Shoulder and Elbow Problems Flashcards
(89 cards)
1
Q
What are the expected injuries if someone presents with shoulder pain aged:
u30
30-50
50+
A
U30: instability
30-50: imingement/rotator cuff
50: arhtritis/degenerative rotator cuff
2
Q
Causes of painful shoulder
A
-
Rotator cuff inuries
- Burisitis
- Impingement
- Tendonitis
- Labrum tears (full/partial)
- Calcific changes
- Frozen shoulder (adhesive capsulitis)
- Referred pain (abdo, chest, neck)
- Arthritis of glenohumaral joint/AC joint
- Bicep tendon tear
3
Q
What is frozen shoulder/adhesive capsulitis?
A
Painful condition where the connective tissue surrounding the shoulder capsule becomes inflammed and stiffens, greatly restriciting the ROM and causes chronic pain
4
Q
What is the pathogenesis of frozen shoulder/adhesive capsulitis?
A
Progressive capsular fibrosis - 3 overlapping clinical phases
- Painful phase - Active and passive movements restricted (up to a year)
- Frozen Phase - pain usually settles, but shoulder remains stiff (6-12 months)
- Thawing phase - shoulder slowly regains ROM (1-3 years)
5
Q
What is the cause of Frozen shoulder?
A
Unclear cause
Trauma
- Rotator cuff lesions
- Following hemiplegia
- Myocardial infarction
Iatrogenic
- Chest or breast surgery
6
Q
How does frozen shoulder present?
A
- Severe shoulder pain - Constant, worse at night and in cold weather
- Severely impaired ROM (active and passive) - decreased abduction (<90o), especially external rotation (screened for in REMS)
Typically a painful freezing phase, an adhesive phase and a recovery phase
7
Q
How would you investigate suspected frozend shoulder/adhesive capsulitis?
A
- Examination - Can’t carry out simple movements
- Normal X-ray
8
Q
How would you treat someone diagnosed with frozen shoulder/adhesive capsulitis?
A
Early presentation
- Physiotherapy
- Steroid/local anaesthetic injection
- NSAIDS - High dose
Operative
- Surgery - arthroscopic release
9
Q
How long do episodes of frozen shoulder typically last?
A
Between 6 months and 2 years
10
Q
What is frozen shoulder associated with?
A
Diabetes mellitus (up to 20% of diabetics have an episode)
11
Q
What is subacromial impingement?
A
- Syndrome of painful arc due to impingement in the subacromial space
- Results from any pathology which decreases the volume of the subacromial space or increases the size of the contents (under the coracromial arch)
- Bursa + cuff inflamed ⇒ subacromial impingement syndrome
12
Q
What are the symptoms of subacromial impingement syndrome?
A
Pain - Radiates to upper arm
- Painful arc syndrome - Often worse during the middle of the range of abduction (45-120o)
- Decreased ROM - due to pain, some rotation preserved, unlike frozen shoulder
13
Q
How would you confirm someone had subacromial impingment syndrome?
A
- Examination - Painful Arc syndrome
- X-ray/Ultrasound - only if symptoms are peristent
14
Q
How would you manage someone with subacromial impingment syndrome?
A
Early presentation
- Physiotherapy
Specific/empirical
- Subacromial Steroid injection
Operative
- Arthroscopic subacromial decompression
15
Q
What is the specrum of rotator disease?
A
Rotator cuff injuries are the most common cause of shoulder problems. A spectrum of disease is recognised:
- Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
- Calcific tendonitis
- Rotator cuff tears
- Rotator cuff arthropathy
16
Q
What is calcific tendinitis?
A
Unkown why it hapens but is the deposition of crysals in the joint over hours.
17
Q
What is a rotator cuff tear?
A
Tear in any of the rotator cuff muscles (supraspinatus, infraspinatus, subscapularis). Can be degenerative or traumatic in nature
18
Q
How are rotator cuff tears described?
A
- Partial-thickness - Often appear as fraying of an intact tendon.
-
Full-thickness
- Small pinpoint, larger buttonhole, or involve the majority of the tendon
- Complete detachment from the humeral head
19
Q
How do rotator cuff tears present?
A
- WEAKNESS + PAIN - night pain can be a sign
-
Impaired active abduction of the arm
- Initiate elevation using the unaffected arm
- Once elevated, the arm can be held in place by the deltoid muscle
20
Q
How would you investigate someone who you suspected had a rotator cuff tear?
A
- Examination
- X-ray
- MRI
21
Q
How would you manage someone diagnosed with a rotator cuff tear?
