Shoulder injuries - Overview

Shoulder injuries Anatomy; Musculature There are 3 groups of muscles; Scapulohumeral – rotator cuff, deltoid, teres major. Axiohumeral – trapezius, rhomboids, serratus anterior, levator scapulae Axioscapular – pectoralis major, pectoralis minor, latismus dorsi. Anatomy; Rotator Cuff • Reinforces joint capsule • Annulus formed from musculotendinous insertions A Supraspinatus B Joint Capsule C Labrum D Subscapularis E Long head of biceps F Infraspinatus G Teres Minor Anatomy;Bones • Anterior Posterior View A Glenoid B Lateral border of scapula C Medial Border of scapula D Spine of scapula E Acromium F Coracoid G Humeral Head H Clavicle Anatomy; Bones (cont) • Axial Lateral view J Lateral border of scapula K Acromium L Coracoid M Glenoid N Clavicle Anatomy; Bones (cont) • Translateral view A Glenoid B Coracoid C Acromioclavicular D Parabolic curve Basic Examination; Inspection • General; Swelling Erythema Joint Deformity Muscle wasting Sternoclavicular Joint prominence Clavicle deformity Acromioclavicular joint prominence Deltoid wasting Front; • • • Side; Swelling Behind; Scapula shape and situation Webbing of the skin Winging Above; Clavicle Supraclavicular fossae Swelling Basic Examination; Palpation • • • • Heat Crepitations Bony tenderness Humoral head and shaft Basic Examination; Movement • • • • • • • • • • Active before passive Abduction – 0 - 170° Adduction – 50° Flexion – 0 - 165° Extension – 0 - 60° Internal rotation in abduction - 70° External rotation in abduction - 100° Internal rotation in extension – touch the opposite scapula External rotation in extension - 70° External rotation in abduction – hand behind the head Examination; Other tests • • • • • • • • Lift off test Belly Press test Drop sign Neer‟s test Hawkin‟s test Jobe‟s test Apprehension test Arm raise test Practical assessment • Lift your arm right up (demonstrates full abduction) • Now let your arm down (painful arc often more evident on downstroke) • Put your hand behind your head (tests external rotation) • Put your hands behind your waist (tests internal rotation) Investigations • • • • • • • • • • X-ray WCC ESR Blood Culture Aspiration of the Joint CAT MRI Arthroscopy Arthography Examination under anesthetic X-Rays • Anterior Posterior view The standard view in all hospitals. Articular surfaces of humerus and glenoid are parallel. Inferior aspects of acromium and clavicle should be at the same level. Humeral head looks like a walking stick. X-Rays • The „Y‟ view The „Y‟ sits under the humeral head. The stem of the „Y‟ is the blade of the scapula. The limbs of the „Y‟ are the coracoid and the acromium process. Pathology • • • • • • • • • • • • • • Referred pain; neck, wrist, elbow, diaphragm, gall bladder, MI. Impingement syndrome Rotator cuff tear Rotator cuff Arthropathy Frozen Shoulder Calcifying Supraspinatus Tendinitis Infection Fractures Exostosis from scapula/ ribs Congential syndromes Winged Scapula Ruptured Biceps tendon Rheumatoid Arthritis Osteoarthritis; Acromioclavicular joint Glenohumoral joint Supraspinatus Tendonitis • pain is caused by inflammation of the tendon and subacromial bursa • age of onset is 43 • men being more commonly affected • Clinical features; rapid onset without warning, disturbance of sleep, severe pain, apprehension to move the arm, acute localised tenderness. • X-ray = calcium deposit close to insertion of the supraspinatus tendon. • Treatment; • mild cases = physiotherapy, anti-inflammatories • severe cases = aspiration of the joint, possibly under general anaesthetic followed by long acting steroid injections. Rotator Cuff Tear • An injury of older age • Degeneration of the cuff makes it weaker making it more likely to rupture. • Tears occur after sudden stress to the cuff, this can happen in a fall or during everyday activities. Major • In a major tear there is no activity of the supraspinatus muscle. • Treatment is operative repair of the tendon, followed by physiotherapy. Minor • In minor tears the supraspinatus muscle is still able to function. • It is characteriased by painful arc syndrome. • It is treated conservatively with rest, and exercises. Impingement Syndrome • The pain is due to irritation of the supraspinatus tendon. • Commonly caused by repeated overhead movements