Upper limb problems Flashcards
Shoulder joint type of joint
Ball and socket synovial joint
Shoulder joint depends on what factor for stability
Surrounding muscles - especially rotator cuff muscles
Shoulder joint is the articulation of
Head of humerus with glenoid fossa of the scapula
Importance of the glenoid labrum
Deepens the glenoid fossa to allow more stability and shock absorption
Why is the shoulder joint the most commonly dislocated joint
Because the humeral head is much bigger than the glenoid fossa
= decreased stability
What is a joint capsule
Fibrous sheath which encloses the structures of the joint
Borders of the joint capsule of the shoulder
From anatomical neck of the humerus to the border of the glenoid fossa
What is at the inner surface of the joint capsule of the shoulder
Synovial membrane producing synovial fluid
Synovial Bursae
Function of bursae
To reduce friction, acting as a cushion between tendons and other joint structures
What are the bursae in the shoulder joint
Subscapular bursa
Subcoracoid bursa
Subcacromial bursa
Subdeltoid bursa
Function of the subacromial bursa
To protect the supraspinatus from wear between the humeral head and acromion
Function of the subscapular bursa
To protect the subscapularis from wear and tear during movement at the shoulder joint
Which shoulder bursa is the most commonly inflamed
Subacromial bursa
Name the rotator cuff muscles
Subscapularis
Supraspinatus
Infraspinatus
Teres minor
Main common function of the rotator cuff muscles
Pulls the humeral head into the glenoid fossa to provide a stable point for deltoid muscle to abduct the arm
Innervation of supraspiantus
suprascapular nerve
Innervation of infraspinatus
Suprascapular nerve
Innervation of subscapularis
Upper and lower Subscapular nerve
Innervation of teres minor
Axillary nerve
Function of the supraspinatus (except from providing a stable fulcrum for deltoid to abduct arm)
abduct arm 0-15 degrees
Function of infraspinatus (except from providing a stable fulcrum for deltoid to abduct arm)
Laterally rotates the arm
Function of teres minor (except from providing a stable fulcrum for deltoid to abduct arm)
Laterally rotates the arm
Function of subscapularis (except from providing a stable fulcrum for deltoid to abduct arm)
The ONLY rotator cuff muscle that medially rotates the arm
What are the ligaments of the shoulder joints
Glenohumeral ligament
Coracoacromial ligament
Coracohumeral ligament
Transverse humeral ligament
The joint capsule of the shoulder is formed from which ligament
Glenohumeral ligament
Function of glenohumeral ligament
Main stabilizer of the joint
Prevents anterior dislocation
Function of coracoacromial ligament
Prevents superior dislocation of the humeral head
Roof of subacromial space
Function of transverse humeral ligament
Holds the tendon of long head of biceps in the inter tubercular groove
Describe how the abduction of the arm is performed
- FIrst 0-15 degrees performed by supraspinatus
- Middle fibres of the deltoid are then responsible for the next 15-90 degrees
- Past 90 degrees, the scapula needs to be rotated which is performed by trapezius and serratus anterior
Extension of the shoulder is performed by
Posterior deltoid
Latissimus dorsi
Teres major
Flexion of the shoulder is performed by
pectoralis major
anterior deltoid
coracobrachialis
biceps brachii weakly assists
Adduction of the shoulder is performed by
Pectoralis major
Latissimus dorsi
Teres major
Shoulder dislocation is most commonly seen in
Sporty younger patients
Most common type of shoulder dislocation
Anterior shoulder dislocation - humeral head anterior to glenoid
Mechanism of injury for anterior shoulder dislocation
Fall with shoulder in external rotation
complication for anterior shoulder dislocation
Damage to axillary nerve
Shoulder instability
Which nerve is most at risk of damage from anterior shoulder dislocation
Axillary nerve
What is required to assess axillary nerve injury
Regimental badge area sensory assessment
How may shoulder instability occur after shoulder dislocation
Due to
- Bankart lesion
- Hillsach lesion
What is Bankart lesion
Damage to glenoid labrum
What is Hillsach lesion
posterolateral humeral head depression fracture
Injury mechanism of posterior shoulder dislocation
Fall with shoulder in anterior location
Direct blow to anterior shoulder
Injury mechanism of inferior shoulder dislocation
Shoulder forced into hyperabduction
Why should you do a prompt neuromuscular assessment of a patient with inferior shoulder dislocation
Because it is close to the brachial plexus
Symptoms of shoulder dislocation
Severe shoulder pain
Inability to move shoulder
Clinical signs of shoulder dislocation
