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Musculoskeletal System > Shoulder + Elbow Problems > Flashcards

Shoulder + Elbow Problems Flashcards

1
Q

Shoulder epidemiology i.e. what conditions are most common in what ages

A
  • TEENS/20s = FRACTURES & INSTABILITY/DISLOCATIONS
    • 30s & 40s = ROTATOR CUFF & CAPSULITIS
    • 50s & 60s = IMPINGEMENT & AC JOINT
    • 70s+ = DEGENERATIVE ROTATOR CUFF & JOINT
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2
Q

Upper limb #

A
  • SIMILAR EPIDEMIOLOGY to HIP FRACTURES
  • YOUNG = HIGH ENERGY INJURIES
  • ELDERLY = OSTEOPOROTIC INJURIES

MANAGEMENT: DEPENDS on FRACTURE CONFIGURATION & PT. BIOLOGY

○ DISPLACED PROXIMAL HUMERAL FRACTURES INVOLVING SURGICAL NECK = NO SIG. DIFFERENCE bwtn SURGICAL & NON-SURGICAL TREATMENT in pt.-reported clinical outcomes
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3
Q

Traumatic shoulder dislocation: presentation + management

A
  • SHOULDER JOINT = MOST MOBILE JOINT in body
  • STABILITY SACRIFICED for MOBILITY

90% - anterior; 9% - posterior, 1% - inferior

PRESENTATION:

* SPORTING Hx usually
* IF FRACTURE/DISLOCATE when YOUNG = MORE LIKELY to have RECURRENT DISLOCATION as SOFT LABRUM DAMAGED (labrum is soft when young & can become damaged; labrum should be tightly adhered to glenoid)

MANAGEMENT:

* MANIPULATION
* IMMOBILISATION
* PHYSIOTHERAPY
* SURGERY - individual discussion, depending on pt. & injury characteristics; can also be used to reattach labrum to glenoid

• DISCUSSION = esp. for young pt. about engaging in high risk activities e.g. rugby
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4
Q

Rotator cuff tear: aetiology

A
  • TRAUMATIC = INJURY

* DEGENERATIVE = AGEING (INSIDIOUS presentation)

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5
Q

Rotator cuff tear: presentation

A

• SHOULDER WEAKNESS + PAIN
○ NIGHT PAIN - may affect sleep as pt. unable to keep arm in comfortable position
○ PSEUDOPARALYSIS = not actually paralysed - passively have full ROM, actively don’t - as w/o supraspinatus tendon, the humerus migrates upwards & the deltoid cannot work effectively due to this

• FALLEN OVER + SHOULDER PAIN + NORMAL X-RAY = could be ROTATOR CUFF INJURY

TYPICAL AGE: > 40yrs

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6
Q

Rotator cuff tear: pathophysiology

A

• TEARS in SUPRASPINATUS TENDON/SUBSCAPULARIS & INFRASPINATUS

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7
Q

Rotator cuff tear: investigations

A

• X-RAY
• USS
MRI - can also give info about + QUANTIFY MUSCLE WASTING (can be useful prognostic indicator)

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8
Q

Rotator cuff tear: management

A
  • ACUTE ROTATOR CUFF TEARS = EARLY SURGERY (if they had a normal shoulder beforehand)
    • CHRONIC DEGENERATIVE TEARS = SURGERY if SYMPTOMATIC○ Depends on SIZE, TIME, AGE
    • INCOMPLETE = SURGERY if SYMPTOMS PERSIST
    • COMPLETE = PROMPT REFERRAL for OPEN/ARTHROSCOPIC REPAIR
    • SUPERIOR CAPUSLAR RECONSTRUCTION = option for MASSIVE, IRREPARABLE ROTATOR CUFF TEARS; CADAVERIC SKIN GRAFT to RECONSTRUCT SUPERIOR CAPSULE NOT TENDON
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9
Q

Frozen shoulder (capsulitis): aetiology

A
  • PRIMARY = IDIOPATHIC
    • SECONDARY
    • NO OBVIOUS TRIGGERS
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10
Q

Frozen shoulder (capsulitis): presentation

A
  • SEVERE PAIN = may present to A&E, occurs at NIGHT + WORSE at NIGHT (may wonder if joint is infection, calcific tendonitis as they also present to A&E w/ painful shoulder)
    • Will EVENTUALLY RESOLVE - may take years
    1. PAINFUL PHASE = up to 1yr, ACTIVE & PASSIVE MOVEMENT RANGE REDUCED e.g. ABDUCTION < 90° ± EXTERNAL ROTATION < 30°
    2. FROZEN PHASE = 6 - 12 months, PAIN usually SETTLES, SHOULDER REMAINS STIFF
    3. THAWING PHASE = 1 - 3yrs, shoulder SLOWLY REGAINS RANGE of MOVEMENT
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11
Q

