Shoulder and Elbow Problems

Question 1

What sort of shoulder conditions do patients of different ages get the most?

Answer 1

Teens/20s: fractures and instability

30s & 40s: rotator cuff and capsulitis

50s and 60s: impingement and AC joint problems

70s + : degenerative rotator cuff and arthritic joint

Question 2

In which direction is the shoulder most commonly dislocated out of the GH joint?

Answer 2

• Anterior: 90%

- Posterior 9%, inferior 1%

Question 3

What is a common complication of shoulder dislocation that leads to future instability?

Answer 3

Avulsion of the labrum from the glenoid during the dislocation

Question 4

What should be done prior to reduction of a dislocated shoulder?

Answer 4

Examine axillary nerve function and presence of radial pulse

Question 5

Management of dislocated shoulder?

Answer 5

• Manipulation to reduction
• Immobilization
• Physiotherapy
• Surgery in young, active person with avulsed labrum as most go on to recurrent dislocations

Question 6

Who tends to get proximal humeral fractures?

Answer 6

Elderly osteoporotic patients

• Fall onto their outstretched arm

Question 7

Treatment of proximal humeral fracture?

Answer 7

• Majority can be treated conservatively with collar and cuff
• Displaced comminuted (multiple fragments) fractures may need open reduction or shoulder hemiarthroplasty

(Hemiarthroplasty replaces one half of the shoulder joint, humeral head is replaced with a prosthesis)

Question 8

Symptoms of subacromial impingement?

Answer 8

• Painful arc on abduction: initial abduction is painless but then becomes painful, painless again after about 120 degrees

Question 9

Pathophysiology of subacromial impingement?

Answer 9

Degeneration in the acromioclavicular joint produces osteophytes and as the arm is abducted the greater tuberosity impinges on the rotator cuff below the AC joint

the bursal covering between cuff and joint becomes inflamed, further reducing the available space

Question 10

Management of subacromial impingement?

Answer 10

• Steroid injection + physiotherapy (improves about 70%)

- Arthroscopic subacromial decompresion

Question 11

What is adhesive capsulitis (frozen shoulder)? What are the 3 phases of the condition?

Answer 11

Can be a idiopathic or secondary to shoulder injury condition, characterized by reduction in ROM of the shoulder joint

Painful phase: gradual onset of predominantly night pain
Frozen phase: progressive reduction in ROM
Thawing phase: progressive improvement in pain and ROM

Question 12

Treatment of adhesive capsulitis (frozen shoulder)?

Answer 12

If caught early:
- steroid injections / hydrodilatation of capsule. Usually resolves within 3 years

If late / resistant:
- Arthroscopy / manipulation under anaesthesia

Question 13

Investigations for adhesive capsulitis?

Answer 13

Not usually investigated, usually a clinical diagnosis

Question 14

What are the two types of rotator cuff tear? Investigations?

Answer 14

• Traumatic (younger patients)
• Degenerative
• Diagnosis can usually be made based on clinical examination
• Confirmatory studies include USS and MRI

Question 15

Treatment of rotator cuff tears?

Answer 15

• Early surgery for acute tears
• Chronic degenerative tears get surgery if symptomatic

Interval between when injury is sustained and when surgery is performed is often a good prognostic factor. Late surgery can be difficult. Patients often present late with RC injuries

Question 16

What can be a complication of a massive, irreparable rotator cuff tear? How can this be treated?

Answer 16

Humeral head migrates out of position, can result in pain and reduction in effectiveness of deltoid

• Cadaveric skin graft to reconstruct joint capsule

Question 17

What types of arthritis may be seen in the shoulder? What can be a crucial element to successful treatment of shoulder arthritis?

Answer 17

• Osteoarthritis
• Inflammatory arthritis (esp. RA)
• Post-traumatic arthritis
• Integrity of rotator cuff

Question 18

Treatment of shoulder arthritis?

Answer 18

• Hemiarthroplasty + resurfacing of the glenoid surface (if rotator cuff is alright)
• Reverse shoulder prosthesis (if rotator cuff is compromised - to prevent upward subluxation)
• May need custom implants if glenoid is severely degenerated

Question 19

What sort of elbow conditions do patients of different ages get the most?

Answer 19

Young people - fractures and dislocations

Middle age - Tendinopathies

Elderly - Degenerative disease

Any age - cubital tunnel syndrome

Question 20

What are two common elbow tendinopathies?

Answer 20

Medial epicondylitis - Golfers elbow: area affected is medial aspect of elbow, pain on inside of forearm

Lateral epicondylitis - Tennis elbow: area affected is lateral aspect of elbow, are of pain outside forearm. Affects extensors of the forearm - pain on wrist flexion

Question 21

Treatment of common elbow tendinopathies?

Answer 21

• Rest & physiotherapy
• Analgesia
• Steroid injections
• Platelet rich plasma injection