Upper Limb Conditions - SHOULDER

Question 1

4 causes of Impingement

Answer 1

Tendonitis, subacromial bursitis, acriomioclavicular OA with inferior osteophyte, hooked acromium

Question 2

Pathogenesis of Impingement

Answer 2

Tendons of the rotator cuff are inflamed and become compressed in the subacromial space during movement causing pain

Question 3

Symptoms of Impingement

Answer 3

Painful arc at 60-120 degrees of abduction, pain can radiate down the deltoid and upper arm, tenderness at lateral edge of acromium

Question 4

Diagnosis of Impingement

Answer 4

Pain on Hawkin’s Kennedy Test

Question 5

Treatment of Impingement

Answer 5

NSAIDS, analgesia, physiotherapy, subacromial steroid injections (up to 3), if no improvement then subacromial decompression with surgery

Question 6

Epidemiology and causes of rotator cuff tear

Answer 6

Over 40s (manual workers, painters, athletes in throwing events), due to age related degeneration + sudden jerk (holding onto bus + it brakes)

Question 7

Symptoms of rotator cuff tear

Answer 7

Dull/achy pain + weakness that gradually increases, difficulty seeing on affected side, tenderness at glenohumeral + AC joint
Pain on external rotation= infraspinatus
Pain on abduction= supraspintaus
Pain on internal rotation= subscapularis

Question 8

Diagnosis of rotator cuff tear

Answer 8

Scarf + Hawkin’s Kennedy test
Gold standard= dynamic MRI
Most commonly partial/fullthickness tear of the supraspinatus

Question 9

Treatment of rotator cuff tear

Answer 9

Surgery: Repair + subacromial decompression (tendon is diseased so often fails) 
Non-surgical: Physio to strengthen remaining cuff muscles
Subacromial injections (steroid + anaesthetic) to help symptoms

Question 10

Epidemiology + Risk factors of adhesive capsulitis

Answer 10

40-60s: Diabetes, hypercholesterolaemia, Duputyren’s disease

Question 11

Symptoms of adhesive capsulitis

Answer 11

Pain for 2-9 months –> stiffness for 4-12 month –> recovery + normal shoulder motion

Question 12

Diagnosis of adhesive capsulitis

Answer 12

LOSS OF EXTERNAL ROTATION

Question 13

Treatment of adhesive capsulitis

Answer 13

Resolves after 18-24 months
Physiotherapy + analgesia
Steroid injections in the painful phase
MUA surgical capsular release in the stiffness phase

Question 14

Describe the differences between traumatic and atraumatic instability

Answer 14

Traumatic: Following anterior dislocation that fails to stabilise, recurrence is higher if the first dislocation happened when young. Treated with Bankart repair (reattach labrum + capsule to the anterior glenoid)
Atraumatic: Ligamentous laxity due to (idiopathic, EDS, Marfans), pain from recurrent multidirectional dislocations/subluxations, difficult to treat

Question 15

Causes of anterior and posterior dislocation

Answer 15

Anterior: MOST COMMON (young adults + sports) fall with arm in external rotation
Posterior: (Epilepsy/seizures) fall with arm in internal rotation or direct blow from behind

Question 16

Define a barkart lesion vs a hill sachs lesion

Answer 16

Bankart Lesion: Detachment of inferior anterior glenoid labrum + capsule
Hill-sachs lesion: Impaction of humeral head against anterior glenoid causing posterior humeral head compression fracture

Question 17

Diagnosis of dislocation

Answer 17

Anterior: XR loss of symmetry, roundness of shoulder, regimental badge patch area sensory assessment (axillary nerve_
Posterior: Lightbulb sign

Question 18

Treatment of dislocation

Answer 18

Closed reduction + sedation (Hippocratic manoeuvre)
Open reduction for delayed presentation/greater tuberosity fracture
Stabilisation/rehab with sling for 2-3 weeks + physio

Question 19

Biceps tendinopathy causes, symptoms, treatment

Answer 19

Due to overuse, instability, impingement
Symptoms: Anterior shoulder pain, radiates to elbow + pain on resisted biceps contraction, aggravated by shoulder flexion, forearm pronation, elbow flexion
Popeye deformity from tendon rupture
Treatment: Rest + physio, long head not repaired surgically short head can be

Question 20

Describe Acute Calcific tendonitis

Answer 20

Calcium deposition on the supraspinatus tendon giving severe acute onset shoulder pain. XR shows calcium deposition proximal to greater tuberosity, usually self-limiting can give subacromial steroid + anaesthetic injections

Question 21

ACJ dislocation causes, diagnosis, treatment

Answer 21

Due to fall onto point of shoulder
Can be sprained, sublimed (AC ligaments disrupted), or dislocated (AC + Coracoclavicular ligaments ruptured)
POSITIVE SCARF TEST
Treated with physio + sling (surgery + chronic pain)

Question 22

Causes + treatment of Humeral neck fracture

Answer 22

FOOSH or direct fall on shoulder, most common is fracture of the surgical neck Treated with sling or if persistent displacement then internal fixation, shoulder replacement if comminuted/head splitting fractures

Question 23

Causes and complications of humeral shaft fracture

Answer 23

Due to direct trauma, can cause radial nerve damage=wrist drop + loss of sensation in first dorsal web space