis presentation?
over 60s gradual onset intermittent exacerbations stiffness pain at rest and night functional difficulties
common arthritis in shoulder?
OA
RA
post traumatic
arthritis examination?
…….
arthritis radiograph features?
LOSS
non operative treatment of arthritis?
analgesia
physio
GH steroid injection
operative arthritis treatment?
shoulder replacement - resurfacing - total shoulder arthroplasty - reverse polarity shoulder replacement rotator cuff arthroplasty
post arthroplasty rehab?
sling 6 weeks
……..
who does carpal tunnel syndrome affect?
>30s females pregnancy hypothryroidism diabetes obesity RA
what causes CTS?
relative reduction in blood supply
can be intrinsic or extrinsic cause
what does the median nerve innervate?
LOAF lumbricals IF and MF Opponens Abductor pollicis brevis flexor pollicis brevis
sensory innervation of median nerve?
thumb
first 2 and a half fingers
CTS symptoms?
early = pins and needles, pain, clumbsiness later = numbness, weakness
functional symptoms of CTS?
early morning wakening
……..
CTS signs?
thenar atrophy (if long term)
altered sensation
weakness of abductor pollicis brevis
positive durkins, tinnels and phalens test
CTS investigations?
carpal tunnel queastionaire
nerve conduction studies
CTS treatment?
mild/moderate = splintage, physio, steroid injections
severe CTS treatment? what are the aims of this?
carpal tunnel decompression (division of transverse carpal ligament)
- prevents progression and reduce symptoms
carpal decompression rehab?
pincer grip returns in 6 weeks
…….
who does cubital tunnel syndrome affect?
>30s more males post traumatic causes direct pressure (sleeping position) arthritis
what does the ulnar nerve innervate?
everything else apart from LOAF
early symptoms of cubital tunnel syndrome?
ulnar pins and needles
…
late symptoms of cubital tunnel syndrome?
……
signs of cubital tunnel syndrome?
hypothenar wasting
cubital tunnel tests?
tinnels
modified phalens
froments test
cubital tunnel investigation?
clinical examination
nerve conduction studies
mild/moderate treatment for cubital tunnel?
elbow splinatge
physio
NSAIDs
severe treatment for cubital tunnel?
ulnar nerve decompression
