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Chapter: Medicine Study Notes : Musculo-Skeletal

Upper Limb

If shoulder dislocated, there will be a convexity or flattening of the deltoid below the acromion

Upper Limb






·        Look:

o  Compare both sides

o  Effusions not scene unless significant.

o  Look at each muscle group

o  If shoulder dislocated, there will be a convexity or flattening of the deltoid below the acromion

·        Feel:

o  For tenderness and swelling 

o  Start at sterno-clavicular joint ® AC joint and corocoid process ® gleno-humeral joint ® spine of scapula 

o  Feel along groove between acromion process and head of the humerus for ligaments of teres minor, infraspinatus and supraspinatus

o  Feel and look in axilla: lymph nodes, check soft tissues for swelling/tenderness

·        Move:

o  If active movement is reduced, try passive movement for the remainder of the normal range

o  Abduction: test with elbow flexed.  Test passively from behind.  Normal is 90º 

o   Elevation: If done actively, possible to 180º. Thumbs facing forwards, arms straight. Look for painful arch from 60 – 120º due to insertion of inflamed rotator tendons catching on the acromion. Is it the same with the arm laterally or medially rotated? Checks for tendon impingement 

o  Adduction to 50º across the front of the chest.  Pain in full adduction if AC joint injury 

o  External rotation: with elbow flexed to 90º, can externally rotate to ~ 60º. Good test of glenohumeral joint (eg for frozen shoulder) 

o  Internal rotation: Test actively: place hand behind back and scratch as high as they can. Compare with good arm

o  Extension is possible to 65º

o  Testing Rotator Cuff:

§  Pain worst at 90º abduction 

§  Supraspinatus: test abduction against resistance, especially from 0 - 30º (deltoid doesn‟t help much in that range) with thumbs pointing to the ground (turns the glenoid tubercle forward ® greater impingement)

§  Infraspinatus: externally rotate against resistance 

§  Subscapularis: „Lift-off test‟: Hold hand behind back, with patient pushing out from their back. Try and push them in (Pectoralis Major inactive in this position)

§  Teres Minor: hard to test in isolation

o   Check for stability:


§  Sulcus test: pull arm down and look for sulcus deep to the deltoid muscle (distracting the gleno-humeral joint)


§  Anterior draw test: from the side, hold acromion and corocoid process between your thumb and index finger, hold proximal humerus between the other thumb and forefinger and try and push forward and backwards against each other


§  Apprehension test for dislocating shoulder: posterior pressure during elevation on an abducted and externally rotated arm


§  Push-ups against the wall: look for winging of scapula ® seratus anterior dysfunction

·        Always examine neck and elbow (joint above and joint below) and distal pulses

·        X-rays:


o   Do AP and lateral obliquely – as scapular is oblique and don‟t want spine and other shoulder in the lateral film

o   Can do an axillary film: abducted 90% and x-rayed from above

·        Differentiating:


o   Intra-articular disease ® painful limitation of movement in all directions

o   Tendonitis ® painful limitation of movement in one plane only

o   Tendon rupture and neurological lesions ® painless weakness

o   Referred pain:

§  Cervical root lesions (eg due to cervical spine lesions)

§  Brachial plexus, thoracic outlet syndromes

§  Referred pain from abdominal visera, diaphragm




·        Most frequently affected by non-arthritic conditions involving bursa and surrounding tendons: tendonitis, bursitis, frozen shoulder

·        Frozen shoulder:

o   = Adhesive Capsulitis 

o   Gradual onset of pain, pain at night, then ­stiffness as pain gradually subsides

o   May follow minor trauma 

o   ¯ Active and passive movement in all directions, following minor trauma. Cause unknown – but due to a tendonitis/capsulitis ® adhesion of capsule to the humeral head 

o   Treatment: physio, mobilisation, NSAIDs, corticosteroid injection into subarcromial bursa

o   Prognosis: resolution may take years

o   Differential:

