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Clinical-Shoulder
Organisation of the Body
| Question | Answer |
|---|---|
| What bones form the pectoral girdle | Clavicle Scapular |
| Scapular | Posterior border of shoulder girdle Connects axial and appendicular skeletons Assists optimal movement of glenohumeral joint Site of attachment for 17 muscles which function across multiple joint |
| Clavicle | Sternoclavicular joint - saddle synovial Acromio-clavicular joint-plane synovial Attached to coracoid process by coraco-clavicular ligament Attached to 1st costal cartilage by costo-clavicular ligament Attached to sternum by sternoclavicular ligaments |
| Sterno-clavicular dislocation | Anterior is most common Direct - force applied to the medial aspect of clavicle forces it posteriorly (car accident or athletes falling on each other) Indirect - force applied to the shoulder and is transmitted medially (fall on outstretched arm) |
| Treatment for sterno-clavicular dislocation | Conservative - sling, Nonsteroidal anti-inflammatory frugs and ice (mostly for anterior dislocation) Surgical - Open reduction - posterior dislocation (associated with mediastinal injury/ pulseless limb) |
| Fractured clavicle | Weakest and thinnest point - middle and distal thirds (80-85%) Medial portion pulled superiorly by the sternocleidomastoid muscle Lateral portion pulled inferiorly by weight of the upper limb |
| Treatment for clavicle fracture | Conservative - immobilisation (triangular sling to support arm) Surgical - open, displayed fracture - plate and screws, intramedular nail fixation |
| Shoulder joint | Multi-axial ball and socket synovial joint Most mobile joint in the body - very unstable Enables vast movement of the arm Humoral head articulates with glenoid fossa Supported by glenoid labrum and joint capsule |
| Stabilisation of the shoulder | Static - glenohumeral and coracohumeral ligament Dynamic - rotator cuff muscles (pull humeral head medially into glenoid fossa during movement) - supraspinatus, infraspinatus, teres minor, subscapularis |
| Shoulder pathology | Dislocation Fractures Adhesive capsulitis Impingement syndrome Rotator cuff tendonosis Rotator cuff tears Arthritis |
| Shoulder dislocation | Anterior is most frequent Complications - damage to auxiliary nerve/artery Treatment - closed reduction and immobilisation, rehabilitation Surgical - if repeated shoulder dislocations despite strengthening and rehabilitation |
| Proximal humeral fracture | Common in elderly, osteoporotic patients Bimodal distribution - also peaks in children Conservative treatment - immobilisation Surgical - open reduction and internal fixation (nails, plates, screws) Hemi-arthroplasty for 3/4 part fractures |
| Adhesive capsulitis | Thickening and contraction of join capsule and synovium Develops with rotator cuff lesions, or following hemiplegia, chest/breast surgery or myocardial infarction Severe shoulder pain initially and gradually reducing range of movement as pain lessens |
| Treatment of adhesive capsulitis | Conservative - NSAIDs and intra-articular injections of LAs and corticosteroids, physiotherapy in later phases Surgical - Arthroscopic release - removal of scarring tissue and part of capsule, once pain settles it speeds functional recovery |
| Impingement Syndrome | Subacromial impingement diagnosis - clinical and radiological Inflammation and irritation of rotator cuff muscles as they pass through subacromial space - repeated contact with arm raised Leads to pain worse with abduction and reduced mobility |
| Treatment of impingement syndrome | Conservative - NSAIDs, physiotherapy, steroid injection Surgical - subacromial decompression (arthroscopic) |
| Rotator cuff tendonosis | Degeneration of the tendons collagen in response to chronic overuse Leads to pain in the upper arm made worse by abduction/elevation (middle abduction) passive abduction reduces impingement and is less painful Can occur with subacromial bursitis |
| Imaging of tendonosis | X ray is often normal Ultrasound is useful to distinguish tendonitis, bursitis, tendonitis or complete/partial tendon tears |
| Treatment of tendonosis | Analgesics, NSAIDs and/or physiotherapy Severe pain - injection of corticosteroid into subacromial bursa |
