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Flashcards in Shoulder Disorders Deck (91):
1

Which muscles make up the rotator cuff?

- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis

2

What is the motor innervation of the axillary nerve?

Deltoid (shoulder abduction)

3

What is the sensory innervation of the axillary nerve?

Patch overlying the deltoid (badge sign)

4

Typical age at presentation - Acute tendinitis

25-40

5

Typical age at presentation - Chronic tendinitis (painful arc syndrome)

40-60

6

Typical age at presentation - Adhesive capsulitis

40-60

7

Typical age at presentation - Rotator cuff tears

45-75

8

Typical age at presentation - Biceps tendinitis

30-40

9

Typical age at presentation - ruptured biceps tendon

>50

10

What is the most common cause of shoulder pain?

Subacromial impingement

11

What is the cause of subacromial impingement?

Degeneration; repeated wear and tear leads to chronic thickening of the rotator cuff

12

What is subacromial impingement clinically characterised by?

Painful arc of abduction

13

What pathology is associated with subacromial impingement?

- Arthritis of the acromioclavicular joint with inferior osteophytes
- Hypertrophic coracoacromial ligament
- Down turning of the tip of the acromion
- Degeneration of supraspinatus tendon
- Subacromial bursitis
- Tears of the rotator cuff

14

Clinical presentation of subacromial impingement

Hx of repeated bouts of shoulder pain exacerbated by reaching up
Painful arc (30-120deg)
Special tests for impingement - NEER sign, HAWKIN's test, JOB-EMPTY CAN test, GERBER-LIFT OFF test

15

Describe NEER's sign

- Start with arm at side and elbow fully extended
- Arm internally rotated with thumb touching side of leg
- Passively forward flex the arm overhead to 180deg
- Positive for impingement if pain located to the SUB-ACROMIAL SPACE or ANTERIOR EDGE of the acromion

16

Describe HAWKIN's test

- Start with shoulder forward flexed to 90deg and elbow flexed to 90deg
- Grasp patients elbow with one hand and wrist with the other
- Passively internally rotate the shoulder
- Positive for impingement if pain is located to the SUB-ACROMIAL SPACE

17

What is the treatment for subacromial impingement?

Ultrasound guided injections of steroid + local anesthetic
If intractable/disabling - consider arthroscopic subacromial debridement with partial acromionectomy

18

Describe the epidemiology of rotator cuff tears

Incidence increases with age
- Acute tears may occur in young adults
- Tears considered a normal part of the spectrum of degeneration
- Trivial injury may be sufficient to cause a tear in an elderly patient

19

Describe the biomechanics of a full thickness rotator cuff tear

- The rotator cuff stabilises the humeral head in the glenoid during movement
- The deltoid provides strength to shoulder movement but has reduced strength at full elevation
- Fulcrum stability is lost when the rotator cuff is torn - abduction relies solely on the deltoid
- Therefore there is a weakness of abduction which is clinically demonstrated with the drop arm test

20

Describe the JOBE-EMPTY CAN test

Start with the arm straight at 90deg of abduction
Rotate the arm with the thumb pointing down (internal rotation)
Examiner applies downward pressure and ask the patient to hold the position against resistance
Test is positive for impingement if pain is located in the SUBACROMIAL SPACE

21

Describe GERBER'S LIFT OFF test

For ANTERIOR IMPINGEMENT - INVOLVING SUBSCAPULARIS
Subject places hand behind small of back
Ask subject to push backwards and lift hand off back against resistance
Test positive if it produces ANTERIOR SHOULDER pain

22

Clinical presentation of a rotator cuff tear

- Pain on attempting to move the shoulder
- If full thickness - initiating active abduction is not possible
- Partial thickness tears are painfull during abduction (+ abduction is weak)
- Full passive abduction is possible

23

Describe the DROP ARM TEST

The arm is raised to 90deg abduction
Patient slowly lowers the arm

Signs of rotator cuff tear = arm drops to side quickly and not smoothly; gentle pressure to the abducted arm may force arm to give way

24

Describe the radiological findings associated with rotator cuff tears

XR - little value; major full-thickness tears may show a high-riding humeral head with little space beneath the acromion
Best demonstrated on MRI or arthrogram

25

Treatment of rotator cuff tears

Acute tears in young adults - surgically repeaired
Elderly - repair often unsuccessful due to degenerative changes

Initial treatment - non-operative
- Heat
- Analgesia
- Strengthening exercises

26

Complication of rotator cuff tear

Adhesive capsulitis (frozen shoulder)

27

What is the cause of adhesive capsulitis?

