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Trauma + Orthopaedics > 2: Joint Disorders Of The Shoulder > Flashcards

2: Joint Disorders Of The Shoulder Flashcards

1
Q

How may impingement syndrome present

A

pain on abduction of the shoulder

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2
Q

What is a sign of impingement syndrome

A

‘painful arc’: pain on abduction of the arm from 60-120’

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3
Q

Which is the most common rotator cuff to tear

A

supraspinatus

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4
Q

How will supraspinatus tear present

A

pain over the deltoid region particularly on over-head activities

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5
Q

How will adhesive capsulitis present

A

restricted range of movement in all directions

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6
Q

which movement is particularly worse in adhesive capsulitis

A

external rotation

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7
Q

how will glenohumeral OA present

A

pain on activity, waking pain at night

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8
Q

how will acromioclavicular OA present

A

pain on raising arms above the head

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9
Q

how will biceps tendinopathy present

A

anterior shoulder pain worse on bicep contraction

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10
Q

what is the most common cause of shoulder problems

A

rotator cuff injury

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11
Q

explain the ‘spectrum of rotator cuff injury’

A
  1. Impingement syndrome
  2. Calcific tendonitis
  3. Rotator cuff tear
  4. Rotator cuff arthropathy
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12
Q

how can rotator cuff tears be classified

A

Partial thickness or full thickness

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13
Q

what is a full-thickness tear

A

When the rotator cuff is separated from the humerus

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14
Q

what is a partial thickness tear

A

Tear within the rotator cuff, remains attached to the humerus

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15
Q

which rotator cuff is most commonly affected

A

Supraspinatus

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16
Q

what causes an acute rotator cuff tear

A

Violent stretching of tendons

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17
Q

what causes a chronic rotator cuff tear

A

‘Wear and tear’ of the rotator cuffs over time

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18
Q

explain the pathophysiology of chronic rotator cuff tears

A

On ageing, blood supply to the rotator cuff muscle decreases. This means they are less adapted to heal from injury leading to progressive damage.

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19
Q

in which population are chronic rotator cuff tears more common

A

Elderly.

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20
Q

what causes impingement

A

When there is a bony spur from the acromion than impinges the rotator cuff tendons during abduction

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21
Q

How will an acute rotator cuff tear present

A
  • Acute + intense pain over the deltoid region.
  • Night pain
  • Pain is exacerbated by overhead movements
  • Shoulder weakness (abduction and rotation)
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22
Q

How may a chronic rotator cuff tear present

A

Pain may be absent or only when lifting shoulder overhead

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23
Q

When should a rotator cuff injury be suspected in >50y

A

Pain or Loss Of Function, following low energy trauma

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24
Q

When should a rotator cuff injury be suspected in <50y

A

Pain following high-energy trauma

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25
Q

What test is used to identify supraspinatus damage

A

Jobe’s test

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26
Q

Explain Jobe’s test

A

Patient abducts arm to 70’ and internally rotates (thumb is downwards). Then tries to resist force pushing arm downwards.

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27
Q

If a patient exhibits pain on Jobe’s test what does it indicate

A

Supraspinatus tendonitis

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28
Q

If a patient exhibits weakness on Jobe’s test what does it indicate

A

Supraspinatus tear

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29
Q

How is infraspinatus pathology tested for

A

External rotation against resistance

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30
Q

What does pain on testing infraspinatus indicate

A

Infraspinatus tendonitis

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31
Q

What does weakness on testing infraspinatus indicate

A

Infraspinatus tear

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32
Q

How is teres minor tested for

A

External rotation against resistance

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33
Q

How is subscapularis tested for

A

Gerber’s lift off test

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34
Q

What does weakness in ‘Gerber lift off’ test indicate

A

Subscapularis tear

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35
Q

What are the 4 rotator cuff muscles

A
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis
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36
Q

