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Orthopaedic Surgery > Conditions Of The Shoulder And Surgery > Flashcards

Conditions Of The Shoulder And Surgery Flashcards

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1
Q

What are the rotator cuff muscles and their actions?

A
  • supraspinatus: ABduct arm 0-15
  • infraspinatus: external rotation of arm
  • teres minor: external rotation of arm
  • subscapularis: internal rotation of arm
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2
Q

What muscles ABduct the arm?

A
  • supraspinatus: 0-15
  • deltoid: 15-90
  • trapezius + serratus anterior: +90
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3
Q

Presentation of rotator cuff tears

A
  • shoulder pain
  • weakness + pain with movements relating to the action of the torn muscle
  • tenderness over greater tuberosity
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4
Q

Investigations of rotator cuff tears

A
  • x ray to rule out fracture
  • USS or MRI scan for diagnosis
  • Shoulder examination with special tests
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5
Q

What special tests on a shoulder examination indicate a rotator cuff tear?

A
  • internal rotation against resistance - subscapualris
  • external rotation against resistance - infraspinatus + teres minor
  • empty can test - supraspinatus
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6
Q

Management of rotator cuff tears

A
  • rest + adapted activities
  • analgesia
  • Physiotherapy
  • arthroscopic rotator cuff repair: if surgery is needed
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7
Q

Risk factors of rotator cuff tears

A
  • increasing age
  • trauma
  • overuse
  • repetitive overhead shoulder motions
  • obesity
  • smoking
  • DM
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8
Q

Complications of rotator cuff tears

A

Adhesive capsulitis/frozen shoulder

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9
Q

What is subacrominal impingement syndrome?

A

Inflammation + irritation of the rotator cuff tendons as they pass through the subacrominal space

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10
Q

Pathophysiology of subacrominal impingement syndrome

A
  • intrinsic mechanisms (due to tension): muscular weakness, overuse of shoulder, degenerative tendinopathy
  • extrinsic mechanisms (due to external compression: anatomical variations of acromion, scapular musculature, glenohumeral instability
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11
Q

Presentation of subacromial impingement syndrome

A
  • progressive pain in anterior superior shoulder
  • worsened by abduction
  • relieved by rest
  • pain in 60-120 of ABduction
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12
Q

What special tests can be done to look for subacromial impingement syndrome?

A

Neers impingement test
Hawkin’s test
Painful arc

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13
Q

Investigations of subacromial impingement syndrome

A
  • clinical diagnosis
  • MRI imaging
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14
Q

Management of subacromial impingement syndrome

A
  • analgesia
  • Physiotherapy
  • corticosteroid injections into subacrominal space
  • surgery if pain persists over 6 months
  • surgical repair of muscular tears
  • surgical removal of subacromial bursa
  • surgical removal of part of the acromion
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15
Q

Why does tendiopathy have a risk of tendon rupture?

A

Tendons become disorganised, hyper vascular + degenerative

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16
Q

Presentation of biceps tendinopathy

A
  • pain in anteior arm
  • worse when stressing tendon
  • better with rest + ice
  • weakness in flexion of arm + shoulder + supination
  • stiffness
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17
Q

Management of biceps tendinopathy

A
  • analgesia
  • ice therapy
  • Physiotherapy
  • USS guided steroid injections
  • arthroscopic tendesis or tenotomy
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18
Q

When do biceps tendon ruptures often occur?

A

Following suddenly forced extension of a flexed elbow

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19
Q

Risk factors of biceps tendon rupture

A
  • biceps tendinopathy
  • steroid use
  • smoking
  • CKD
  • fluoroquinolone abx
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20
Q

Presentation of biceps tendon ruptures

A
  • reverse pop eye sign
  • sudden onset pain + weakness
  • swelling + bruising in antecubital fossa
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21
Q

Imagining for suspected biceps tendon rupture

A

USS

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22
Q

Management of biceps tendon rupture

A
  • analgesia
  • Physiotherapy
  • surgery last line
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23
Q

What is frozen shoulder/adhesive capsulitis?

