Upper limb - shoulder

Question 1

What is the age range associated with instability in the shoulder?

Answer 1

20-30s

Question 2

What condition is commonly linked to the 30-40s age group in the shoulder?

Answer 2

Impingement

Question 3

Which shoulder condition is typically seen in individuals aged 40-50s?

Answer 3

Frozen Shoulder

Question 4

At what age is a rotator cuff tear most commonly seen?

Answer 4

50-60s

Question 5

What shoulder condition is most prevalent in those over 60?

Answer 5

Arthritis

Question 6

What movements are measured under shoulder range of motion (ROM)?

Answer 6

Forward Flexion
Extension
Abduction
External Rotation
Internal Rotation

Question 7

What is the most common joint dislocation?

Answer 7

Shoulder dislocation

= because the head of the humerus is substantially larger than the glenoid fossa

Question 8

What should always be checked in a shoulder dislocation?

Answer 8

always check pulses and nerves (particularly AXILLARY - as commonly injured)

Question 9

What is the most common type of shoulder dislocation?

Answer 9

Anterior shoulder dislocation

Question 10

What is the key mechanism for anterior shoulder dislocation?

Answer 10

A fall with the shoulder in external rotation on the arm or shoulder

Question 11

What is a characteristic feature of posterior shoulder dislocation?

Answer 11

The humeral head is positioned posterior to the glenoid

Question 12

Posterior dislocation of shoulder cause and how should it be managed?

Answer 12

caused by seizure or electrocution + refer to orthopaedic surgeon

Question 13

How is inferior shoulder dislocation different from the others?

Answer 13

The humeral head is inferior to the glenoid, and it is a rare type, caused by the shoulder being forced into hyperabduction

Question 14

What is the most common clinical presentation of a shoulder dislocation?

Answer 14

(1) Severe shoulder pain
(2) Inability to move the shoulder
(3) Empty glenoid fossa (dent) may be visible

Question 15

What sign is typically seen in posterior dislocations on X-ray?

Answer 15

The “light bulb sign”

Question 16

What is the preferred imaging technique for assessing shoulder dislocation?

Answer 16

MRI arthrogram

Question 17

What is the management of shoulder dislocation?

Answer 17

1. Reduction of the dislocated joint
2. Analgesia and O2
3. Immobilise in a sling for 1-3 weeks
   = A broad arm sling

Question 18

A 40-year-old female comes to the emergency department after a fall while walking. She complains of pain in her right shoulder. On examination, the right arm is abducted and externally rotated, and she resists all movement. The acromion appears prominent. The humeral head is seen in a subcoracoid position in anteroposterior view on X-ray.

What percentage of shoulder dislocations are similar to that found in this patient?

Answer 18

> 95

Question 19

A 24-year-old man presents to the emergency department after a fall whilst cycling a couple of hours ago. He is grasping his right shoulder and is in obvious pain. The patient does not report any fever or other systemic symptoms and there is no red skin around the joint. An anteroposterior x-ray is ordered which shows that the humeral head is dislodged from the glenoid cavity of the scapula anteriorly.

Given the likely diagnosis, what is the most appropriate initial management?

Answer 19

Kocher-technique reduction

Question 20

A 25-year-old male attended the emergency department after dislocating his shoulder while playing rugby. His shoulder was reduced in the emergency department and then put into a sling. Following this, the emergency department doctor tested for sensation in the ‘ regimental badge area’, which was normal.

Which nerve is commonly injured during a dislocation of the shoulder joint, and the one in which the emergency department doctor was testing?

Answer 20

Axillary nerve

Question 21

What is commonly associated with shoulder instability?

Answer 21

Labral tear, teenagers and sporty

Question 22

What is shoulder instability?

Answer 22

Painful abnormal translational movement, subluxation, and/or recurrent dislocation of the shoulder

Question 23

What are the acute clinical symptoms of shoulder instability?

Answer 23

Painful in a sling

Question 24

Why is treatment for atraumatic instability difficult?

Answer 24

Soft tissue procedures may not work effectively for atraumatic instability

Question 25

What is the treatment for traumatic shoulder instability?

Answer 25

Bankart repair (open or arthroscopic), which reattaches the labrum and capsule to the anterior glenoid

Question 26

What is the main test for shoulder instability?

Answer 26

The anterior apprehension test = assesses pain or instability by placing the shoulder in a vulnerable position

Question 27

A 45-year-old woman presents to the GP with pain in her left shoulder. She says this has been going on for the past 3 weeks and is limiting her ability to work. She works for a food packaging company and has to move heavy boxes and stack tall shelves as part of her job. She has no significant past medical history. On examination, there is tenderness at the anterolateral aspect of her left shoulder. There is pain with active abduction of the arm at 90 degrees, limiting further abduction. There is a good range of movement elsewhere. Except for weakness attributed to pain, neurovascular examination of the upper limb is normal. What is the most likely diagnosis? and why?

Answer 27

Subacromial bursitis = (1) Pain with active abduction at 90 degrees (2) Tenderness at the anterolateral shoulder (3) Job-related overhead lifting

Question 28

What is the painful arc range for subacromial impingement?

Answer 28

Between 60 and 120 degrees

Question 29

In which range of abduction is pain present in rotator cuff tears?

Answer 29

Pain is typically in the first 60 degrees of abduction along with weakness

Question 30

Which injury causes pain in the first 60 degrees of abduction?

Answer 30

Rotator cuff tears

Question 31

What is a common symptom of rotator cuff injuries?

Answer 31

Shoulder pain, particularly worsened during abduction

Question 32

What is the cause of a frozen shoulder?

Answer 32

Inflammation and fibrosis of the joint capsule, leading to contracture of the shoulder joint

Question 33

What are the three stages of frozen shoulder?

Answer 33

(1) Freezing = Pain and increased stiffness with minimal synovitis (2) Frozen = Limited range of motion (ROM), less pain, but capsule contraction and axillary recess adhesion (3) Thawing = Decrease in inflammation, gradual improvement in ROM.

Question 34

What is the hallmark symptom of frozen shoulder?

Answer 34

Gradual severe pain, especially at night and at rest, along with stiffness in the shoulder.

Question 35

What is a common sign of a frozen shoulder on examination?

Answer 35

Global restriction in range of motion (ROM), especially in external rotation

Question 36

What is the main surgical procedure for a frozen shoulder and how long should a patient be in a sling after this surgery?

Answer 36

Surgical capsular release = short period, followed by aggressive physiotherapy to regain motion

Question 37

What are common risk factors for developing frozen shoulder?

Answer 37

(1) Age 40s-50s (2) Higher incidence in females (3) Associated with diabetes, hypercholesterolaemia, endocrine disease, and Dupuytren's disease

Question 38

Another name for frozen shoulder is what?

Answer 38

Adhesive Capsulitis

Question 39

You review a middle-aged man with shoulder pain. He has limited movement of the right shoulder in all directions. What are the most consistent clinical findings regarding limited movements and those that are affected when the diagnosis is frozen shoulder (adhesive capsulitis)?

Answer 39

Active and passive movement limited + external rotation most affected

Question 40

A middle-aged man presents with shoulder pain and limited movement in all directions. Upon examination, both active and passive movements are restricted, with the most significant limitation in external rotation. What is the most likely diagnosis?

Answer 40

Frozen shoulder (adhesive capsulitis)