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Orthopaedics > The Shoulder > Flashcards

The Shoulder Flashcards

1
Q

How common are clavicle fractures, who do they affect?

A

3% all fractures

Adolescents & young adults
Second peak 60yrs - osteoporosis

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2
Q

Allman classification system for clavicle fractures

A

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)

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3
Q

Investigations & management of clavicular fractures

A

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

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4
Q

Classification of rotator cuff tears

A

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

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5
Q

What are the 4 rotator cuff muscles?

A

Supraspinatous - abduction
Infraspinatous - ER
Teres minor - ER
Subscapularis - IR

Also stabilise humeral head in glenoid fossa

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6
Q

Features of rotator cuff tears & the three specific tests

A

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
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7
Q

Investigations for rotator cuff tears

A

Urgent plain film radiograph exclude fracture - most unremarkable - chronic May reduced acromiohumeral distance/ sclerosis/ cyst

Ultrasonography presence & size

MRI size/ characteristics/ location

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8
Q

Management of rotator cuff tears

A

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

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9
Q

What’s the main complication of rotator cuff tears?

A

Adhesive capsulitis -> stiffness glenohumeral joint

40% age related tears enlargement within 5yrs (80% symptomatic)

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10
Q

What is the most common type of shoulder dislocation? How does it occur?

A

Anteroinferior 95% - force applied to extended abducted ER humerus

(Posterior - seizures/ electrocution, direct blow anterior)

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11
Q

What are some associated shoulder dislocation injuries?

A

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
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12
Q

Investigations for shoulder dislocation

A

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

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13
Q

Management of shoulder dislocations

A

A-E trauma assessment - stabilise - examine other injuries - analgesia

  • reduce - immobilise - rehabilitate

Broad arm sling 2wks

Physiotherapy

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14
Q

Which peripheral N is most at risk from anterior shoulder dislocations?

A

Axillary

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15
Q

Who most often gets humeral shaft fractures? What are the clinical features?

A

Bimodal: younger (high energy trauma), elderly (low impact)

Pain & deformity
FOOSH/ fall laterally

RN involved (10%) - reduced sensation dorsal 1st webspace & weakness wrist extension

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16
Q

What is a Holstein-Lewis fracture?

A

Fracture distal 1/3rd humerus -> entrapment RN -> neuropraxia -> loss sensation radial distribution & wrist drop

☑️surgery

17
Q

Investigations & management for humeral shaft fractures

A

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

18
Q

What is biceps tendinopathy?

A

Tendinopathy - encompasses variety pathological changes that occur in tendons typically from overuse (younger repetitive, older degenerative) -> painful, swollen weaker tendon - risk rupture

19
Q

Clinical features of biceps tendinopathy including 2 specific tests

A

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
20
Q

Investigations & management of biceps tendinopathy

A

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 &amp; reattached) 
Tenotomy (division tendon)
21
Q

What are chronic cases of biceps tendinopathy at increased risk of? What are the clinical features including a test?

A

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
22
Q

Investigations & management of biceps tendon rupture

A

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
23
Q

What is the real term for frozen shoulder & what is it?

A

Adhesive capsulitis
Glenohumeral joint capsule -> contracted & adherent to humeral head -> shoulder pain & reduced range of movement

3% population
Wm, 40-70yrs

24
Q

Pathophysiology of frozen shoulder

A

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

25
Q

Features of frozen shoulder

A

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

26
Q

Investigations & management of frozen shoulder

A

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

27
Q

What is subacromial impingement syndrome?

A

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)

28
Q

Where is the subacromial space? What does it contain?

A

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

29
Q

Pathophysiology of subacromial impingement syndrome

A 
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
30
Q

Investigations for subacromial impingement syndrome

A

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
31
Q

Clinical features of subacromial impingement syndrome including two tests

A 
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

Orthopaedics (14 decks)

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