A
Operative
- Acute rotator cuff tears = early surgery
- Chronic degenerative tears = surgery if symptomatic
-
Based on thickness of tear
- Partial - physiotherapy - opreate if still symptomatic after this
- Complete - referral for assessment ⇒open/arthroscopic repair
22
Q
Name some lesions of the biceps tendon
A
- Tendinitis of the biceps tendon (usually occurs with rotator cuff impingement)
- Rupture of long head of biceps - usually accompanies rotator cuff disruption.
- SLAP lesion 0 compresive loading fo the shoulder in the flexed abduced psotion (eg FOOSH) can damage the Superior Labrum Anteriorly and Posteriorly (SLAP).
23
Q
Disorders of the glenohumeral joint
A
- TB
- RA
- Osteoarthritis
- Rapid destructive arthropathy (milwakee shoulder) - usually rapidly progressive adn destructive form of osteoarhritis.
24
Q
Types of referred shoulder pain
A
Pain from C5 - deltoid
Pain from C6, 7 and 8 - superior border of scapula
Shoulder tip pain - diaphragmatic irritation
25
Types of operation shoulder
* **Arthrosopy**
* **Arthroplasty**
* **Arthrodesis**
26
What is Tennis elbow?
Also known as lateral epicondylitis, it is an inflammatory process at the forearm extensor origin (ennthesitis) on the humeral ***_lateral_*** supra-condylar ridge
27
What is Golfer's Elbow?
Also known as medial epicondylitis, it is an inflammatory process at the common forearm flexor origin on the humeral ***_medial_*** supra-condylar ridge
28
What can cause tennis/golfers elbow?
* Playing racquet sports
* Throwing sports
* Manual work
* Activities that involve fine, repetitive hand and wrist movement
29
How does tennis elbow present?
* **Pain** - felt at front of lateral condyle, exacerbated when tendon is most stretched (wrist and finger flexion with hand pronated)
30
What is the clinical presentation of golfer's elbow?
* **Pain** - exacerbated by pronation and forearm flexion
* **Ulnar neuropathy** - Ulnar nerve can occassionally be affected as it runs behind medial epicondyle (tingling 4th and 5th nerve)
31
How would you treat tennis/golfer's elbow?
**General** - generally last for 6-24 months
* Rest + Ice + NSAIDs
* Physiotherapy
**Specific/empirical**
* Corticosteroids
* PRP injections - short term relief
**Surgical**
* **Surgical release** - May be indicated if persistent problem
32
What is olecranon bursitis?
Traumatic bursitis following pressure on the elbows
33
How does olecranon bursitis present?
**Pain and swelling** - over the olecranon
Typically middle aged men
34
What can be a complication of olecranon bursitis?
**Abscess formation** - leading to septic bursitis
35
How does osteoarthritis of the shoulder present?
**NOT AS COMMON AS LOWER LIMB OA**
* **Pain**
* **Decreased ROM of GH joint** - globally, but most particularly external rotation.
36
How does Biceps tendon rupture present?
* **Feeling like "something has gone" on lifting something**
* **Popeye appearence** - ball appearence on flexion of the elbow
37
What are the signs of subacromial impingement?
* **Early scapular rotation**
* **Passive elevation** - reduces impingement + less painful
* **Painful trapezius spasm**
* **Subacromial bursitis**
38
What muscles are involved in flexion of the shoulder?
* **Pec major**
* **Deltoid anterior 1/3rd**
* **Coracobrachialis**
39
What muscles are involved in extension of the shoulder?
Primarily Deltoid posterior 1/3rd, but movement initiated by:
* **Latissimus dorsi**
* **Pec Major**
* **Teres Major**
40
What muscles facilitate abduction at the shoulder?
Supraspinatus first 15o, then deltoid
41
What muscles facilitate Adduction at the shoulder?
* **Pec major**
* **Latissimus dorsi**
* **Teres major**
* **Subscapularis**
42
What are the muscles of the rotator cuff?
SITS
* **Subscapularis**
* **Infraspinatus**
* **Teres Minor**
* **Supraspinatus**
43
What muscles are involved in internal rotation at the shoulder?
* **Pec Major**
* **Deltoid middle 1/3rd**
* **Latissimus dorsi**
* **Teres major**
* **Subscapularis**
44
What muscles are involved in lateral rotation of the shoulder?
* **Teres minor**
* **Infraspinatus**
45
What muscles are involved in elevation of the scapula?
* **Levator scapulae**
* **Trapezius**
46
What muscles are involved in depression of the scapula?
* **Serratus anterior**
* **Pec Minor**
47
What muscles are involved in protraction of hte scapula?