§  Disuse stiffness

§  Complex Regional Pain Syndrome Type 1

·        Rotator Cuff:


o   Humeral head is held in place by the rotator cuff muscles forming part of the joint capsule: infraspinatus posteriorly, supraspinatus superiorly, teres minor and subscapularis anteriorly


o   Due to impingement of rotator cuff tendons under the coraco-acromial arch. May be due to osteophytes or narrowing under the coraco-acromial arch


o   With age or injury the tendons of these muscles are prone to hyaline degeneration, fibrosis and calcification ® friction, swelling and pain. Prone to rupture

o   Tendonitis of more than one tendon Þ rotator cuff syndrome

o   Presentation:

§  Local tenderness over rotator cuff insertion

§  Supraspinatus tendonitis: the most common: pain on abduction of the arm

§  Subscapularis tendonitis: pain on internal rotation

§  Infraspinatus tendonitis: pain on external rotation 

§  May be accompanies by bicepital tendonitis: pain on resisted forearm flexion and supination and on pressure on the tendon of biceps in the bicepital grove


o   Treatment:


§  Conservative: · NSAIDs


·        Local injection of steroid with local anaesthetic to tendon insertion

·        Rest shoulder initially, in sling if necessary

·        Short-wave diathermy, ultrasound therapy to reduce pain

·        Exercise to lessen the risk of adhesive capsulitis or help restore movement

§  Surgical:

·        „Decompress‟ the rotator cuff

·        Excise the coraco-acromial ligament, anterior acromial process or any obstructive masses

·        Cuff reconstruction for large tears

·        Anterior dislocation:

o  Head of humerus anterior to the glenoid fossa:

§  Usually sub-glenoid (ie also inferiorly displaced)

§  Can rarely be subclavicular

o  Mechanism: arm abducted and externally rotated then hit from behind (eg tackle injury)


o  Clinical: Very painful. Patient holds arm at elbow to prevent any movement. Palpate under acromion, is humeral head there?

o  Consequential injuries


§  Check axillary nerve (cutaneous sensation from axillary nerve palsy over regimental badge area [over deltoid on upper arm] and action of teres major – medial rotator and adductor - and deltoid – adduction) 

§  Hill-Sackes lesion: injury to posterior of head of humerus

§  Bankart Lesion: injury to the anterior margin of the glenoid fossa

o  Reduction: Kocher or Hippocratic manoeuvres


o  Management: immobilisation in a sling for 2 to 3 weeks while structures anterior to gleno-humeral joint heal (otherwise recurrence), then physio avoiding external rotation

·        Posterior dislocation:

o  Mechanism: Direct trauma from the front, electric shocks or Grand mal seizures

o  Head of humerus lies posterior to glenoid.

o  Clinical: Pain, deformity, local tenderness

·        Shoulder Instability: 2 types:

o  Atraumatic, multidirectional (ie generalised laxity), bilateral, treatment: rehab (Physio)


o  Traumatic, unidirectional/unilateral, Bankart Lesion (capsule at the front detaches from the glenoid), Treatment: surgery. Progressively less traumatic force required to dislocate it. External rotation causes apprehension


·        Fracture of Clavicle:

o  Mechanism: fall on outstretched hand

o  Clinical: arm clasped to chest to prevent movement, subcutaneous lump

o  Xray: usually middle third

o  Treatment: support arm in sling until pain subsides (2-3 weeks)

·        A/C Joint:

o  Mechanism: usually involves fall in which patient rolls on shoulder


o  Clinical: Outer end of clavicle prominent, local tenderness present. Confirm subluxation by supporting elbow and detecting movement of clavicle downwards.


o  Clavicle is usually attached to the acromion by the ac joint, coroid ligament and trapezoid ligament. In serious injuries all three of these areas can be damaged

o  Treatment: Broad arm sling for 4-6 weeks usually sufficient

·        Infantile Torticolis: Two types

o  Congenital shortening of sterno-mastoid muscle


o  Neurological: damage to the spinal accessory nerve from infected lymph nodes in the posterior triangle

·        Brachial Plexus injury:


o   Erb‟s Palsy: C5, C6: paralysis of deltoid, supraspinatus, teres major, biceps ® Porter‟s tip position


o  Klumpke‟s Paralysis: C8, T1: arm in adduction, paralysis of small muscles of the hand. May also be Horner‟s syndrome


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