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Common Shoulder Conditions in General Practice

Common Shoulder Conditions in General Practice. Mr. T P Selvan MB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho) Consultant Orthopaedic Surgeon East Surrey Hospital Redhill. Scope. Anatomy Diagnostic clues Examination Investigations (X-ray indications) Injection- indications & techniques

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Common Shoulder Conditions in General Practice

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  1. Common Shoulder Conditions in General Practice Mr. T P Selvan MB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho) Consultant Orthopaedic Surgeon East Surrey Hospital Redhill

  2. Scope • Anatomy • Diagnostic clues • Examination • Investigations (X-ray indications) • Injection- indications & techniques • Referral to Orthopaedic Specialist • Red flag signs • Surgical procedures performed

  3. Diagnostic Clues • AGE • 10-35 yrs Instability • 30-50 yrs AC joint disease • 40-60 yrs Frozen Shoulder • >60 yrs GH arthritiis • 35-75 yrs Rotator cuff disease

  4. Diagnostic Clues • HISTORY • Pain on overhead activities Impingement • Night Pain Rotator cuff disease, GH arthritis, Frozen shoulder • Dead arm Instabiltiy • Trauma Rotator cuff tear, Fracture

  5. Diagnostic Clues 1. Under deltoid 2. Side of arm 3. Front of arm LOCATION OF PAIN Rotator cuff disease

  6. LOCATION OF PAIN Pain in the shoulder blade area (location 4) is usually muscular or nerve related

  7. Wasting of supraspinous and infraspinous fossae Long head of biceps rupture

  8. Non-shoulder examination • SUPRACLAVICULAR FOSSA • NEUROLOGICAL EXAMINATION • VASCULAR EXAMINATION

  9. CERVICAL SPONDYLOSIS

  10. CERVICAL SPINE FRACTURE AND TUMOUR

  11. Range of Movement ACTIVE/PASSIVE

  12. Special tests • DELTOID FUNCTION • SUPRASPINATUS FUNCTION • TERES MINOR/INFRASPINATUS FUNCTION • DROP SIGN • SUBSCAPULARIS FUNCTION 1. GERBER’S LIFT OFF TEST 2. NAPOLEON’S BELLY PRESS TEST • BICEPS TENDON 1. YERGASSON’S TEST 2. SPEED’S TEST

  13. Supraspinatus function Abduction in scapular plane

  14. Teres minor/infraspinatus function ELBOW AT 90 DEGREES Ext. Rotation against resistance

  15. The drop sign

  16. Subscapularis function BELLY PRESS (NAPOLEON’S) TEST GERBER’S LIFT OFF TEST

  17. Biceps tendon tests SPEED’S TEST

  18. Impingement signs and tests NEER’S IMPINGEMENT TEST GREAT CAUTION! IN YOUNG PATIENTS CLOSELY EVALUATE FOR SIGNS OF INSTABILITY, THE MOST LIKELY CAUSE OF IMPINGEMENT

  19. Investigations Why do we need X-rays? • Frozen Shoulder to exclude other pathology • Rotator cuff disease • Impingement Sclerosis GT and Acromion • Cuff tear Superior migration of humerus(+/-) • Cuff arthropathy Humero-acromial articulation • Instability Hill Sachs lesion • Glenohumeral OA • AC joint dislocation / OA

  20. Acromial spur • ACJ arthritis

  21. ROTATOR CUFF ARTHROPATHY OSTEO ARTHRITIS

  22. CALCIFICATION PATHOLOGICAL FRACTURE

  23. Other Investigations • Ultrasound (one stop clinic) • MRI • Arthrogram • CT Scan • EMG • Bone Scan • ARTHROSCOPY

  24. Treatment at Primary Care Rest NSAIDs / Analgesia Physiotherapy Steroid Injection

  25. Indications for Injection • Diagnostic • Subacromial impingement • Acromioclavicular joint pain • Aspiration • Therapeutic • Subacromial impingement • Rotator cuff tendinitis / Bursitis • Calcific tendinitis • Glenohumeral OA • Long head of biceps tendinitis • Frozen Shoulder • AC joint arthritis

  26. Injection Techniques Subacromial space Glenohumeral joint

  27. Injection techniques Subacromial space Palpate the posterolateral corner of acromion 1-2 cm below and medial to point Needle directed towards the coracoid process

  28. Injection techniques Glenohumeral joint Palpate the coracoid process 1-2 cm below and lateral to point Needle directed towards the joint

  29. WHEN TO REFER??? • Failure of conservative treatment for 6 months • Signs & Symptoms of INSTABILITY • Suspected ACUTE ROTATOR CUFF TEAR • Uncertain diagnosis • Red flags

  30. Shoulder Pain – Signs • Infection : red hot skin, pyrexial, systemically unwell • Unreduced dislocation: h/o trauma/fit/electric shock, abnormal contour, loss of movements • Acute rotator cuff tear: acute onset pain and weakness, recent trauma, drop arm sign • Tumour: S/S of cancer, h/o cancer, abnormal mass, swelling or deformity • Neurological: severe sensori-motor deficit, unexplained muscle wasting.

  31. Surgical procedures performed Subacromial Impingement Subacromial decompression

  32. Shoulder instability • RECONSTRUCTIVEANTERIOR STABILISATION

  33. Glenohumeral arthritis Surface replacement Total shoulder replacement

  34. Rotator cuff arthropathy Reverse Delta Shoulder replacement

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