| Calcific tendonosis | Calcium pyrophosphate deposits in supraspinatus tendon are visible on X-ray Pathogenesis - unclear, ischaemia involved Not always symptomatic If symptomatic - acute or chronic recurrent shoulder pain and restriction of movement |
| Treatment for calcific tendonosis | Conservative - pain management by local corticosteroid injection Percutaneous treatment - ultrasound guided aspiration or breaking up of the deposit Surgical - arthroscopic removal |
| Calcific Bursitis | Shedding of crystals into the subacromial bursa Symptoms - severe pain and shoulder restriction Examination - shoulder hot and swollen X ray - diffuse opacity in burse Differential diagnosis - gout, pseudogout, septic arthritis |
| Treatment of calcific bursitis | Aspiration Corticoid injection |
| Rotator cuff tears | Prevalence increases with age Caused by trauma in young patients Occurs spontaneously in the elderly with rheumatoid arthritis Symptoms - loss of active abduction of the arm. Patients learn to initiate elevation using the unaffected arm- deltoid holds |
| Treatment of rotator cuff tears | Conservative - physiotherapy Surgical - arthroscopic/open tendon repair, tendon transfer, shoulder replacement |
| Arthritis of the shoulder | Inflammation of the shoulder joint, damage of the cartilage Symptoms - pain, limited mobility, crepitus (clicking sound of the limbs during movement) |
| Treatment of arthritis | Conservative - rest/change activities/NSAIDs/physiotherapy, corticosteroid injections Surgical - Arthroscopy (debrides inside joint for pain relief) Shoulder joint replacement - arthroplasty or prosthesis |
| Types of shoulder arthritis | Osteoarthritis Rheumatoid arthritis Posttraumatic arthritis Rotator cuff tear arthropathy Avascular necrosis |
| Osteoarthritis | >50 years old Pain, stiffness. reduced mobility |
| Rheumatoid arthritis | Multiple joints affected symmetrically Swollen synovium |
| Posttraumatic arthritis | After fracture or dislocation |
| Rotator cuff tear arthropathy | After large, long standing rotator cuff tendon tear Torn rotator cuff can no longer hold the head of the humerus - humerus in direct contact with acromion |
| Avascular necrosis | Disrupted blood flow to the head - bone collapses and disrupts articular cartilage Initially humeral head damaged, collapsed head of the humerus damages glenoid socket Causes - steroids, alcohol, sickle cell disease, trauma, idiopathic |
| Muscles of the shoulder | Trapezius Deltoid Latissimus dorsi Serratus anterior Pectoralis major |
| Trapezius | Broad, flat, superficial back muscle Upper fibres - elevation and rotation of scapular during abduction Middle fibres - retraction of scapular Lower fibres - depression of scapular Innervated by the accessory nerve (11 cranial nerve) |
| Deltoid | Anterior fibres - flexion Posterior fibres - extension Middle fibres - major shoulder abductors, taking over from supraspinatus Innervated by axillary nerve |
| Latissimus Dorsi | Wide, flat muscle originating from the crest of ilium, sacrum, spinous processes T7-L5 and 9-12 ribs Insertion - medial lip of intertubercular sulcus Extends, adducts and medially rotates upper limb Innervated by thoracodorsal nerve |
| Serratus anterior | From lateral aspect of 1-8/9 ribs Inserts - anterior surface of medial border of scapular Retracts scapular against chest wall Innervated by long thoracic nerve |
| Pectoralis major | Large fan shaped muscle originating from sternum and clavicle Inserts - lateral lip of intertubercular sulcus Flexes, adducts and medially rotates upper limb Innervated by pectoral muscles |
| Paralysis of trapezius muscle | Injury to the accessory nerve Affected movement - shrugging of shoulder, abduction Leads to shoulder asymmetry - atrophy of trapezius and depression of scapular on affected side |
| Deltoid paralysis | Auxiliary nerve injury Impairs shoulder abduction and weakens flexion and extension Can be due to humoral fractures Cannot abduct the injured shoulder - can only do first 15 degrees |
| Paralysis of serratus anterior | Injury of long thoracic nerve Leads to winged scapular - when asked to raise the arms the scapular will wing Serratus anterior cannot pull scapular against the chest wall if paralysed |
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