which cause pinching of the tendon. • The clinical features are; onset usually insidious but can be sudden after overuse, painful lateral aspect of upper arm, worse at night, can not lie on affected arm, pain on overhead and behind the back movements. • Treatment is rest in the younger patient, modification of activity (i.e. not playing golf/ racket sports). • In chronic cases physiotherapy, analgesics and sometimes steroid and local anaesthetic injections become necessary. Frozen Shoulder • Term used to describe all conditions involving pain, limitation of movement. • It often follows trauma, a period of immobility, other shoulder problems or neck pathology. • Onset is typically between 40-60 • Women are much more commonly affected than men. Frozen Shoulder • Clinical features are; reduction in movement, severe pain, more common in the non-dominant shoulder. There is classically 3 stages; 1. Freezing Stage – Gradual onset of pain becoming severe associated with increasing stiffness. 2. Frozen Stage – Pain subsides, leaving stiffness and severe decrease in function. 3. Thawing Stage – Return to normal function gradually • Treatment is usually analgesics, physiotherapy and reassurance. Occasionally steroid injections, manipulations (only in the frozen stage) and rarely surgical release may be required. Treatment • Mild RICE NSAID’s or other painkillers if contra indicated • ModerateEffective pain relief Sling Physiotherapy • Severe Effective pain relief Steroid/ local anaesthetic injections Orthopaedic referral Shoulder Fractures/Injuries • • • • • • • • Upper humerus Clavicle Shaft of humerus Dislocation AC joint subluxation Sternoclavicular joint subluxation Fracture scapula Rupture biceps Fracture Upper Humerus • Most common in elderly • Direct trauma/FOOSH • Classification by number fragments • Usual Rx collar and cuff/poly-sling • More comminuted /displaced may require MUA or replacement Fracture Clavicle • Common in children • FOOSH or onto point of shoulder • Check skin for compromise • May cause neurovascular damage • Rx broad arm sling occ. Requires internal fixation Fracture Shaft of Humerus • • • • • Fall onto arm Painful swelling over biceps/bruising Check for neurovascular deficit-radial nerve Rx U- slab/collar and cuff Occasionally surgery Shoulder Dislocation • Most commonly dislocated joint due to lack of bony stability • May be : • - Anterior • - Posterior • - Inferior • - Associated fracture Anterior Dislocation • • • • • Most common type Forced external rotation or fall “squared off” appearance of shoulder Palpable gap below the acromion Humeral head palpable antero-inferiiorly to glenoid • Must examine distal pulses and axillary nerve Reduction • Kocher‟s method- external rotation,adduction,internal rotation • Hippocratic methodtraction on arm, counter traction with foot in axilla • Simple traction- patient lies flat with arm hanging over edge of bend. Gentle traction applied Posterior Dislocation • Fall onto anterior shoulder • Associated with fitting • Difficult to Dx on x-ray“light bulb sign” • Request axial view if in doubt • Rx traction and external rotation with arm 90 degrees to body Inferior Dislocation • • • • • Uncommon also known as Luxatio erecta Arm held abducted, over head Around 1% of shoulder dislocations Usually associated injury to capsule Rx in-line traction with abduction then adduction often requires GA AC Joint Subluxation • • • • • • Fall onto point of shoulder Localised tenderness over AC joint Pain on crossover manouvere Grading on x-ray - I minimal separation (sprain) - II subluxation but some overlap( AC lig rupture) III complete dislocation(coracoclavicluar lig rupture) Rx BAS/occasionally needs fixing • • Sterno-clavicular subluxation • Usually from fall onto anterior shoulder • Clinical diagnosis poorly seen on x-ray • Swelling tenderness over sterno-clavicular joint • Usually bruising ++ • Rx sling/analgesia Scapula fracture • High energy injury • Usually direct blow • Look for associated injuries • Rx analgesia/broad arm sling Ruptured biceps • Sudden sharp pain above elbow • May hear audible snap • A bulge in the upper arm above the elbow and a dent at the shoulder • Bruising from the middle of the upper arm to the elbow • Rx rest/analgesia/physio/surgery ? QUESTIONS ?