Axillary nerve injury
- weakness of shoulder abudction
- Loss of sensory in regimental badge area
Anterior shoulder dislocation - externally rotated and abducted
Posterior shoulder dislocation - internally rotated and adducted
Investigations for shoulder dislocation
Xray - AP and Oblique
MRI arthrogram (if suspect Bankart lesion)
Regimental badge area sensory assessment
Extension lag test
Why should both AP and oblique Xray be used to investigate shoulder dislocation
Because posterior dislocation is difficult to see on AP xray
Xray sign of posterior shoulder dislocation
Light bulb sign
What is the extension lag test
Elevate the patient’s arm to near full extension
Ask the patient to maintain the position
If arm drops = deltoid is weak = axillary nerve damage
Management for shoulder dislocation
Analgesia
Closed reduction under sedation / open reduction
Post reduction management for shoulder dislocation
Analgesia
Rehabilitation
Recurrent dislocation (shoulder instability) risk is higher in
younger patients
What genetic syndromes can cause ligamentous laxity hence atraumatic shoulder instability
Ehler Danlos
Marfan’s
Management for traumatic shoulder instability
Bankart repair surgery
What tests can be used to check for shoulder instability
Posterior and anterior drawer test
Sulcus sign
Posterior and anterior apprehension test
Describe the posterior apprehension test
- Patient in supine
- Place the patient’s arm in flexion, adducted, and internally rotated
- Apply a posteriorly directed force
- Pain / sense of instability = positive
Describe the anterior drawer test
- Patient in supine / sitting
- Shoulder is held in abduction, flexed, and externally rotated
- Immobilise the scapula with left hand
- Grab the proximal upper arm and pull it anteriorly
Positive = pain / instability
Describe the sulcus sign
- Patient sitting
- Grab the patient’s forearm below the elbow and pull it inferiorly
Positive = depression under the acromion
Shoulder impingement most commonly affects
under 25
Sporty
What is shoulder impingement
Inflammation of the rotator cuff tendons as they are compressed in the subacromial space during movement
Causes of shoulder impingement
Tendonitis
Subacromial bursitis
Acromioclavicular OA with inferior osteophyte
Which rotator cuff tendon is the most commonly inflamed in shoulder impingement
Supraspinatus
Symptoms of shoulder impingement
Pain radiating to deltoid and upper arm
Tenderness at lateral edge of acromion
Difficulty reaching over head
Investigations for shoulder impingement
Hawkins Kennedy test
Jobe’s
Xray - AP and oblique
Xray result for shoulder impingement
Normal
This helps rule out joint arthritis
Describe the Hawkins Kennedy test
Internally rotating the flexed shoulder
Describe the Jobe test
- Patient raises both his arms to scapular level
- Arms internally rotated so thumb points at the floor
- Ask patient to resist the upcoming force
- Examiner apply a downward directed force to the arm
Pain = positive
Management for shoulder impingement
Rest
Analgesia
NSAID
Physiotherapy
Subacromial injection of steroid
Surgery if indicated
When is subacromial injection of steroids used indicated in shoulder impingement
Symptoms does not settle after analgesia / NSAID
Subacromial bursitis
How many times can subacromial injection of steroid be used in shoulder impingement
3
When is surgery indicated in shoulder impingement
If after 6 months of conservative management the symptoms continue
Tendons of rotator cuff muscles most commonly tear in
> 40 years old
Tendons of rotator cuff can tear with minimal or no trauma due to
Degenerate changes in tendon
What is a classic history of rotator cuff tear
Sudden jerk (holding a rail on a bus which suddenly stops) in a patient over 40, with subsequent pain and weakness
Can rotate cuff tear be asymptomatic
Yes, in patients over 60, it can be asymptomatic
Which tendon of rotator cuff muscle is the most commonly torn
Supraspinatus
Extent of tears of rotator cuff muscle can be
Partial or full thickness
Large tear of rotator cuff muscle can
Extend from supraspinatus to subscapularis and infraspinatus
Symptoms of rotator cuff tear
Can be asymptomatic in elderly
Pain radiating down the arm
Weakness
What weaknesses can be seen in rotator cuff tear
Initiation of abduction - supraspinatus
Internal rotation - subscapularis
External rotation - infraspinatus
Clinical signs of rotator cuff tear
Weaknesses
Muscle wasting of supraspinatus
Investigations for rotator cuff tear
Jobe’s test
Xray
US if good ROM
MRI if reduced ROM
Treatment for rotator cuff tear
Surgery (controversial)
Physiotherapy
Subacromial injection for symptomatic relief
Why is rotator cuff repair surgery controversial