Frozen shoulder (capsulitis): pathophysiology

A

• JOINT CAPSULE bwtn BALL & SOCKET = INFLAMED, TIGHT, THICK, CONSTRICTED = GLOBAL RESTRICTION of MOVEMENT

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12
Q

Frozen shoulder (capsulitis): risk factors

A
  • 40S, 50S
    • IDDM, THYROID DISEASE
    • CERVICAL SPONDYLOSIS (MORE GLOBAL RESTRICTION of MOVEMENT)
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13
Q

Frozen shoulder (capsulitis): investigations/diagnosis

A

• CLINICAL DIAGNOSIS + NORMAL RADIOGRAPH (NORMAL X-RAY)

	○ X-RAY = as only other DDx is ACUTE INFLAMMATORY ARTHRITIS/DISLOCATION of SHOULDER

	○ TEST = STAND UP w/ LEGS APART = ARMS should ABDUCT &amp; IF it DOESN'T ABDUCT to ~ 50% of NORMAL ARM then it's frozen shoulder

• ARTHROGRAM = will show GREATLY REDUCED SPACE
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14
Q

Frozen shoulder (capsulitis): management

A

• EARLY PRESENTATION = HYDRODILATION (CONTRAST MEDIUM + ANAESTHETIC + CORTISONE - trying to reduce inflammation, which can reduce pain + increase space inside capsule)

	○ ARTHROSCOPIC ARTHROLYSIS = PHYSICALLY INCREASE SPACE = CONTRAST MEDIUM + LOTS of SALINE (keep pushing in saline, looking for SUDDEN GIVE = CAPSULAR RUPTURE; may INJECT STEROID)

* LATER = SURGERY
* EARLY PHYSIOTHERAPY + NSAIDs may help if tolerated, as may CORTICOSTEROID JOINT INJECTIONS early on to reduce pain
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15
Q

Subacromial impingement: aetiology

A

SUPRASPINATUS TENDINOPATHY/PARTIAL RUPTURE of SUPRASPINATUS TENDON = PAIN REPRODUCED by ADDUCTING PRESSURE on PARTIALLY ABDUCTED ARM:

TYPICAL AGE: 35 - 60yrs

MANAGEMENT:

• PHYSIOTHERAPY (ACTIVE SHOULDER MOVEMENT) + PAIN RELIEF
• SUBACROMIAL BURSA INJECTION of CORTICOSTEROID W/ LOCAL ANAESTHETIC might help ≥ 6 MONTHS REFRACTORY SYMPTOMS = REFER for consideration of ARTHROSCOPIC SUBACROMIAL DECOMPRESSION

CALCIFYING TENDINOPATHY = one of the ACUTE CALCIFIC TENDINOPATHIES; ACUTE INFLAMMATION of SUPRASPINATUS; PAIN MAXIMAL DURING PHASE of RESORPTION:

TYPICAL AGE: ~ 40yrs

MANAGEMENT:

* PHYSIOTHERAPY
* NSAIDs
* STEROID INJECTION
* RARELY - CALCIUM EXCISION

ACROMIOCLAVIULAR JOINT OSTEOARTHRITIS:

COMMON among YOUNG WEIGHTLIFTERS

MANAGEMENT:

* REST
* NSAIDs
* STEROID INJECTIONS
* EXCISION of AC JOINT = only if RESISTANT to NON-OPERATIVE measures
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16
Q

Subacromial impingement: presentation

A
  • PAINFUL ARC when pt. ABDUCTING = 50° - 120° (or bwtn 45° - 160°) is PAINFUL + CANNOT MOVE BEYOND 180° = due to NARROW SPACE in SUBACROMIAL SPACE
    • Only some have painful arc - OTHERS have INCREASING PAIN UP TO FULL ABDUCTION

BIGLIANI DEFINITION (1991)

* PAIN + DYSFUNCTION
* RESULTING from ANY PATHOLOGY, which DECREASES the VOLUME of the SUBACROMIAL SPACE/INCREASES the SIZE of ITS CONTENTS

	○ DECREASING VOL. of the SPACE = EXTRA BONE
	○ INCREASING CONTENTS = SWOLLEN TENDON, SWOLLEN BURSA

The NARROWED SUBACROMIAL SPACE results in the SUPRASPINATUS TENDON CATCHING UNDER the ACROMION during ABDUCTION

