The Shoulder Flashcards by Iona Brett

How common are clavicle fractures, who do they affect?

3% all fractures

Adolescents & young adults
Second peak 60yrs - osteoporosis

How well did you know this?

Not at all

Perfectly

Allman classification system for clavicle fractures

Type 1 - middle 1/3rd 75%
Significant deformity

Type 2 - lateral 1/3 20% 
Often unstable (displace inferiorly)

Type 3 - medial 1/3 5%
Multi-system polytrauma
Mediastinum behind - neurovascular/ pneumothorax/ haemothorax
(Displace superiorly)

How well did you know this?

Not at all

Perfectly

Investigations & management of clavicular fractures

Plain film anteroposterior & modified- axial radiographs

Most conservatively >90% unite
✅sling until pain free movement
✅early movement of shoulder prevent frozen
Healing time 4-6wks

Surgery (open/ v comminuted/ v shortened/ bilateral)

Failed to unite - ORIF 2-3months post injury

How well did you know this?

Not at all

Perfectly

Classification of rotator cuff tears

Common 20%, 40-70yrs

Classification:
Acute <3mths (tendons pre-existing degeneration)
Chronic >3mths (degenerative microtears tendon, older)
Partial thickness
Full thickness: small <1cm, medium 1-3cm, large 3-5cm, massive >5cm/ involving multiple tendons

How well did you know this?

Not at all

Perfectly

What are the 4 rotator cuff muscles?

Supraspinatous - abduction
Infraspinatous - ER
Teres minor - ER
Subscapularis - IR

Also stabilise humeral head in glenoid fossa

How well did you know this?

Not at all

Perfectly

Features of rotator cuff tears & the three specific tests

Pain lateral shoulder
Inability abduct arm >90d
Tenderness greater tuberosity
Supraspinatous/ infraspinatous atrophy

Jobe’s test (supraspinatous)
Shoulder 90d abduction 30d forward flexion & IR fully -> push down arm
➕weakness on resistance
Gerber’s lift off test (infraspinatous & teres minor)
IR dorsal hands on lower back -> lift hand away against resistance
➕weakness actively lifting hand away
posterior cuff test (infraspinatous & teres minor)
Arm at side elbow flexed 90d, ER against resistance
➕weakness

How well did you know this?

Not at all

Perfectly

Investigations for rotator cuff tears

Urgent plain film radiograph exclude fracture - most unremarkable - chronic May reduced acromiohumeral distance/ sclerosis/ cyst

Ultrasonography presence & size

MRI size/ characteristics/ location

How well did you know this?

Not at all

Perfectly

Management of rotator cuff tears

Depends type of tear & functional status

Conservative (not limited pain/ LOF, not fit surgery):
Within 2 wks- analgesia + physiotherapy + corticosteroid injections subacromial space

Surgery:
Arthroscopically or open

How well did you know this?

Not at all

Perfectly

What’s the main complication of rotator cuff tears?

Adhesive capsulitis -> stiffness glenohumeral joint

40% age related tears enlargement within 5yrs (80% symptomatic)

How well did you know this?

Not at all

Perfectly

What is the most common type of shoulder dislocation? How does it occur?

Anteroinferior 95% - force applied to extended abducted ER humerus

(Posterior - seizures/ electrocution, direct blow anterior)

How well did you know this?

Not at all

Perfectly

What are some associated shoulder dislocation injuries?

Bony
- bony bankart lesions (fractures anterior inferior glenoid bone)
- Hill-Sachs defects
(Impaction injuries chondral surface posterior/ superior humeral head)
- fractures greater tuberosity/ surgical neck

Labral, ligamentous & rotator cuff

bankart lesions (avulsion anterior labrum & inferior glenohumeral ligament)
glenohumeral ligament avulsion
rotator cuff injuries

How well did you know this?

Not at all

Perfectly

Investigations for shoulder dislocation

Plain radiographs - trauma shoulder series: anterior-posterior, Y scapular, axial

Anterior dislocations: anterior-posterior film humeral head out of glenoid fossa

Posterior: light bulb sign humerus fixed IR

MRI - labral/ RC injury

How well did you know this?

Not at all

Perfectly

Management of shoulder dislocations

A-E trauma assessment - stabilise - examine other injuries - analgesia

reduce - immobilise - rehabilitate

Broad arm sling 2wks

Physiotherapy

How well did you know this?

Not at all

Perfectly

Which peripheral N is most at risk from anterior shoulder dislocations?

Axillary

How well did you know this?

Not at all

Perfectly

Who most often gets humeral shaft fractures? What are the clinical features?

Bimodal: younger (high energy trauma), elderly (low impact)

Pain & deformity
FOOSH/ fall laterally

RN involved (10%) - reduced sensation dorsal 1st webspace & weakness wrist extension

How well did you know this?

Not at all

Perfectly

What is a Holstein-Lewis fracture?

Study These Flashcards

Fracture distal 1/3rd humerus -> entrapment RN -> neuropraxia -> loss sensation radial distribution & wrist drop

☑️surgery

Investigations & management for humeral shaft fractures

Study These Flashcards

AP & lateral plain film radiographs

Severely comminuted - CT May

Re-alignment
✔️majority conservatively - functional humeral brace -> repeated plain film imaging regularly
90% full union 8-12wks

Surgical:
Fixation minority - open reduction & internal fixation with plate
Intamedullary nailing - pathological features, polytrauma or severely osteoporotic

What is biceps tendinopathy?