Because failure of repair occurs in 1/3 of cases
Goal of physiotherapy for rotator cuff tear
Strengthen the other muscles to compensate for the loss of supraspinatus
complications of rotator cuff tear
Torn rotator cuff = deltoid can pull the head of humerus upwards
Abnormal forces on glenoid leads to OA
What is adhesive capsulitis (frozen shoulder)
Inflammation and fibrosis of the shoulder joint capsule leading to contracture of the shoulder joint
Risk factors for adhesive capsulitis
40-50
Female
Diabetes
Hypercholesterolaemia
Dupuytren’s disease
Stages of adhesive capsulitis
- Freezing stage - pain
- Frozen stage - pain subsides but stiffness increases
- Thawing stage - stiffness resides -> recovery of shoulder motion
How long does freezing stage last in adhesive capsulitis
2-9 months
How long is stiffness felt in adhesive capsulitis (frozen stage)
4-12 months
What is the main clinical sign of adhesive capsulitis
Loss of external rotation
OA of the shoulder can also cause loss of external rotation. How do you differentiate between OA and adhesive capsulitis
OA occurs in much older patients
Management of adhesive capsulitis
Self limiting
Physiotherapy
Analgesia
Glenohumeral injection can help in painful stage
Manipulation under anaesthetic / surgical capsular release if indicated
When is manipulation under anaesthetic / surgical capsular release indicated in adhesive capsulitis
If the patient cannot tolerate the functional loss due to stiffness
What are the other causes of shoulder pain
Inflammation of the tendon of long head of biceps
Tears in glenoid labrum (SLAP lesions)
Referred pain
Complication of inflammation of the tendon of long head of biceps
Popeye deformity - abnormal shortening of bicep muscles due to rupturing of the inflamed tendon
How can tears in glenoid labrum be detected
MRI arthrogram
What conditions can cause referred pain to the shoulders
Neck problems
Diaphragmatic irritation.- biliary colic, hepatic, subphrenic abscess
Name A - G of the humerus
A - anatomical neck
B - Greater tuberosity
C- Surgical neck
D - Humeral head
E - Intertubercular groove
F - Lesser tuberosity
G - Deltoid tuberosity
Name A - F of the shoulder joint
A - acromion process
B - articular cartilage of humeral head
C - Humerus
D - Glenoid fossa
E - Scapula
F - Coracoid Process
The greater tubercle of humerus is an attachment point for
Supraspinatus muscle tendon
Infraspinatus muscle tendon
Teres minor muscle tendon
The lesser tubercle of humerus is an attachment point for
Subscapularis muscle tendon
Name A-G
A - supraspinatus muscle
B - greater tuberosity
C - lesser tuberosity
D - Subscapularis muscle
E - Supraspinatus muscle
F - Infraspinatus muscle
G - Teres minor
The inter tubercular groove of the humerus is an attachment point for
Long head of biceps (runs along the groove)
Pectoralis major
Latissimus dorsi
Teres major
Name A-D
A- intertubercular groove
B - Pectoralis major
C - teres major
D - Latissimus dorsi
Deltoid tuberosity is the attachment point for
Deltoid muscle
This image is describing the course of
Radial nerve
Describe the course of radial nerve
- Arises from the posterior cord of brachial plexus in the axilla region
- Descends down the arm along the radial groove
- Then wraps around the humerus laterally
- then reaches the forearm by traveling anteriorly to the lateral epicondyle of the humerus, through the cubital fossa.
Radial groove is at the posterior / anterior aspect of humerus
Posterior
What structures run along the radial groove
Radial nerve
Radial artery
The borders of cubital fossa
Superior - transverse line between medial and lateral epicondyles
Medial - Pronator teres
Lateral - Brachioradialis
Name A-C
A - Pronator teres
B - Transverse line between medial and lateral epicondyle
C - brachioradialis
What muscles attach to the anterior shaft of humerus
Coracobrachialis
deltoid
brachialis
brachioradialis
Name A-E
A - Subscapularis (attached to lesser tubercle not the inter tubercular groove)
B - teres major
C - Coracobrachilais
D - Triceps brachii
E - Brachialis
Name this muscle
Brachioradialis
Attachment point
Which muscles attach to the posterior aspect of humeral shaft
Medial and lateral heads of triceps brachii
Name A-E
A - Lateral head of triceps
B - Medial head of triceps
C - Long head of triceps
D - triceps tendon
E - Ulna
The long head of triceps does not insert onto the posterior humeral shaft. Where does it origin and attach to
Originate from infraglenoid tubercle of scapula
Insert onto Posterior surface of the olecranon process of the ulna
Name A-G
A - olecranon fossa
B - Lateral epicondyle
C - Trochlea
D - medial epicondyle
E - Coronoid fossa
F - Radial fossa
G - capitulum
