Shoulder problems - part two

THE ESSENTIALS
- The shoulder is the most unstable and commonly dislocated joint.
- Recurrent shoulder dislocation is a significant disability.
- Shoulder replacement is not as successful as hip replacement.
- Epicondylitis usually resolves in six to 12 months.
- Brachial plexus injury can be devastating.

1. THE DISLOCATED SHOULDER

The shoulder is by far the most mobile joint in the human body.

To achieve this mobility, stability has been sacrificed, so the shoulder is also the most commonly dislocated joint.

Dislocated shoulders need to be reduced quickly. If a shoulder becomes dislocated and is not reduced, the ligaments around it soon stretch and become ineffective.

After five to seven days, it may become impossible to relocate the humeral head by closed methods. If there is any doubt about dislocation, X-rays in two planes should be taken.

Groups of patients suffering dislocation

There are two groups of patients who suffer shoulder dislocations. These are young patients who receive high-energy injuries, such as rugby players, and an older group with weak rotator cuffs receiving low-energy injuries.

Almost all shoulder dislocations are anterior, with less than 5 per cent being posterior.

When a young man (the patient is usually male) dislocates his shoulder for the first time, it is usually an anterior dislocation following a violent event. He gives a clear-cut history of a sudden force during a contact sport or a fall, with sudden swelling, immobility and pain around the joint.

The joint then has to be relocated, usually under anaesthetic in the A&E department or in theatre. It is left in a sling for three to four weeks, followed by active mobilisation.

Most of these patients recover well, helped along by their youth. Paradoxically, the younger a patient is at first time dislocation, the more likely they are to have a recurrence.

About one in three become recurrent dislocators, that is they repeatedly present with a shoulder dislocation that needs reducing - often after increasingly trivial injuries.

Eventually, there may be a sense of subluxation or dislocation practically all the time.

Older adults, particularly those over the age of 65, are more likely to be once-only dislocators, but they are often left with a stiff shoulder for a long time. In practice, this almost always involves anterior dislocations.

These patients have often torn vital structures around the shoulder joint.

Hill-Sachs lesion

In a classic 1938 paper, Bankart described a common lesion in unstable shoulders, where the anterior part of the glenoid labrum is torn off, allowing the shoulder to dislocate anteriorly.

When the head of the humerus first dislocates, it sometimes collides with the edge of the glenoid as it comes out. This produces an indentation in the humeral head called a Hill-Sachs lesion, and may be seen on an axillary view X-ray. MRI or CT scanning, sometimes with the addition of a contrast agent (arthrography), can enable the torn labrum and any additional tears in the capsule to be seen.

KEY POINTS

- Dislocated shoulders always need to be reduced quickly.

- Almost all shoulder dislocations are anterior, with less than 5 per cent being posterior.

- One in three become recurrent dislocators.

- MRI or CT scanning, sometimes with the addition of a contrast agent (MRI arthrography), can be useful.

2. TREATMENT OF RECURRENT DISLOCATION

Recurrent shoulder dislocation is a significant disability, and these patients can be offered surgery. The modern shoulder surgeon is now able to plan a repair operation for the individual patient's injury before they are admitted.

Although there are a variety of operations available, a number of standard terms crop up. The Bankart operation repairs the Bankart lesion that he described (see above).

The Putti-Platt operation involves reefing the subscapularis muscle.

The Bristow-Laterjet procedure attempts to move extra muscles in front of the shoulder to stop it dislocating.

It is possible to perform many forms of stabilisation operations using arthroscopy, although some procedures still require open surgery.

Postoperative care

Postoperatively the patient has to wear a shoulder immobiliser for six weeks, before starting graduated physiotherapy exercises.

The patient should not return to contact sports for at least six months.

Even after final recovery from a shoulder repair, the range of movement may be restricted, especially external rotation. The undisciplined and unreliable patient is not a good candidate for shoulder surgery.

Posterior dislocations

Posterior dislocations are rare, but when they do occur, they may be associated with specific circumstances, such as epileptic fitting and electrocution.

Because of their rarity, and also because they are difficult to see on an AP shoulder X-ray, junior doctors often misdiagnose patients with posterior dislocation.

There is also less of a consensus within the profession as to how to treat posterior dislocations.

Some patients develop a form of instability that is not specifically anterior or posterior but multidirectional.

The shoulder tends to sublux with everyday activity. There is sometimes an association with generalised joint laxity. It is often treated effectively by physiotherapy.

Voluntary dislocation

Voluntary, or habitual dislocators are rare but they do exist. Some schoolchildren develop an ability to dislocate the shoulder at will and often use it as an excuse to escape from lessons.

This act of dislocation is not painful. Surgery should be avoided in these circumstances.

KEY POINTS

- Patients with recurrent shoulder dislocation should be offered surgery.

- Surgeons are now able to plan a repair operation before admission.

- Posterior dislocations are rare, but they may be associated with specific circumstances.

- Some schoolchildren develop an ability to dislocate the shoulder at will.

3. SHOULDER OA AND REPLACEMENT SURGERY

Glenohumeral osteoarthritis (OA) is associated with true shoulder pain, which is described as anterior and lateral pain over the shoulder itself. In its primary form it is far less common than OA of the hip or knee.

Shoulder OA shows up well on a plain X-ray, with classical features of decreased glenohumeral joint space, sclerosis, marginal osteophytes and cysts.

On examination rough crepitus is often felt in the joint. There may be an effusion.

Surgery is rarely necessary except in the most painful cases.

Acromioclavicular OA is more common and presents with pain and tenderness that is well localised over the acromioclavicular joint, often with associated swelling.

Arm adduction across the chest can be painful. Excision of the distal end of the clavicle may be carried out in such patients, usually to good effect.