Study These Flashcards

Tendinopathy - encompasses variety pathological changes that occur in tendons typically from overuse (younger repetitive, older degenerative) -> painful, swollen weaker tendon - risk rupture

Clinical features of biceps tendinopathy including 2 specific tests

Study These Flashcards

Pain, worse with stressing the tendon (alleviated rest/ ice)

Weakness

Stiffness

Tenderness over tendon

Disuse atrophy

speed test (proximal biceps tendon)
Stands elbows extended, forearms supinated, forward flex shoulders against resistance
Yergason’s test (distal)
Stands elbows flexed 90d, forearm pronated -> actively supinate against resistance

Investigations & management of biceps tendinopathy

Study These Flashcards

Largely clinical - further tests if unsure

Exclude differentials:

blood tests (FBC, CRP)
plain film radiograph

Rarely:
USS - thickened tendons
MRI - thickened inflamed tendons

✅ conservative - nearly all - analgesia (NSAIDs), ice, physiotherapy

✅USS steroid injections - conservative doesn’t work

✅surgery - rare 
Arthroscopic tenodesis (tendon severed &amp; reattached) 
Tenotomy (division tendon)

What are chronic cases of biceps tendinopathy at increased risk of? What are the clinical features including a test?

Study These Flashcards

Biceps tendon rupture

Complete or partial
Sudden forced extension of flexed elbow

RFs: steroids, smoking, CKD, fluroquinolones

Sudden onset pain & weakness - pop on incident - swelling & brusing antecubitical fossa - bulge (reverse popeye sign)

Hook test (distal rupture):
Elbow flexed 90d supinated- examiner hooks index finger under lateral edge biceps tendon 
➕can’t be done

Investigations & management of biceps tendon rupture

Study These Flashcards

Diagnosed clinically, confirmation usually - USS -> if unclear MRI

Management:

conservative (analgesia, physiotherapy) low demand pts
operative (anterior single incision or dual incision -> form bone tunnel radius & re-insert tendon)
longer few weeks initial injury - reconstruction tendon allograft

What is the real term for frozen shoulder & what is it?

Study These Flashcards

Adhesive capsulitis
Glenohumeral joint capsule -> contracted & adherent to humeral head -> shoulder pain & reduced range of movement

3% population
Wm, 40-70yrs

Pathophysiology of frozen shoulder

Study These Flashcards

Primary (idiopathic)

Secondary:
Associated rotator cuff tendinopathy, subacromial impingement syndrome, biceps tendinopathy, surgical intervention, trauma, inflammatory conditions, DM
May autoimmune element

Progresses 3 stages:
Initial painful
Freezing
Thawing

Features of frozen shoulder

Generalised deep, constant pain shoulder Often disturbs sleep Stiffness Reduction function Loss arm swing Atrophy deltoid Generalised tenderness Limited range ER, flexion Differentials: Acromiclavicular pathology, subacromial impingement syndrome, muscular tear, AI disease

Investigations & management of frozen shoulder

Clinical Plain radiographs - unremarkable (rule out acriomioclavicular pathology & atypical fractures) MRI - thickening glenohumeral joint or rule out subacromial impingement syndrome & plain radiographs HBA1c blood glucose useful DM/ glucose intolerance ``` Management: Self-limiting: months-yrs Education - active, physiotherapy Paracetamol/ NSAIDs 1st Glenohumeral injections Oral corticosteroids ``` Surgical (no improvement 3months conservative or significant symptoms) Joint manipulation GA - remove adhesions, arthrogaphic distension or surgical release

What is subacromial impingement syndrome?

SAIS Inflammation & irritation of rotator cuff tendons as pass through subacromial space -> pain, weakness, reduced range motion Encompasses: rotator cuff tendinosis, subacromial bursitis, calcific tendinitis -> attrition coracoacromial arch & supraspinatous tendon or subacromial bursa <25yrs, active/ manual professions, 60% all shoulder presentations (most common)

Where is the subacromial space? What does it contain?

Below the coracoacromial arch (acromion, coracoacromial ligament, coracoacromial process) Above humeral head Contents: Rotator cuff tendons, long head biceps tendon, coracoacromial ligament Surrounded by subacromial bursa

Pathophysiology of subacromial impingement syndrome

``` Intrinsic mechanisms: (Pathologies rotator cuff tendons due tension) - muscular weakness - overuse - degenerative tendinopathy ``` Extrinsic mechanisms (pathology rotator cuff tendons due external compression): - Anatomical factors - scapular musculature (reduction in function) - glenohumeral instability

Investigations for subacromial impingement syndrome

Clinical confirmed - MRI (subacromial osteophytes, sclerosis, subacromial bursitis, humeral cystic changes, narrowing subacromial space) Management - conservative mainstay - analgesia, physiotherapy, exercises - corticosteroid injections Resolves 60-90% pts Surgical (>6mths without response) - repair muscular tears - removal subacromial bursa - removal section acromion

Clinical features of subacromial impingement syndrome including two tests

``` Progressive pain anti error superior shoulder Exacerbated abduction Relieved rest Weakness Stiffness ``` Neers impingement test - Arm by side IR then flexed passively ➕pain anterolateral aspect Hawkins test - Shoulder & elbow flexed 90d then passively IR ➕ pain anterolateral

The Shoulder Flashcards

(31 cards)