* **Serratus anterior**
* **Pectoralis major**
48
What muscles are involved in retraction of the scapula?
* **Trapezius**
* **Rhomboids**
49
What mnemonic can be used to remember the features and treatment of atraumatic shoulder dislocations?
* **A**traumatic
* **M**ultidirectional
* **B**ilateral
* **R**ehabilitation
* **I**nferior capsular shift surgery if rehab fails
50
What is the typical age of rotator cuff tear?
\>40 years
51
When are results of a rotator cuff repair better?
If performed within 3 months of injury
52
What investigationds might you perform in someone with olecranon bursitis?
Mainly clinical diagnosis, but can aspirate fluid and send for gram stain, culture and crystal analysis
53
How would you manage olecranon bursitis?
* **Non septic** - analgesia, consider steroid injection and surgery
* **Septic** - Abx and aspiration, analgesia, surgical debridement and lavage
54
What is the following?
AC joint separation
55
What are featurs of AC joint dislocation?
* **Tender bony prominence - AC joint**
* **Scarf test +ve**
56
How would you manage someone with AC joint dislocation?
X-ray
* **Sling and analgesia followed by early mobilisation**
* **Consider surgery in persistent**
57
What is the most common cause of proximal humeral fractures?
Osteoporosis
58
What nerve is at risk from a humeral shaft frcature?
Radial nerve
59
What signs might indicate that damage of local nerves has occured due to humeral shaft fracture?
Wrist drop and loss of sensation over 1st dorsal interosseous space - **Radial nerve**
60
What are signs of anterior shoulder dislocation?
* **Loss of shoulder countour** - prominent acromion
* **Anterior bulge** - head of humerus
* **Arm in slight abduction**
* **Elbow flexed**
* **Forearm supported by other hand, pronated**
61
What would you want to make sure you check on examination in someone with anterior shoulder dislocation?
**Before and after reduction** - Pulses and nerves - including axillary nerve over badge area
62
What investigations would you consider doing in someone with anterior shoulder dislocation?
**X-ray** - is there a break
63
How would you manage someone with anterior shoulder dislocation?
* **Pain relief** - entonox, consider strong analgesia
* **Reduction**
* **Simple reduction**
* **Kocher's method**
64
What would you want to do once you had reduced a dislocated shoulder?
Examine pulses and nerves, and X-ray to ensure in the right place
65
What can you see on the following X-ray?
Anterior shoulder dislocation
66
What can be seen in the following X-ray?
Fractured clavicle
67
What is the risk of using Kocher's method to relocate someones shoulder?
Humeral fracture
68
How would you manage a fracture of the clavicle?
* **Broad arm sling**
* **Follow-up X-ray** - 6 weeks
69
What are potential complications of a clavicular fracture?
* **Brachial plexus inkjury**
* **Subclavian vessel damage**
* **Pneumothorax**
70
What is the most common fracture of childhood?
Supracondylar fracture
71
What is the most common cause of supracondylar fracture?
Hyperextension
72
What is a complication that can occur from a supracondylar fracture?
Cubitus varus deformity from malunion
73
How would you manage an olecranon fracture?
ORIF
74
What is the most common elbow fracture in adults?
Fracture of the radial head
75
What are features of a radial head fracture?
* **Swollen and tender over radial head**
* **Flexion/extension possible**
* **Pronation/supination painful**
76
How would you manage a fractured radial head?
* **Undisplaced** - collar and cuff
* **Displaced** - ORIF/removal of radial head
77
What is the most common direction for elbows to dislocate in?
**Posterior** - 90%
78
What are features of an elbow dislocation?
* **Posterior ulna displacement**
* **Swollen elbow**
* **Fixed flexion**
79
How would you manage a non-displaced supracondylar fracture?
Above elbow back slab + sling
80
How would you manage a supracondylar fracture which is distally angulated?
OR under GA
81
How would you manage a posteriorly displaced supracondylar fracture?
ORIF + K wires
82
What nerve is threatened in a posteromedial displaced supracondylar fracture?
Radial nerve
83
What nerve is threatened in a posterolaterally displaced supracondylar fracture?
Median nerve, esp. anterior interosseous
84
What is cubital tunnel syndrome?
* initially intermittent tingling in the 4th and 5th finger
* may be worse when the elbow is resting on a firm surface or flexed for extended periods
* later numbness in the 4th and 5th finger with associated weakness
85
86
How do you test the subscapularis?
Gerber's lift off test
87
How do you test supraspinatus?
Jobe's test
88
How do you test teres minor and ifnraspinatus
Resisted external rotation
89
Test for impingement syndrome
Hawkin's test
