MSK block > Shoulder Pathology > Flashcards

Shoulder Pathology Flashcards

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1
Q

What joint attaches the upper humerus to the shoulder girdle?

What type of joint is this?

A

Glenohumeral Joint - ball and socket

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2
Q

List 3 features of the GH joint which provide stability?

A

Bony Congruence
Ligaments
Rotator Cuff and other muscles

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3
Q

Static restraint of the shoulder joint is provided by what 4 things?

A
  1. Articular Anatomy
  2. Labrum
  3. Negative intra-articular pressure
  4. Glenohumeral ligaments
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4
Q

Dynamic restraint of the shoulder joint is provided by what 2 things?

A
  1. Joint Compression
  2. Steering effect of cuff muscles
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5
Q

List the ligaments of the GH joint

A
  1. Glenohumeral (superior, middle, inferior)
  2. Coracohumeral
  3. Coracoclavicular
  4. Coracoacromial
  5. Transverse Humeral
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6
Q

What is the purpose of the glenoid labrum and joint capsule?

A

Labrum – Increases surface area, stability

Capsule – Support, boundary layer

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7
Q

What is the purpose of the rotator cuff muscles?

List/lable these on the image below

A

Purpose is to depress and stabilise humeral head against glenoid

Supraspinatus, Infraspinatus, Subscapularis, Teres Minor

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8
Q

List the following regarding the Supraspinatus:

  • origin
  • insertion
  • action
  • innervation
A
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9
Q

List the following regarding the Infraspinatus:

  • origin
  • insertion
  • action
  • innervation
A
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10
Q

List the following regarding the Subscapularis:

  • origin
  • insertion
  • action
  • innervation
A
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11
Q

List the following regarding the Teres Minor:

  • origin
  • insertion
  • action
  • innervation
A
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12
Q

State the following regarding ‘other muscles’

  • 5 muscles which connect scapula to spine?
  • 4 muscles which connect upper limb to thoracic wall?
  • 6 muscles act on shoulder joint itself
A
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13
Q

Revise ‘look, feel, move’ for an shoulder examination

A
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14
Q

List 4 differentials for shoulder pain

A
  1. Dislocation
  2. Fractures
  3. Acromio-clavicular OA
  4. Cervical Radiculitis
  5. Suprascapular nerve entraptment
  6. Tendinitis
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15
Q

List 3 features which may indicate vascular damage in a shoulder injury

A
  1. absent pulses
  2. prolonged capillary refill time
  3. pallor
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16
Q

How do we test the Supraspinatus?

Ie. for Supraspinatus tendinopathy

A

Jobe’s test (empty can test) ➞ arm abducted to 20, in the plane of the scapula, thumb pointing down

Neer test (full can test)

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17
Q

How do we test the Deltoid muscle?

A

Resisted abduction at 90o

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18
Q

How do we test the Infraspinatus muscle?

A

Resisted External Rotation

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19
Q

How do we test the Subscapularis muscle? (2)

A
  1. Gerber’s Lift of test
  2. Resisted Internal Rotation
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20
Q

How do we test the Long Head of Biceps?

Rupture of the LHB tendon will show what deformity?

A

Resisted elbow flexion – ‘popeye’ sign

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21
Q

What is Hawkin’s test and how is it performed?

A

Test to identify subacromial impingement syndrome

Flexion to 90o + internal rotation will cause pain

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22
Q

What is the scarf test used to test

How is it performed?

A

Test for ACJ pathologies ie. AC joint arthritis

Forced cross body adduction in 90o flexion (+) pain at the extreme of motion

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23
Q

What is the Sulcus Test?

A

To assess the GH joint for inferior instability

(+) = sulcus sign, when downward force applied to arm by patients side in neutral rotation

Sulcus = hollow under acromion

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24
Q

What is the Apprehension test and how is it performed?