17
Q

Subacromial impingement: management

A

• STEROID INJECTION + PHYSIOTHERAPY = EQUAL to SURGERY

	○ SUBACROMIAL STEROID INJECTION = USS GUIDED, IF ROTATOR CUFF OK = then INJECTION occurs
	○ PHYSIOTHERAPY = 1ST ASK PT. WHAT EXERCISES they have SPECIFICALLY DONE - want them to do exercises to STRENGTHEN ROTATOR CUFF MUSCLES specifically

• ARTHROSCOPIC SUBACROMIAL DECOMPRESSION = ONLY if above 2 FAILED
18
Q

Shoulder arthritis: types

A
  • OSTEOARTHRITIS
    • INFLAMMATORY ARTHRITIS
    • POST-TRAUMATIC ARTHRITIS
    • ROTATOR CUFF INTEGRITY paramount
19
Q

Shoulder arthritis: investigations

A

• X-RAYS = AP + AXILLARY VIEW (axillary view imp. for assessing)

20
Q

Shoulder arthritis: management

A
  • MECHANICAL SHOULDER REPLACEMENT = rotator cuff has to be intact, otherwise the plastic head of the replacement will wear out due to instability; CERAMIC HEADS also exist
    • REVERSE SHOULDER REPLACEMENT (ball is on the socket) = try to MAXIMISE RANGE of DELTOID MOVEMENT
    • COMPLEX RECONSTRUCTION using CUSTOM MADE IMPLANTS = based on 3D reconstructions from CT, pt. specific implants rather than standard off the shelf implants
21
Q

Elbow epidemiology i.e. what conditions are most common in what ages

A
  • YOUNG = FRACTURES & DISLOCATIONS
    • MIDDLE AGE = TENDINOPATHIES
    • ELDERLY = DEGENERATIVE DISEASE
    • ANY AGE = CUBITAL TUNNEL SYNDROME
22
Q

Elbow dislocation

A
  • V. UNLIKELY in NORMAL PT.

* e.g. PT. ON STEROIDS = OSTEOPOROTIC + POOR SOFT TISSUES

23
Q

Elbow tendinopathies: presentation

A

Lateral epicondylitis:

  • INFLAMMATION where COMMON EXTENSOR TENDON arises from LATERAL EPICONDYLE of HUMERUS
    • CLEAR Hx of REPETITIVE STRAIN
    • PAIN = FRONT of LATERAL CONDYLE + WORSE when TENDON MOST STRETCHED (wrist + finger flexion w/ hand pronated

INVESTIGATIONS/DIAGNOSIS:

• CLINICAL TEST: EXTEND WRIST + RESIST EXTENSION of MIDDLE FINGER = IS PAIN ELICITED?

Medial epicondylitis:

  • INFLAMMATION of FOREARM FLEXOR MUSCLES at their ORIGIN on MEDIAL EPICONDYLE
  • MOST COMMON CAUSE of MEDIAL ELBOW PAIN
    • PAIN = WORSE when doing PRONATION + FOREARM FLEXION
    • Occasionally ass. w/ ULNAR NEUROPATHY as ulnar nn. runs behind epicondyle
24
Q

Elbow tendinopathies: management

A
  • PHYSIOTHERAPY - mainly
    • PLATELET-RICH PLASMA INJECTION = IN & ~ TENDON - tries to use body’s own healing system + GROWTH FACTORS

1 INJECTION BLINDLY ~ MOST TENDER SPOT

25
Q

Elbow tendinopathies: aetiology

A
  • DEGENERATIVE CONDITIONS rather than inflammatory conditions
    • CASES TYPICALLY LAST 6 - 24 months + 90% RECOVER w/I 1yr
26
Q

Cubital tunnel syndrome: presentation

A

• PAIN + PARAESTHESIA in ULNAR DISTRIBUTION

	○ 1ST = SENSORY SYMPTOMS then CLUMSINESS of HAND + WEAKNESS of 4 SMALL HAND MUSCLES INNERVATED by ulnar nn.
27
Q

Cubital tunnel syndrome: pathophysiology

A
  • ULNAR NN. LIKELY to be COMPRESSED in CUBITAL CANAL; could be ANYWHERE ALONG NN. COURSE
    • OA/RA NARROWING of ULNAR GROOVE & CONSTRICTION of ulnar nn. as it passes BEHIND MEDIAL EPICONDYLE
    • Or FRICTION of ULNAR NN. due to CUBITUS VALGUS (poss. Due to childhood supracondylar fractures) = can cause ULNAR NN. FIBROSIS & ULNAR NEUROPATHY
28
Q

Cubital tunnel syndrome: investigations

A

• NERVE CONDUCTION STUDIES = confirm site of lesion

29
Q

Cubital tunnel syndrome: management

A

• SURGICAL DECOMPRESSION

Musculoskeletal System (16 decks)

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