The Shoulder Flashcards
How common are clavicle fractures, who do they affect?
3% all fractures
Adolescents & young adults
Second peak 60yrs - osteoporosis
Allman classification system for clavicle fractures
Type 1 - middle 1/3rd 75%
Significant deformity
Type 2 - lateral 1/3 20% Often unstable (displace inferiorly)
Type 3 - medial 1/3 5%
Multi-system polytrauma
Mediastinum behind - neurovascular/ pneumothorax/ haemothorax
(Displace superiorly)
Investigations & management of clavicular fractures
Plain film anteroposterior & modified- axial radiographs
Most conservatively >90% unite
✅sling until pain free movement
✅early movement of shoulder prevent frozen
Healing time 4-6wks
Surgery (open/ v comminuted/ v shortened/ bilateral)
Failed to unite - ORIF 2-3months post injury
Classification of rotator cuff tears
Common 20%, 40-70yrs
Classification:
Acute <3mths (tendons pre-existing degeneration)
Chronic >3mths (degenerative microtears tendon, older)
Partial thickness
Full thickness: small <1cm, medium 1-3cm, large 3-5cm, massive >5cm/ involving multiple tendons
What are the 4 rotator cuff muscles?
Supraspinatous - abduction
Infraspinatous - ER
Teres minor - ER
Subscapularis - IR
Also stabilise humeral head in glenoid fossa
Features of rotator cuff tears & the three specific tests
Pain lateral shoulder
Inability abduct arm >90d
Tenderness greater tuberosity
Supraspinatous/ infraspinatous atrophy
- Jobe’s test (supraspinatous)
Shoulder 90d abduction 30d forward flexion & IR fully -> push down arm
➕weakness on resistance - Gerber’s lift off test (infraspinatous & teres minor)
IR dorsal hands on lower back -> lift hand away against resistance
➕weakness actively lifting hand away - posterior cuff test (infraspinatous & teres minor)
Arm at side elbow flexed 90d, ER against resistance
➕weakness
Investigations for rotator cuff tears
Urgent plain film radiograph exclude fracture - most unremarkable - chronic May reduced acromiohumeral distance/ sclerosis/ cyst
Ultrasonography presence & size
MRI size/ characteristics/ location
Management of rotator cuff tears
Depends type of tear & functional status
Conservative (not limited pain/ LOF, not fit surgery):
Within 2 wks- analgesia + physiotherapy + corticosteroid injections subacromial space
Surgery:
Arthroscopically or open
What’s the main complication of rotator cuff tears?
Adhesive capsulitis -> stiffness glenohumeral joint
40% age related tears enlargement within 5yrs (80% symptomatic)
What is the most common type of shoulder dislocation? How does it occur?
Anteroinferior 95% - force applied to extended abducted ER humerus
(Posterior - seizures/ electrocution, direct blow anterior)
What are some associated shoulder dislocation injuries?
Bony
- bony bankart lesions (fractures anterior inferior glenoid bone)
- Hill-Sachs defects
(Impaction injuries chondral surface posterior/ superior humeral head)
- fractures greater tuberosity/ surgical neck
Labral, ligamentous & rotator cuff
- bankart lesions (avulsion anterior labrum & inferior glenohumeral ligament)
- glenohumeral ligament avulsion
- rotator cuff injuries
Investigations for shoulder dislocation
Plain radiographs - trauma shoulder series: anterior-posterior, Y scapular, axial
Anterior dislocations: anterior-posterior film humeral head out of glenoid fossa
Posterior: light bulb sign humerus fixed IR
MRI - labral/ RC injury
Management of shoulder dislocations
A-E trauma assessment - stabilise - examine other injuries - analgesia
- reduce - immobilise - rehabilitate
Broad arm sling 2wks
Physiotherapy
Which peripheral N is most at risk from anterior shoulder dislocations?
Axillary
Who most often gets humeral shaft fractures? What are the clinical features?
Bimodal: younger (high energy trauma), elderly (low impact)
Pain & deformity
FOOSH/ fall laterally
RN involved (10%) - reduced sensation dorsal 1st webspace & weakness wrist extension
What is a Holstein-Lewis fracture?
Fracture distal 1/3rd humerus -> entrapment RN -> neuropraxia -> loss sensation radial distribution & wrist drop
☑️surgery
Investigations & management for humeral shaft fractures
AP & lateral plain film radiographs
Severely comminuted - CT May
Re-alignment
✔️majority conservatively - functional humeral brace -> repeated plain film imaging regularly
90% full union 8-12wks
Surgical:
Fixation minority - open reduction & internal fixation with plate
Intamedullary nailing - pathological features, polytrauma or severely osteoporotic
What is biceps tendinopathy?