A

When the glenohumeral joint capsule becomes contracted and adherent to the humeral head
Resulting in shoulder pain and reduced ROM

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24
Q

Demographic of frozen shoulder pain

A
  • women
  • 40-70s
  • diabetes mellitius
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25
Categories of frozen shoulder pain
- **primary**: idiopathic - **secondary**: occurs in response to trauma, surgery or immobilisation *e.g. rotator cuff tendinopathy, impingement syndrome biceps tendinopathy etc.*
26
Pathophysiology of adhesive capsulitis
- Inflammation + fibrosis in the joint capsule lead to adhesions - this binds the capsule + cause it to tighten around the joint - restricting movement
27
Outline the three stages of adhesive capulitis
- **freezing/painful stage**: shoulder pain, worse at night - **frozen/stiff stage**: stiffness on both active + passive movement (ER worst) - **thawing stage**: gradual improvement in stiffness until normal
28
What movement is affected in the freezing stage of adhesive capsulitis?
Stiffness in active + passive movement Especially external rotation
29
Presentation of adhesive capsulitis
- generalised deep + constant shoulder pain - disturbs sleep + worse with movement - reduced ROM - tenderness on palpation - joint stiffness
30
Imaging of adhesive capsulitis + findings
MRI Thickening of glenohumeral joint capsule
31
Management of frozen shoulder
- self limiting 1-3 years - education + reassurance - analgesia - continue to use arm - physiotherapy - intra-articular corticosteroid injections - manipulation under anaesthesia - arthroscopy
32
Surgical options for adhesive capsulitis
Manipulation under anaesthesia Arthroscopy
33
Management of OA in the shoulder
- NSAIDs - weight loss - Physiotherapy - intra-articular steroid injection - hemiarthroplasty - reverse total shoulder replacement
34
What is a shoulder dislocation?
Where the head of the humerus comes entirely out of the glenoid cavity
35
What is the most common type of shoulder dislocation? Mechanism of action What % of dislocations?
**Anterior dislocation** Force applied to extended, ABducted + externally rotated arm >95%
36
What are posterior shoulder dislocations associated with?
Electric shocks + seizures
37
What associated damage can occur in shoulder dislocations?
- bankart lesion - hill-sachs lesion - axillary nerve damage - fractures - rotator cuff tears
38
What are bankart lesions? Causes
**Tears to the anterior portion of the glenoid labrum** Due to repeated anterior subluxations or dislocations of the shoulder
39
What are Hill-Sachs lesions?
Compression fractures of the posterolateral head of the humerus during an anterior dislocation of the shoulder
40
What does axillary nerve damage cause?
- weakness in deltoid + teres minor - loss of sensation in regimental badge area
41
What could be fractured in a shoulder dislocation?
- humeral head - greater tuberosity of humerus - acromion - clavicle
42
What nerve is commonly damaged in anterior shoulder dislocations?
Axilllary nerve C5 C6
43
What is the apprehension test?
- used to assess for shoulder instability - shoulder ABducted to 90 + elbow flexed to 90 - shoulder is externally rotated - as the arm approaches 90 of ER, the patient will becomes anxious + apprehensive (but no pain)
44
Investigations of shoulder dislocations
- X-rays - magnetic resonance arthrography - arthroscopy
45
What is a magnetic resonance arthrography? When is it used in shoulder dislocations
- MRI of the shoulder with contrast injected to the joint - used to assess for damage *e.g. Bankart + Hill-Sachs lesions* + planning for surgery
46
Acute management of shoulder dislocations
- relocate shoulder as soon as safely possible (**Kocher technique reduction**) - analgesia + muscle relaxants - gas + air - broad arm sling - post reduction X-ray - immobilisation
47
Ongoing management of shoulder dislocations
- Physiotherapy - shoulder stabilisation surgery (can correct underlying structural problems)
48
Presentation of shoulder dislocation
- painful shoulder - acutely reduced mobility - asymmetry - loss of shoulder contours (flattened deltoid)