Inflammatory condition often precipitated by minor trauma
- May occur spontaneously with inactivity of the arm following a Colle's fracture, MI or stroke

28

When is adhesive capsulitis most common?

Middle age with degenerative changes of rotator cuff

29

Natural history of adhesive capsulitis

Initial phase - severe pain and decreasing movement (may last up to 9mo)
Middle phase - slow improvement in pain but persisting stiffness
Recovery phase - shoulder slowly returns to normal (up to 2 years)

30

Clinical features of adhesive capsulitis

Loss of gleno-humeral movement
Retention of the normal scapulo-thoracic range (allows up to 60deg of shoulder abduction)
Deltoid may atrophy (disuse)
Active and passive aduction limited; external rotation particularly affected

31

Describe the biomechanics of adhesive capsulitis

120deg of should abduction is lost but the scapula can still rotate on the thorax
This allows 45-60deg of abduction but no more
Rotation is lost due to intra-articular adhesions

32

Radiological findings - adhesive capsulitis

Clinical diagnosis
XR - usually normal; reduced subacromial joint space
Arthrography - loss of infraglenoid capsular redundancy

33

Treatment - adhesive capsulitis

Initial phase - analgesia (NSAIDs, steroids, steroid injections)
Encourage movement
Recovery phase - passive stretching and manipulation, hydrodilation of the shoulder, arthroscopic capsular release

34

Pathophysiology - Acute supraspinatus tendinitis

Acute inflammation causes swelling which causes impigement
Associated with deposition of amorphous calcium crystals (hydroxyapatite) in the tendon near insertion
Characterised by acute pain which interrupts sleep and may cause swelling and redness of the shoulder;
MUST EXCLUDE INFECTION
Pain settles after several days as calcium disperses and absorbs

35

Clincal presentation - acute supraspinatus tendinitis

- Swelling and inflammation
- tender over anterior rotator cuff
- painful arc beyond 30deg

36

Radiology - acute supraspinatus tendinitis

Calcium in the supraspinatus tendon adjacent to the greater tuberosity
- resolving stage - calcium disperses and resorbs

37

Treatment - acute supraspinatus tendinitis

- Rest, NSAIDs
- Infiltration of LA and steroids into subacromial bursa
- Improves rapidly with surgical removal / washout / arthroscopy
- Extracorporeal shock wave treatment

38

Complications of acute supraspinatus tendinitis

Adhesive capsulitis
Rupture of tendin in intra-tendinous injection of steroids

39

Clinical presentation - Biceps tendinitis

Tenderness over the front of the shoulder in the bicipital groove (long head of biceps in the anterior aspect of the humerus)
Speed's test positive

40

Treatment of biceps tendinitis

Injection of hydrocortisone
Physiotherapy

41

Describe SPEED'S test

Start with arm forward flexed 50deg, hand supinated
Subject then flexes elbow against resistance
Test is positive if pain occurs over BICIPTAL GROOVE

42

Clinical presentation of biceps tendon rupture

Painless swelling in the arm on contraction of the shoulder
- occurs of the anterior aspect of the long head of the biceps

43

What is commonly associated with biceps tendon rupture

Age - degenerated tendon more likely to rupture
Osteoarthritis of the shoulder

44

Treatment of biceps tendon rupture

Does not cause any appreciable disability
Treatment not required

45

Pathology associated with osteoarthritis of the shoulder

Trauma
Avascular necrosis
Impingement syndrome
Rotator cuff tears

46

XR appearance - OA of the shoulder

Osteophytes
Narrow joint space
Sclerosis
Subchondral cysts

47

What is RA of the shoulder characteristically associated with?