What is the action of the supraspinatus muscle

A

It abducts the arm to 15’ before the deltoid takes over

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37
Q

Where does supraspinatus insert

A

greater tubercle of the humerus

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38
Q

What is the action of infraspinatus

A

external rotation

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39
Q

Where does infraspinatus insert

A

greater tubercle of the humerus

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40
Q

What is the action of teres minor

A

external rotation

adduction

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41
Q

Where does teres minor insert

A

greater tubercle of the humerus

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42
Q

What is the action of subscapularis

A

internal rotation

adduction

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43
Q

Where does subscapularis insert

A

lesser tubercle of the humerus

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44
Q

Which rotator cuff muscles is responsible for external rotation

A
  • Infraspinatus

- Teres minor

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45
Q

Which rotator cuff muscles adduct the arm

A
  • Subscapularis
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46
Q

Which rotator cuff muscle is responsible for internal rotation

A

subscapularis

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47
Q

Which rotator cuff muscle abducts the arm to 15’

A

supraspinatus

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48
Q

Which rotator cuff muscle inserts on the lesser tubercle of the humerus

A

teres minor

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49
Q

Which rotator cuff muscle inserts on the greater tubercle of the humerus

A

supraspinatus
infraspinatus
teres minor

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50
Q

What is the function of all the rotator cuffs together

A

provide dynamic stability to the shoulder

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51
Q

what investigations may be ordered in a suspected rotator cuff tear

A
  • USS
  • X-Ray
  • MRI
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52
Q

how will a rotator cuff tear present on x-ray

A
  • There may be migration of the humeral head superiorly due to unopposed action of the deltoid
  • may be evidence of secondary arthritis (rotator cuff arthropathy)
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53
Q

what can USS show

A

whether a partial or full thickness tear

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54
Q

what is the best imaging modality used to identify rotator cuff tears

A

MRI

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55
Q

what is first-line management for rotator cuff tears

A

conservative

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56
Q

what is involved in conservative management of rotator cuff tears

A
  • Physiotherapy
  • NSAIDs
  • Rest
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57
Q

what is second-line management for rotator cuff tears

A

Surgery

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58
Q

what surgery is indicated for partial-thickness rotator cuff tears

A

arthroscopic subacromial decompression (SAD)

59
Q

what surgery is indicated for full thickness tears

A

arthroscopic re-attachment of the rotator cuffs to the greater tubercle

60
Q

What is impingement syndrome

A
  • Impingement of rotator cuff tendons in the subacromial space usually caused by inflammation of the supraspinatus
61
Q

How will impingement syndrome present in severe cases

A
  • calcification of the tendons (termed subacromial bursitis)
62
Q

If there is tendon calcification what is it called

A

subacromial bursitis

63
Q

Explain the continuum of rotator cuff pathology

A
  1. Impingement syndrome
  2. Calcific tendonitis
  3. Rotator cuff tear
  4. Rotator cuff arthropathy
64
Q

what age is the peak incidence of rotator cuff pathology

A

40-60y

65
Q

how will shoulder impingement present

A
  • pain on shoulder abduction
  • lateral aspect of the arm and can radiate to the shoulder
  • sleep disturbance
66
Q

what are two signs of impingement syndrome

A
  • Painful arc

- Positive Jobe’s test (if supraspinatus)

67
Q

explain the painful arc

A

There is pain on shoulder abduction between 60-120’

68
Q

explain Jobe’s test

A

Individual abducts and internally rotates the arm to 70’. They must then resist downwards force

69
Q

what is calcific tendonitis

A

calcification of the supraspinatus tendon - which presents as acute onset impingement syndrome

70
Q

how many views should an x-ray of impingement syndrome be taken in

A

3 views (as rotator cuff disease may present as sclerosis on under-side of the acromion)

71
Q

what is the main imaging modality used to view impingement syndrome

A

MRI

72
Q

what is first-line management of impingement syndrome

A

Conservative:

  • NSAIDs
  • Rest
  • Physiotherapy
73
Q

what is second-line management of impingement syndrome

A

Arthroscopic Subacromial Decompression (SAD)