49
Most common site of shoulder fracture Mechanism of action for this
**Proximal humerus** Elderly patients FOOSH (most common) High energy trauma injuries in younger patietns
50
Presentation of shoulder fracture
- pain in upper arm + shoulder - restricted arm movement - inability to ABduct arm - swelling + bruising
51
Investigations of shoulder fracture
- urgent bloods incl. coag, G+S - **X-ray AP, lateral + axillary views** - CT scan
52
Classification of shoulder fracture
**Neer classification** - characterise proximal humeral fractures based on relation between: - greater tuberosity - lesser tuberosity - articular segment (anatomical neck) - humeral shaft (surgical neck)
53
Management of shoulder fractures
- most are conservatively managed - immobilisation initially with early mobilisation at 2-4 weeks post # - correctly applied poly sling - **ORIF**: if head splitting fracture - **inter medullary nailing**: if involving surgical neck - hemiarthroplasty or reverse shoulder arthroplasty (last line)
54
Complications of shoulder fracture
- reduced ROM - avascular necrosis of humeral head - axillary nerve damage
55
Blood supply to the humeral head
Anterior + posterior humeral circumflex arteries
56
Why are scapular fractures very rare?
Lots of protection from surrounding muscles
57
Management of scapular fractures
- mainly treated non operatively as most are aligned acceptably - ORIF
58
Risk factors of humeral shaft fractures
- osteoporosis - increasing age - previous fractures
59
Most common site of humeral shaft fractures Mechanism
- middle 3rd of humerus - high energy trauma in younger people - low energy trauma in older people
60
Presentation of humeral shaft fracture
- pain - deformity - possible damage to radial nerve > reduced in dorsal 1st web space or wrist extension weakness
61
What is a Holstein-Lewis fracture?
- fracture of the distal 3rd of the humerus causing entrapment of the radial nerve - loss of sensation in dorsal 1st web space - wrist drop deformity
62
Investigations of humeral shaft fracture
- AP + lateral X ray - CT if severely comminuted
63
Management of humeral shaft fractures
- realignment - analgesia - most are treated conservatively in **functional humeral brace** - regular follow up X-rays - ORIF with plate or intramedullary nailing
64
Complications of humeral shaft fractures
- radial nerve damage - non union - mal union - varus angulation (in transverse fractures)
65
Demographic of clavicle fractures -
- adolescents + young adults - >60 (osteoporosis)
66
Classifications of clavicle fractures
**Allman classification** - based on the anatomical location of the fracture - **type I**: middle 3rd of clavicle - **type II**: lateral 3rd of clavicle - **type III**: medial 3rd of clavicle
67
What is a type III clavicle fracture? What are associated risks and why?
- fracture in the medial 3rd of the clavicle - mediastinum sits directly behind the medial aspect - neurovascular compromise - pneumothorax or haemothorax
68
Displacement of clavicle fractures -
- medial fragment - superior displacement due to SCM pull - lateral fragment - inferior displacement due to weight of arm
69
Presentation of clavicle fracture
- sudden onset localised severe pain - worse on active movement of arm - tenderness + deformity at fracture site - possible tented, tethered, non blanching skin
70
Investigations of clavicle fracture
X ray AP and modified axial
71
Management of clavicle fracture site
- sling until pt pain free movement of shoulder - early movement of shoulder joint - surgical intervention if open or bilateral fracture - ORIF if non union 2-3 months post injury
72
Complications of clavicle fracture site
- Non union - Neurovascular injury - puncture injury > haemothorax or pneumothorax
73
Presentation of acromioclavicular joint injury
- contact sport *e.g. rugby* or FOOSH - shoulder pain - step off deformity - swelling + bruising
74
What nerve is most likely to be blocked in rotator cuff repair?
Suprascapular

Orthopaedic Surgery (10 decks)

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