Subluxation
Rotator cuff tears
Impingement syndromes
Adhesive capsulitis

48

Clinical presentation - OA of the acromiclavicular joint

Tender bump over the distal clavicle with limited elevation
Positive scarf test (Apley's adduction test)

49

Describe the SCARF test

Adduct arm across front of chest to touch opposite shoulder
Raise elbow to horizontal
Pain indicates positive test for:
- AC joint if located over shoulder
- Sternoclavicular joint if located at top of sternum

50

Types of shoulder dislocation

Anterior
Posterior
Inferior (luxatio erecta)
Associated with fracture
Reccurent

51

In what situation is a ANTERIOR shoulder dislocation most likely

Abduction and extension (throwing) force
May occur with falls

52

Biomechanics - ANTERIOR shoulder dislocation

Head of humerus forced forward tearing the anterior capsule or avulsing the glenoid labrum with the head finishing just below the coracoid process

53

What is a Bankart lesion?

Detachment of the glenoid labrum associated with anterior dislocation of the shoulder

54

Clinical features - anterior dislocation of the shoulder

History of fall or throwing
Shoulder is "squared off" - flatter than normal with prominent acromion
Arm often held supported as adduction is painful
Humeral head palpable anteriorly
Sensation may be absent over the deltoid ("badge patch") if axillary nerve is damaged
ENSURE RADIAL NERVE IS PRESENT

55

Radiology - anterior dislocation of the shoulder

XR TO EXCLUDE FRACTURE
- XR - overlaping of the glenoid and humeral head, the head lying below the coracoid process

56

Management of anterior shoulder dislocation

Closed reduction
Post reduction XR of shoulder
Confirm function of axillary nerve
Hold arm immobilized in sling for 4-6w to allow capsule to heal
Physiotherapy 2-3w after reduction (avoid abduction and external rotation initially)

57

Complications of acute dislocation of the shoulder

NERVE INJURY (axillary n most commonly affected), posterior cord of the brachial plexus occasionally affected
Axillary artery injury - always check for distal ischeimia
Fracture (will require ORIF)
Adhesive capsulitis (elderly)
Secondary OA

58

Natural history of dislocation in young adults

80% recurrence rate if young athlete
Non-operative treatment is unacceptable in young adults and adolescents
Only 14% recurrence rate if >40yo

59

In what situation is POSTERIOR dislocation of the shoulder most likely?

- Forced internal rotation
- Fall onto point of shoulder
- Electrocution / epileptic seizure

60

What is posterior dislocation of the shoulder commonly associated with?

Fracture of the glenoid into the humeral head

61

XR - posterior shoulder disocation

Difficult to Dx
Suspect if overlap of head on glenoid
"Lightbulb" appearance of head of humerus (tubercles not seen)
Best seen on lateral XR

62

Rx - posterior should dislocation

Difficult to reduce
Often require open reduction

63

Recurrent shoulder dislocation is most commonly in what direction?

Anterior

64

Predisposing aetiology to recurrent should dislocation

Hill-Sach's lesion
Bankart lesion
Lax anterior capsule

65

What is a Bankart Lesion?

Anterior dislocation of the shoulder detaches the labrum from the antero-inferior margin of the glenoid
Lesion fails to heal back onto the flenoid
Allows dislocation to recur during external rotation

66

What is a Hills-Sachs lesion?

A posterior impaction fracture of the humeral head caused by impingement of the anterior glenoid margin

67

Describe the shoulder apprehension test?

The patient lies supine with the shoulder at the edge of the bed
The examiner takes the arm by the flexed elbow, abducts and extends the shoulder while externally rotating the arm
Test is positive if the patient TENSES and resists movement at the point of subluxation

68

What is the sulcus test?