74
Q

what is a complication of impingement syndrome

A
  • Rotator cuff tears

- Rotator cuff arthropathy

75
Q

What is the sub-acromial bursa

A

Bursa that separates supraspinatus tendon from coraco-acromio ligament, acromion and coracoid

76
Q

What is subacromial bursitis

A

Inflammation of the bursa which separates superior aspect of the supraspinatus tendon form the coracoacromio ligament, acromion and coracoid

77
Q

How will subacromial bursitis present

A

Symptoms similar to impingement syndrome: pain on abduction, particularly over-head activities, unable to lie on the affected side

78
Q

What is the physiological action of the subacromial bursa

A

Helps motion of supraspinatus over rotator cuffs in over-head action

79
Q

What is adhesive capsulitis also referred to as

A

Frozen capsulitis

80
Q

What is adhesive capsulitis

A

Inflammation and fibrosis of the shoulder joint capsule resulting in contracture at the shoulder joint

81
Q

In which population is adhesive capsulitis more common

A

Middle-aged females

82
Q

What condition is a risk factor for adhesive capsulitis

A

Diabetes

83
Q

What proportion of diabetics will have an episode of adhesive capsulitis

A

20%

84
Q

If someone presents with adhesive capsulitis what should be done and why

A

Fasting blood glucose - to check for + exclude diabetes

85
Q

What are two other risk factors for frozen shoulder

A

Thyroid disease

Cervical spondylosis

86
Q

How will cervical spondylosis present

A

Global restriction of all movement

87
Q

How is the clinical presentation of frozen shoulder divided

A

Into three phases

88
Q

What are the three stages of frozen shoulder

A
  1. Painful phase
  2. Frozen phase
  3. Resolving phase
89
Q

How long is the painful phase

A

1y

90
Q

How will the painful phase present

A
  • Restricted movement in all directions (active = passive)
  • Reduced external rotation
  • Pain on movement
91
Q

What action is most affected in adhesive capsulitis

A
  • external rotation
92
Q

What is stage 2 of adhesive capsulitis

A

frozen (adhesive phase)

93
Q

How long is the ‘frozen’ phase

A

6-12m

94
Q

How will the ‘frozen’ stage presents

A

pain disappears but stiffness remains

95
Q

What is the third phase

A

recovery phase

96
Q

How long is recovery phase

A

1-3y

97
Q

What happens in recovery phase

A

shoulder slowly starts to regain movement

98
Q

Explain the ‘overall’ clinical presentation of adhesive capsulitis

A

there is restricted movement (active = passive). External rotation is particularly affected.
Dull shoulder pain

99
Q

How is adhesive capsulitis diagnosed

A

clinically

100
Q

What may be performed if a patient presents with adhesive capsulitis and why

A

Fasting Blood Glucose - due to high probability of diabetes

TFTs - due to risk of thyroid disease

101
Q

What is first-line management of adhesive capsulitis

A

Conservative

102
Q

what does conservative management entail

A
  • NSAIDs
  • Physiotherapy
  • Corticosteroid injections (helps in the early phases)
103
Q

what is second-line management of adhesive capsulitis

A

Surgical release

104
Q

what two surgeries can be offered

A
  • manipulation under anaesthesia

- arthroscopic arthrolysis

105
Q

what is glenohumeral osteoarthritis

A

damage to articular surface of the glenohumeral joint

106
Q

how does the incidence of glenohumeral OA change with age

A

increases with age

107
Q

in which gender is glenohumeral OA more prevalent

A

females

108
Q

what are 5 causes of glenohumeral OA

A
  • Primary OA
  • Secondary OA
  • Rotator cuff OA
  • Anterior shoulder dislocation
  • Traumatic
109
Q

how will glenohumeral OA present clinically

A
  • Shoulder pain on activity
  • Unable to lie on affected side
  • Reduced range of movement
110
Q

what is primary OA

A

Irreversible loss of articular cartilage causing hypertrophy of the underlying bone

111
Q

explain rotator cuff arthropathy

A

Tears in the rotator cuff cause migration of the humeral head which results in abrasions against the glenoid fossa leading to secondary OA