Which nerve passes between the medial epicondyle and olecranon
Ulnar nerve
Name A-D
A- Medial epicondyle
B- Ulnar nerve
C- Olecranon
D- cubital tunnel retinaculum
What is biceps tendinopathy
Inflammation of long head of biceps tendon
Cause of biceps tendinopathy
Overuse
Instability
Impingement
Trauma
Symptoms of biceps tendinopathy
Pain at anterior shoulder radiating to elbow
Pain worse by movements
What movements worsen the pain of biceps tendinopathy
Shoulder flexion
Forearm supination
Elbow flexion
Clinical signs of biceps tendinopathy
Tenderness
Pop-eye sign
Investigations for biceps tendinopathy
US
Management for biceps tendinopathy
Physiotherapy
Surgical repair (controversial)
Why is surgical repair for biceps tendinopathy controversial
High risk of neurovascular complication
Where does proximal humerus fracture usually occur
Surgical neck of humerus
Proximal humerus fracture is common in
Osteoporotic bone - low energy injury
Symptoms of proximal humerus fracture
Pain
Swelling
Reduced ROM
Signs of Proximal humerus fracture
Extensive bruising of chest, arm and forearm
Axillary nerve injury
Radial nerve injury (less common)
Which nerve is the most commonly damaged in proximal humeral fracture
Axillary nerve
Apart from axillary nerve, which other nerve can be damaged by proximal humeral fracture
Radial nerve but less common
Radial nerve damaged at the axilla region due to proximal humeral fracture / shoulder dislocation can lead to
Tricep brachii weakness or paralysis - unable to extend forearm
Wrist drop
loss of sensation over
- lateral and posterior arm
- posterior forearm
- dorsal surface of the lateral three and a half digits.
Investigations for proximal humerus fracture
Xray - AP and lateral
CT
MRI if need to identify rotator cuff injury
Regimental badge area sensory assessment
Extension lag test
Management for proximal humeral fracture
Collar and cuff
ORIF
replacement
Humeral shaft fracture can present as
Spiral
Oblique
Transverse
Comminuted
What type of fracture does the image show
Comminuted fracture
What type of fracture does this image show
Compound fracture
Which nerve is most likely to be damaged by humeral shaft fracture
Radial nerve
Symptoms of humeral shaft fracture
Pain
Extreme weakness
Signs of humeral shaft fracture
Radial nerve injury
-wrist drop
-reduced sensation in the anatomical snuffbox
-may have weakness in triceps brachii but not paralysis
Why does wrist drop occur in radial nerve injury
Because the extensor muscles of the posterior forearm -> cannot extend the wrist and fingers
Where is the anatomical snuff box
triangular depression found on the lateral aspect of the dorsum of the hand
investigations for humeral shaft fracture
Xray - AP and lateral
Assess radial nerve injury
Management of humeral shaft fracture
Humeral brace
IM nail
ORIF with plate fixation (rare)
IM nail for humeral shaft fracture is indicated in
osteoporotic bone
Name A to J
A - lateral epicondyle
B - Medial epicondyel
C - Radial fossa
D - Trochlear
E - Capitulum
F - Olecranon
G - Trochlear notch
H - Coronoid process
I - radial notch
J - Radial tuberosity
The olecranon is an attachment point for
Long head of triceps brachii
Coronoid process of ulna is an attachment point for
Brachialis
Brachialis origin and insertion point
Anterior shaft of humerus -> coronoid process of ulna
Name A - I
A - Olecranon
B - Trochlear notch
C - Coronoid process
D - Radial notch
E - Ulnar tuberosity
F- Radial tuberosity
G - Interosseuous border
H - styloid process of ulna
I - styloid process of radius
What is the interosseous border
Edge of a bone to which a fibrous membrane is attached so the bone is attached to the adjacent bone
Name A - C
A - Radial notch of ulna
B - Interosseous membrane
C- Ulnar notch of radius
Radial tuberosity is an attachment point for
Biceps brachii - short and long head
Name the superficial contents of cubital fossa (lateral to medial)
(Really Need Beer To Be At My Nicest)
Radial Nerve
Biceps Tendon
Brachial Artery
Median Nerve
What are the superficial veins in cubital fossa
Medial cubital vein
Cephalic vein
Basilic vein
Which other nerve can be seen deep in the cubital fossa
Radial nerve
What does brachial artery bifurcate into and where
Radial and ulnar arteries
Birfurcates at the apex of cubital fossa
Name A-H
A - Brachial artery
B - Median Nerve
C - Pronator. teres
D - Ulnar artery
E - Biceps tendon
F - Radial Nerve
G - Brachioradialis
H - Radial artery
Name A-D
A - Bicipital aponeurosis (aponeurosis of biceps brachii)
B - Cephalic vein
C - Basilic vein
D - Median cubital vein
Cubital fossa is a common site for
venopuncture and siting of peripheral venous cannulas
Due to the superficial veins being easily accessible