Rheumatoid arthritis

In mono-articular rheumatoid arthritis, the shoulder may be affected in isolation, but it may also be part of a generalised rheumatoid picture.

Rheumatoid arthritis begins with the process of synovial inflammation, and this is followed by degenerative change in the glenohumeral joint itself.

Patients are often referred to the orthopaedic surgeon after having been seen by a rheumatologist. Synovectomy is not normally attempted for a rheumatoid shoulder.

Shoulder replacement

At first sight, a shoulder replacement looks like the upper limb equivalent of a hip replacement. However, experience with shoulder replacements is far less extensive than with hips, and the results can be disappointing, although pain is often successfully eliminated.

The range of movement may be improved after shoulder replacement but it is unlikely to go back to normal.

The main indication for shoulder replacement is unremitting pain, especially from OA. It may also be considered after comminuted fractures of the proximal humerus, and in rheumatoid arthritis.

A patient with a stiff, painless shoulder is unlikely to benefit from a shoulder replacement.

KEY POINTS

- Glenohumeral osteoarthritis is associated with true shoulder pain.

- Painful acromioclavicular OA can be treated with excision of the distal end of the clavicle.

- The shoulder may be affected in isolation in some cases of rheumatoid arthritis.

- The main indication for shoulder replacement is unremitting pain.

4. ELBOW PROBLEMS - EPICONDYLITIS

Tennis elbow affects the lateral epicondyle in the common extensor origin at the lateral epicondyle. Golfer's elbow affects the common flexor origin at the medial epicondyle.

The important fact is that a number of such tendons take origin from these prominences. Degenerative changes at either of these sites can cause pain and tenderness over the elbow, termed epicondylitis.

They are often associated with over-use activities such as racquet sports.

Although the name suggests an inflammatory cause, histology of the affected tissue reveals degenerative changes.

Lateral epicondylitis

Tennis elbow is nine times more common than golfer's elbow, and is caused by over-use activities, classically playing the backhand in tennis. It tends to affect the dominant elbow.

If the pain radiates down the forearm, consider the possibility of involvement of the posterior interosseous nerve. The main tests are the detection of tenderness over the lateral epicondyle and pain on resisted extension of the middle finger. There is also pain when trying to lift up a chair with outstretched hands.

Medial epicondylitis

Golfer's elbow is much less common than lateral epicondylitis, and tends to occur in the non-dominant elbow.

There may be an associated ulnar nerve entrapment, with paraesthesia in the little finger and medial aspect of the palm.

Just about any treatment works, since 90 per cent of cases resolve within 12 months. Active treatments include ultrasound, physiotherapy and steroid injections.

Less convincing treatments include acupuncture and vitamins. Surgical treatment can be offered to the 10 per cent that do not resolve within 12 months.

This involves excising an ellipse of degenerative tissue from the tender area.

About 90 per cent of patients improve following this procedure, but it may take six to 12 months.

OA of the elbow OA of the elbow usually occurs in men following heavy repetitive strain, such as in weight lifters. There is pain when the elbow is fully extended.

Carrying even a light item such as an empty briefcase with the elbow fully extended may be very painful.

Loose bodies

Loose bodies result from osteochondritis dessicans, acute or repetitive trauma, or may be idiopathic. Loose pieces of cartilage may grow in size once they become trapped within the joint. They may cause joint snapping, locking or catching.

Surgical removal can be performed arthroscopically or through an open procedure. Results are usually excellent, unless the loose bodies are associated with painful OA.

KEY POINTS

- Tennis elbow is nine times more common than golfer's elbow.

- The name epicondylitis suggests inflammation, but histology only reveals degenerative changes.

- Surgical treatment can be offered to the 10 per cent that do not resolve within 12 months.

- Loose bodies may cause joint snapping, locking or catching.

5. BRACHIAL PLEXUS INJURIES

A complete brachial plexus injury is a particularly distressing injury for the patient.

The classical mechanism of injury is a motorcyclist hitting the ground shoulder first. The head is pushed away from the shoulder abruptly, and the nerve roots to the brachial plexus snap or are severely damaged.

With this common aetiology, it is not surprising that most patients are young men.

A complete brachial plexus injury results in a flail limb. This is a completely 'dead' arm, with no motor or sensory function at all. Ultimately some patients may even request amputation, because the arm serves no useful function and simply gets in the way.

Partial injury

If the injury is only partial, that is if the nerves are severely traumatised but still intact, then some function may return over a period of many months. However, if there has been no return of function at 12 months, it is likely that the deficit will be permanent. Peripheral nerves grow at the rate of about 1mm a day once recovery has begun, so at best they will grow 36.5 cm in a year.

A brachial plexus injury is long way from the peripheral nerves, so recovery is unpredictable.

For a peripheral nerve to regenerate as far as the hand following a nerve root injury is unlikely, and by the time it eventually gets there, many of the specialised receptor cell bodies will have shut down and died off, because they have had no nerve supply.

Many attempts to surgically correct a flail limb have been made over the years, some of them highly imaginative, but none of them uniformly successful.

Any procedure to help this devastating injury is best attempted in one of the few specialist centres.

KEY POINTS

- Motorcyclists get brachial plexus injuries when they fall off and hit the ground with their shoulder.

- Some function may return but this can take many months.

- Complete brachial plexus injury results in a useless flail limb.

- A variety of attempts at surgical correction have not generally been successful.

Further reading

Apley's System of Orthopaedics and Fractures by A Graham Apley and Solomon L, published by Hodder Arnold 2001.

Primary Care Orthopaedics by S Cutts, A Edwards and R Prince, RCGP publications, 2004

 

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