A

To assess for shoulder instability, specifically in the anterior direction

  • Shoulder abducted to 90o, elbow flexed to 90o
  • Slow ER of the shoulder
  • (+) test → At ~ 90o of ER, patient is anxious/apprehensive that shoulder will dislocate (no a/w pain)
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25
When may the apprehension test be positive?
After previous anterior dislocation or subluxation of the shoulder Test may be performed after recovery from any acute injuries
26
What is the Jobe Relocation Test and how is it performed?
Also known as the ‘Fowler Sign’ - used to test for anterior instability of the GH joint * Shoulder abducted to 90o, elbow flexed to 90o, Slow ER of the shoulder, patient apprehensive = (+) apprehension test * At this point, a posterior force is applied to shoulder * If apprehension is reduced = (+) Jobes
27
What 3 views of the shoulder are shown on the MRI below?
28
What may be done for diagnostic and/or therapeutic intervention for shoulder problems?
Shoulder Arthroscopy
29
List 4 complications of Shoulder Arthroscopy
1. fluid extravasation 2. articular cartilage damage 3. infection 4. musculocutaneous nerve palsy
30
What is arthritis of the GH joint? List 4 causes
Destruction articular surface of GH joint resulting in pain and loss of motion Causes: RA, OA, Post traumatic, Cuff Arthropathy, AVN
31
Compare the x-ray of RA vs OA
RA: significanrt errosion of the bone of the glenoid and loss of joint space OA: loss of joint space, sclerosis, osteophytes, cysts
32
Arthroplasty indication for shoulder arthritis? What are the 2 types and explain each?
Indication ➞ pain Hemiarthroplasty ➞ replace humeral head, glenoid remains TSR ➞ Controversy due to problems with glenoid loosening
33
Pathology of Subacromial impingement
Abrasion of the rotator cuff due to narrowing of the bony tunnel through which the tendon passes Image shows how morphological changes in anterior aspect of the acromion can predispose an individual to impingement
34
What is the typical Presentation of impingement? (4)
* 40-50 years * Pain over greater tuberosity * Difficulty sleeping on affected side * Painful arc of abduction 60-120 degrees
35
What X-ray sign may be seen in Impingement?
Sourcil Sign - sclerosis on undersurface of acromion
36
List and explain 2 conservative managements for Impingement
1. Subacromial injection: * steroid and local anaesthetic * reducing inflammation * repeat up to 3 injections in total 2. Physiotherapy * strengthening exercises to rotator cuff * theraband * centering of the head, reducing impingement
37
When is surgery recommended for Impingement? What is the procedure
Failure to respond to conservative measures despite an improvement immediately after subacromial injection Procedure: Sub acromial decompression
38
What is Arthroscopic subacromial decompression?
Shave off attachment of coracoacromial ligament , burr down anterior margin acromion (80% success)
39
Incidence of Rotator Cuff Tears increase with what?
Age - over 80 =70%
40
Management of Rotator cuff tears
1. Conservative – Physio, NSAIDS, Injection 2. Acromioplasty 3. Cuff Repair – open vs arthroscopic 4. Shoulder Hemiarthroplasty
41
What is meant by cuff tear arthropathy?
Arthritis secondary to patients with chronic rotator cuff pathology Commonly affects patients 70-80 yrs
42
List 2 X-ray changes associated with cuff tear arthropathy
1. Subluxation of humerus superiorly 2. Glenoid arthritis - arthritic humeral head articulating with acromion
43
Calcific Tendonitis usually involves the _______ muscle and is often associated with \_\_\_\_\_\_\_
supraspinatus, tendon degeneration
44
How does Calcific Tendonitis present?
Severe **crescendo pain** in shoulder with **spontaneous onset**
45
What X-ray change is seen in Calcific Tendonitis
Characteristic calcification within tendon
46
Management of Calcific Tendonitis
1. Physio 2. Corticosteriod Injections 3. Operative decompression