Tendinopathy - encompasses variety pathological changes that occur in tendons typically from overuse (younger repetitive, older degenerative) -> painful, swollen weaker tendon - risk rupture
Clinical features of biceps tendinopathy including 2 specific tests
Pain, worse with stressing the tendon (alleviated rest/ ice)
Weakness
Stiffness
Tenderness over tendon
Disuse atrophy
- speed test (proximal biceps tendon)
Stands elbows extended, forearms supinated, forward flex shoulders against resistance - Yergason’s test (distal)
Stands elbows flexed 90d, forearm pronated -> actively supinate against resistance
Investigations & management of biceps tendinopathy
Largely clinical - further tests if unsure
Exclude differentials:
- blood tests (FBC, CRP)
- plain film radiograph
Rarely:
USS - thickened tendons
MRI - thickened inflamed tendons
✅ conservative - nearly all - analgesia (NSAIDs), ice, physiotherapy
✅USS steroid injections - conservative doesn’t work
✅surgery - rare Arthroscopic tenodesis (tendon severed & reattached) Tenotomy (division tendon)
What are chronic cases of biceps tendinopathy at increased risk of? What are the clinical features including a test?
Biceps tendon rupture
Complete or partial
Sudden forced extension of flexed elbow
RFs: steroids, smoking, CKD, fluroquinolones
Sudden onset pain & weakness - pop on incident - swelling & brusing antecubitical fossa - bulge (reverse popeye sign)
Hook test (distal rupture): Elbow flexed 90d supinated- examiner hooks index finger under lateral edge biceps tendon ➕can’t be done
Investigations & management of biceps tendon rupture
Diagnosed clinically, confirmation usually - USS -> if unclear MRI
Management:
- conservative (analgesia, physiotherapy) low demand pts
- operative (anterior single incision or dual incision -> form bone tunnel radius & re-insert tendon)
- longer few weeks initial injury - reconstruction tendon allograft
What is the real term for frozen shoulder & what is it?
Adhesive capsulitis
Glenohumeral joint capsule -> contracted & adherent to humeral head -> shoulder pain & reduced range of movement
3% population
Wm, 40-70yrs
Pathophysiology of frozen shoulder
Primary (idiopathic)
Secondary:
Associated rotator cuff tendinopathy, subacromial impingement syndrome, biceps tendinopathy, surgical intervention, trauma, inflammatory conditions, DM
May autoimmune element
Progresses 3 stages:
Initial painful
Freezing
Thawing
Features of frozen shoulder
Generalised deep, constant pain shoulder
Often disturbs sleep
Stiffness
Reduction function
Loss arm swing
Atrophy deltoid
Generalised tenderness
Limited range ER, flexion
Differentials:
Acromiclavicular pathology, subacromial impingement syndrome, muscular tear, AI disease
Investigations & management of frozen shoulder
Clinical
Plain radiographs - unremarkable (rule out acriomioclavicular pathology & atypical fractures)
MRI - thickening glenohumeral joint or rule out subacromial impingement syndrome & plain radiographs
HBA1c blood glucose useful DM/ glucose intolerance
Management: Self-limiting: months-yrs Education - active, physiotherapy Paracetamol/ NSAIDs 1st Glenohumeral injections Oral corticosteroids
Surgical (no improvement 3months conservative or significant symptoms)
Joint manipulation GA - remove adhesions, arthrogaphic distension or surgical release
What is subacromial impingement syndrome?
SAIS
Inflammation & irritation of rotator cuff tendons as pass through subacromial space -> pain, weakness, reduced range motion
Encompasses: rotator cuff tendinosis, subacromial bursitis, calcific tendinitis -> attrition coracoacromial arch & supraspinatous tendon or subacromial bursa
<25yrs, active/ manual professions, 60% all shoulder presentations (most common)
Where is the subacromial space? What does it contain?
Below the coracoacromial arch (acromion, coracoacromial ligament, coracoacromial process)
Above humeral head
Contents:
Rotator cuff tendons, long head biceps tendon, coracoacromial ligament
Surrounded by subacromial bursa
Pathophysiology of subacromial impingement syndrome
Intrinsic mechanisms: (Pathologies rotator cuff tendons due tension) - muscular weakness - overuse - degenerative tendinopathy
Extrinsic mechanisms (pathology rotator cuff tendons due external compression):
- Anatomical factors
- scapular musculature (reduction in function)
- glenohumeral instability
Investigations for subacromial impingement syndrome
Clinical confirmed - MRI (subacromial osteophytes, sclerosis, subacromial bursitis, humeral cystic changes, narrowing subacromial space)
Management
- conservative mainstay - analgesia, physiotherapy, exercises
- corticosteroid injections
Resolves 60-90% pts
Surgical (>6mths without response)
- repair muscular tears
- removal subacromial bursa
- removal section acromion
Clinical features of subacromial impingement syndrome including two tests
Progressive pain anti error superior shoulder Exacerbated abduction Relieved rest Weakness Stiffness
Neers impingement test -
Arm by side IR then flexed passively
➕pain anterolateral aspect
Hawkins test -
Shoulder & elbow flexed 90d then passively IR
➕ pain anterolateral