112
Q

when can glenohumeral OA be diagnosed clinically

A

If all 3 criteria are met:

  1. > 45y
  2. Pain on activity
  3. No morning stiffness, or morning stiffness <30m
113
Q

If not diagnosed clinically, what is first line investigation for OA

A

X-Ray

114
Q

What findings can be seen on x-ray in glenohumeral OA

A

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

115
Q

What is the mnemonic to remember first line management of glenohumeral OA

A

WETT

116
Q

What is first line management of glenohumeral OA

A

Weight loss
Exercise + manual therapy
TENS
Thermotherapy

117
Q

What is second line management of glenohumeral OA

A

Paracetamol PO
Topical NSAIDs

Short-course NSAIDs PO w/PPI

118
Q

What is third-line management of glenohumeral OA

A

Intra-articular corticosteroid injections

119
Q

What is fourth-line glenohumeral OA

A

Surgery

120
Q

What 4 surgeries can be performed for glenohumeral OA

A
  1. Total shoulder arthroplasty
  2. Reverse total shoulder arthroplasty
  3. Hemiarthroplasty
  4. Arthroscopic debridement
121
Q

what are the indications of a total shoulder arthroplasty (TSA)

A
  • Significant OA not able to be managed conservatively

- Rotator cuff muscles are intact

122
Q

describe what happens in total shoulder arthroplasty (TSA)

A

The humeral head is replaced by a metal ball and glenoid fossa by a socket

123
Q

when is a reverse total shoulder arthroplasty indicated and why

A
  • large rotator cuff tear
  • rotator cuff arthropathy

= as the total shoulder replacement relies on rotator cuff muscles for stability. Whereas, reverse total shoulder replacement relies on the deltoid.

124
Q

explain a reverse total shoulder arthroplasty

A

the glenoid fossa is replaced with a metal ball and humeral head with socket

125
Q

what is a hemiarthroplasty

A
  • humeral head is replaced

- glenoid fossa is native but undergoes biological resurfacing

126
Q

when is hemiarthroplasty indicated

A
  • younger patient

- Rheumatoid arthritis

127
Q

when is arthroscopic debridement indicated

A

mild-moderate OA

128
Q

what is the most common condition affecting the acromioclavicular joint

A

acromioclavicular OA

129
Q

what causes AC OA

A

Transmission of a large axial load through a small contact area. Caused by:

  • trauma
  • post-traumatic
  • over-head activities
130
Q

how will acromioclavicular OA present clinically

A

pain on raising the arms: overhead activities and abduction

131
Q

when can AC OA be diagnosed clinically

A

If all 3 criteria are met:

  1. > 45y
  2. Pain on activity
  3. No morning stiffness. Or, morning stiffness less than 30m.
132
Q

what are the x-ray findings of AC OA

A

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

133
Q

what is first line management for AC OA

A 
Conservative (WETT)
Weight loss 
Exercise + manual therapy 
Thermotherapy 
TENS
134
Q

what is second-line management for AC OA

A

Analgesia

135
Q

what is third-line management for AC OA

A

Intra-articular corticosteroids

136
Q

what procedure is offered for AC OA

A

Mumford procedure

137
Q

What is a Mumford procedure

A

Arthroscopic (or open) distal clavicle resection

138
Q

What is biceps tendinopathy

A

Inflammation of the tendon of long-head of the biceps

139
Q

In which age-groups is biceps tendonopathy more common

A
  • > 65y

- young athletic patients with sudden over-use

140
Q

How will biceps tendonopathy present clinically

A
  • anterior shoulder pain

- pain exacerbated by forced contraction of the biceps

141
Q

What test is positive in biceps tendinopathy

A

Speed’s test

142
Q

What is speed’s test

A

Patient supinates their arm and tries to flex against 60’ of resistance

143
Q

How is biceps tendinopathy management

A

NSAIDs

Corticosteroids

144
Q

What is the risk with corticosteroid injections

A

Increases risk of rupture

Trauma + Orthopaedics (11 decks)

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