Transcript Shoulder Pathology and Examination For Finals

Shoulder
Pathology and Examination
For Finals
Sarah White
FY1 RLBUHT
To be covered
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Anatomy
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Common pathology
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Examination
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MCQs
Anatomy- Bones
Anatomy- Muscles
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Rotator cuff (SITS):
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Supraspinatus
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Infraspinatus
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Teres minor
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Subscapularis
Anatomy- Nerves
Pathology- Arthritis
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Osteoarthritis most likely to affect shoulder
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Acromioclavicular joint >glenohumeral
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Symptoms:
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Pain
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Stiffness
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Reduced range of movement
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Rheumatoid arthritis in shoulder uncommon
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Septic arthritis possible
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Avascular necrosis
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Causes
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Trauma
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Sickle cell disease
LOSS Vs.
LESS
LOSS
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Loss of bone
space
Osteophytes
Subchondral
sclerosis
Subchondral
cysts
LESS
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Loss of joint
space
Erosions
Soft tissue
swelling
Soft bones
(osteopenia)
Pathology- Dislocation
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Aetiology
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Traumatic
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(Rare: connective tissue disorders i.e. Ehlers Danlos)
Presentation
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Symptoms: pain, inability to move joint, tenderness,
swelling
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Examination: classical posturing of slight abduction and
external rotation (anterior dislocation=95%)
Management
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Analgesia
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Rule out fracture
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Reduce dislocation
Higher risk for future dislocation, joint instability
Pathology- Impingement
Syndrome
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Clinical sign not a diagnosis
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Aetiology
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Presentation
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Repetitive pinching of supraspinatus tendon as it passes through subchromial
space causing irritation and inflammation- supraspinatus tendonitis
Painful arc
Management
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Rest and ice
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NSAIDS
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Steroids injected in subchromial space
Pathology- Rotator Cuff
Tear
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Aetiology
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Atraumatic in older patients, attrition from bony spurs
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Traumatic in younger patients
Presentation
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Pain
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Restricted mobility in pattern dependent on which muscle is torn- special tests to isolate
muscles
Management
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Rehab and NSAIDS
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Surgical repair
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Physiotherapy
Pathology- Frozen
Shoulder
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AKA adhesive capsulitis
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Aetiology
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Spontaneous
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Following rotator cuff injury
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Following period of immobility i.e. CVA or plaster immobilisation
Presentation
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Non-dominant shoulder more often affected
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Pain followed by stiffness
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Restriction of all shoulder movements both active and passive
Management
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Difficult.
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Analgesia
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Physio
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Corticosteroid injections
Pathology- Long thoracic
nerve injury
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Aetiology
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Trauma to ribs
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Damage during surgery i.e. radical mastectomy
Presentation
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Winged scapula
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Shoulder pain
Management
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Physio
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Surgical repair of nerve
Examination
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Explanation and consent
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Inspection
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Palpation
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Movement: active and passive
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Special tests
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Neurovascular integrity
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Concluding remarks
Examination- Explanation
and Consent
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Introduce self
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What examination you want to do
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Why you want to do it
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What the examination involves
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Chaperone
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Gain consent
Examination- Inspection
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From front/side/back
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Compare side to side for:
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Symmetry
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Muscle wasting
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Scars
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Erythema
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Swelling
Check for long thoracic nerve injury
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Ask pt to stand, face wall, place hands on wall at shoulder height to illicit winged
scapula
Examination- Palpation
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Temperature, compare side to side
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Bony anatomy
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Sternoclavicular joint
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Clavicle
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Acromioclavicular joint
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Head of humerus
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Spine of scapula
What are you feeling for:
• warmth
• tenderness
• loss of bony continuity
• bony abnormality
(osteophytes)
Examination- Movement
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Active range of movement, both shoulders at once to compare side to side.
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From side
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Flexion (180 degrees)
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Extension (60 degrees)
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External rotation (70 degrees)
From back
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Internal rotation (reach up back)
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Abduction (180)
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Adduction (180)
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Repeat all movements passively, hand on shoulder feel for crepitus.
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Slow abduction for painful arc (impingement syndrome, pain at 60-120 degrees)
Examination- Functional
Movement
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Both hands behind head- washing hair, dressing
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Both hands up to mouth- eating
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Both hands down to bottom- cleaning after toilet
Examination- Special
Tests
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Shoulder apprehension test- for shoulder instability
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Young patients
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Pt lies supine
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Abduct shoulder to 90 degrees
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Flex elbow 90 degrees
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Externally rotate shoulder by holding humerus and pushing pt’s hand up
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Positive test- pt is “apprehensive”, feels like shoulder will dislocate
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https://www.youtube.com/watch?v=_JA-qvXcUdQ
Examination- Special
Tests
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Hawkin’s test- Impingement syndrome
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Middle aged patients
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Flex shoulder 90 degrees
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Flex elbow 90 degrees
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Passive internal rotation- stabilise humerus and push down
hand
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Positive test- pain in shoulder
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https://www.youtube.com/watch?v=OYK5qL2om-c
Examination- Special
Tests
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Jobe’s test (empty can)- rotator cuff injury/tear
SUPRASPINATUS
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Older patients
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Straight arm abducted to 90 degrees, angle forwards by 30
degrees, fist with thumbs down
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Force adduction, ask pt to resist you
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Positive test- pain/difficulty with resistance
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May also be positive in impingement syndrome
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https://www.youtube.com/watch?v=cuVWk09sk3k
Examination- Special
Tests
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Gerber’s lift off test- rotator cuff injury/tear SUBSCAPULARIS
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Older patients
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Stand behind pt, ask pt to put dorsum of hand on mid lumbar
spine
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Apply some pressure to pt’s palm
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Ask pt to push hand away from spine
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Positive test- pain or difficulty
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https://www.youtube.com/watch?v=__jgMNMQIQU
Examination- Special
Tests
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Resisted external rotation- rotator cuff injury/tear TERES
MINOR AND INFRASPINATUS
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Older patients
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Arms by side
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Elbows flexed to 90 degrees
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Ask pt to externally rotate shoulders against resistance
Positive test- pain or difficulty
Examination- Neurovascular
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Sensation
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Axillary- regimental badge
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Median- lateral aspect index finger
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Ulnar- medial aspect little finger
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Radial- dorsal 1st interosseous space
Vascular
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Radial pulse
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CRT in finger
Examination- Concluding
remarks
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Examine other shoulder to compare
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Joint above and below (neck, elbow)
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Investigations
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X ray (AP, modified axillary view)
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MRI
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Joint aspiration
MCQ
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1- Which direction is the shoulder most likely to
dislocate in?
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a) Superior
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b) Inferior
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c) Anterior
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d) Posterior
MCQ
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2- Which muscle of the rotator cuff is implicated in
impingement syndrome?
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a) Supraspinatus
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b) Infraspinatus
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c) Teres minor
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d) Subscapularis
MCQ
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3- Which nerve is implicated in winged scapula?
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a) Long thoracic nerve
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b) Axillary
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c) Ulnar
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d) Radial
MCQ
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4- Which nerve is most vulnerable to damage as a
complication of anterior shoulder dislocation?
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a) Long thoracic nerve
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b) Axillary
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c) Ulnar
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d) Radial