47
Adhesive Capsulitis is also known as what? What age and gender is most commonly affected?
Known as Frozen Shoulder Age 56 years, F=M
48
Main risk factor for adhesive capsulitis?
**Diabetics** + Dupuytrens, minor trauma, epileptics
49
What are the 3 phases of symptoms in adhesive capsulitis?
PAINFUL ➞ gradual onset diffuse pain STIFF ➞ stiffness and decreased ROM (ER most affected) THAWING ➞ gradual improvement of motion
50
Pathophysiology of Adhesive Capsulitis
Fibromatosis * Inflammation and fibrosis in joint capsule lead to adhesions * These bind the capsule and cause contracture of the CH ligament * Restricts movement in the joint
51
How long does adhesive capsulitis take to resolve?
Entire illness lasts 1-3 years (~6 months in each phase) However, a large number of patients have persistent symptoms
52
Diagnosis of Adhesive capsulitis?
Clinical diagnosis, based on history, exam and excluding other ddx X-rays are usually normal, but useful to rule out ddx ie. osteoarthritis
53
Non-surgical management of adhesive capsulitis
1. Analgesia (eg. NSAIDs) 2. Physiotherapy 3. Intra-articular steroid injections 4. Hydrodilation (injecting fluid into joint to stretch the capsule)
54
Surgical management of adhesive capsulitis
For resistant or severe cases, options are: 1. MUA 2. Arthroscopy
55
How does a shoulder dislocation present?
1. Present after an acute injury 2. Arm held at the side of their body 3. Flattened deltoid 4. Bulging at the head of the humerus, which is palpable at the front of the shoulder
56
In which direction is shoulder dislocation most common?
Anterior Dislocation (95%)
57
Mechanism of an anterior shoulder dislocation?
Force applied to an ER +/- Hyperextension in abducted arm
58
What fracture is often associated with an anterior shoulder dislocation?
Greater tuberosity fracture
59
What nerve damage is commonly associated with anterior dislocations? How does this present?
Axillary nerve (C5-C6) * loss of sensation over “regimental badge” area * motor weakness in the deltoid and teres minor
60
Mechanism of a posterior shoulder dislocation?
Indirect force to flexed, adducted & IR arm
61
Posterior shoulder dislocations are associated with what 2 things?
electric shocks and seizures
62
What fracture is often associated with a posterior shoulder dislocation?
lesser tuberosity fracture
63
Investigation in the acute in presentation to confirm a dislocation and exclude fractures?
X-ray Not always required before reduction, depends on clinical findings and fracture risk
64
Acute management of a shoulder dislocation?
1. Analgesia, muscle relaxants and sedation 2. Broad arm sling to support the arm 3. Closed reduction (after excl fracture) 4. If a/w a fracture, may require surgery 5. Post-reduction x-rays 6. Immobilisation
65
What does **TUBS** and **AMBRI** stand for?
TUBS ➞ Traumatic Unilateral Bankart lesion often require Surgery (‘Torn Loose’) AMBRI ➞ Atraumatic Multidirectional Bilateral Rehabilitation (sometimes Inferior capsular shift (‘Born Loose’))
66
Ongoing management for shoulder instability or following dislocation?
1. Physiotherapy (minimum one year before considering surgery) 2. Consider shoulder stabilisation surgery
67
List 4 injuries/damage associated with a shoulder dislocation
1. Bankart lesion 2. Hill-Sachs lesions 3. Fractures (humeral head, greater/lesser tuberosity, acromion, clavicle) 4. Axillary nerve damage
68
What is a Bankart Lesion? Treatment?
Detachment of anterior labrum from glenoid Treatment ➞ arthroscopic reattachment
69
What is a Hill Sachs Lesion?
Osteochondral depression fracture ➞ Infra-spinatus inserted into defect Makes shoulder less stable and at risk of further dislocations
70
Imaging to diagnose Bankart and/or Hill-Sachs lesions?
**Magnetic resonance arthrography** An MRI with a contrast injected into the shoulder joint
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