The patient's arm is held at the side, the arm is pulled downwards while the examiner looks for a depression below the shoulder
Demonstration of depression / sulcus - significant CAPSULAR INSTABILITY

69

Radiological diagnosis of recurrent dislocation of the shoulder

Usually has an impaction fracture (Hill-Sachs lesion) of the posterior humeral head
MRI and arthrogram may demonstrate a Bankart lesion (detachment of the labrum from the anterior glenoid)

70

Management of recurrent dislocation of the shoulder

Surgical treatment
Defects in the capsule / labrum - repair by reattachment to the bone (BANKART repair)
Anterior joint can be reinforced by shortening the subscapularis tendon thus limiting external rotation (PUTTI-PLATT operation)

71

Describe habitual subluxation or dislocation

Common in adolescent females; commonly bilateral
Clinical evidence of generalised joint laxity
No treatment indicated

72

Common mechanism of injury leading to dislocation of the acromio-clavicular joint

Fall on the point of shoulder (commonly football)

73

Pathophysiology of dislocation of the acromio-clavicular joint

Due to tear of the capsule of ACJ and coraco-clavicular ligaments
Lateral end of clavicle displaces up from it's articulation with the acromion

74

Clinical presentation - dislocation of the acromio-clavicular joint

Prominent step or lump at end of clavicle above the acromion and point of the shoulder

75

Radiology: dislocation of the acromio-clavicular joint

XR of both shoulders while holding weights will demonstrate degree of displacement
Displacement of ACJ + widening of coraco-clavicular distance - DISLOCATION
Displacement of ACJ but no widening of coraco-clavicular distance - SUBLUXATION

76

Treatment - dislocation of the ACJ

Non-operative for subluxation
Maintain closed reduction by padding + strapping
Active individuals - surgical repair / reconstruction - reduction stabilisation of ACJ capsule + repair of coraco-clavicular ligaments

77

Common mechanism of injury - sternoclavicular dislocation

Uncommon injury; fall on the shoulder

78

Presentation of anterior sternoclavicular dislocation

Visible tender prominence of the medial end of the clavicle

79

Complications of posterior sternoclavicular dislocation

Pneumothorax
Laceration of the superior vena cava
Occlusion of the subclavian artery or vein
Disruption of the trachea

80

Where do the majority of clavicular fractures occur?

Middle 1/3

81

Complications of clavicular fracture

Brachial plexus injury
Subclavian vessel injury

82

Treatment - fractured clavicle (middle 1/3)

Supporting sling for 4-6w - may result in non-union or deformity
ORIF restores alignment and length to clavicle

83

Describe the differences in management of an outer 1/3 clavicular fracture

Fractures commonly associated with rupture of the coracoclavicular ligament
Requires ORIF

84

Common MOI - fractured neck of the humerus

Usually FOOSH
- common in elderly, osteoporosis, women

85

Describe the classification of fractured neck of the humerus

4-part system - classify according to the number of fragments
Fragments relate to anatomical parts - greater tuberosity, lesser tuberosity, epiphysis, metaphysis

86

Treatment of fractured neck of the humerus

Elderly - sling support + assisted active movements
Young - ORIF
Fracture dislocation - shoulder arthoplasty or ORIF

87

Discuss avascular necrosis and fractured neck of the humerus

Blood supply to the humeral head is via the bony tendinous attachments
4 part fractures and fractures through the anatomical neck - high risk of AVN
- best treated w prosthetic replacement

88

Complications of fractured neck of the humerus

AVN
Nerve injury
- most commonly axillary nerve
- posterior cord ot brachial plexus
Axillary artery injury (always check for distal ischemia)
Adhesive capsulitis
Secondary OA

89

Discuss Winged Scapula

Due to injury to long thoracic nerve results in paralysis of serratus anterior

Test by pushing against a wall - amplifies winging
Functionally causes a weakness in elevation

90

Discuss Sprengel's Shoulder

Uncommon congenital abnormality (associated with congenital spine deformity)
Abnormal band between superior angle of scapula and cervical spine - prevents descent of scapula during growth and limits movement

91

Discuss Thoracic Outlet Syndrome

Obstruction due to 1st rib, scalene attachment, cervical rib or coracoid process
Clinically presents as parasthesia of hand, increased sweating of hand, intrinsic muscle wasting of the hand
ADSON'S TEST - abduct arm to 30deg., feel radial pulse, subject turns head to affected side and holds breath. Positive if PULSE OBLITERATED.
May lead to gangrene of the fingers