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

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Presentation on theme: "Page 1 The Shoulder in General Practice Mr T P Selvan MB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho) Consultant Orthopaedic Surgeon East Surrey Hospital,"— Presentation transcript:

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

2 Page 2 Know the Anatomy Examine Clinically & Look For Diagnostic Clues Investigate Identify the Red flags Treat Refer to Specialist Scope

3 Page 3 Anatomy- Deltoid

4 Page 4 Anatomy – Rotator Cuff

5 Page 5 Anatomy - Ligaments

6 Page 6 Anatomy - Bones

7 Page yrsINSTABILITY yrsAC JOINT DISEASE TRAUMATIC CUFF TEAR yrsFROZEN SHOULDER >60 yrsGH ARTHRITIS yrsROTATOR CUFF DISEASE Diagnostic Clues - Age

8 Page 8 Diagnostic Clues - History Pain on overhead activities IMPINGEMENT Night PainGH ARTHRITIS FROZEN SHOULDER CUFF TEAR ARTHROPATHY Dead arm INSTABILITY ApprehensionINSTABILITY TraumaFRACTURES, CUFF TEAR

9 Page 9 LOCATION OF PAIN Rotator cuff disease 1. Under deltoid 2. Side of arm 3. Front of arm

10 Page 10 Pain in the shoulder blade area is usually muscular or nerve related LOCATION OF PAIN

11 Page 11 Diagnostic clues – Deformities ACJ DISRUPTION DISTAL BULKING OF BICEPS INFRASPINATUS WASTING SCAPULAR WINGING

12 Page 12 Clinical Examination Look Feel Move!!! Range of movement. Deltoid function. Tests for Supraspinatus function. Tests for Infraspinatus / Teres minor function. Tests for subscapularis function. Tests for Biceps Tendon Tests for ACJ and Superior labrum.

13 Page 13 Movements

14 Page 14 Supraspinatus

15 Page 15 Infraspinatus / Teres minor

16 Page 16 Obriens test for ACJ/Slap Lesion

17 Page 17 Gerbers Lift off for subscapularis

18 Page 18 Belly Press for Subscapularis

19 Page 19 Neers Test

20 Page 20 Hawkins-Kennedy test

21 Page 21 Biceps tendon-Speed test

22 Page 22 Apprehension Tests ApprehensionRelocation Test Sulcus Test Drawers tets

23 Page 23 Supraclavicular fossa Neurological examination Vascular examination Non-shoulder examination

24 Page 24 Cervical spondylosis

25 Page 25 Cervical spine fracture and tumour

26 Page 26 Frozen ShoulderTo exclude other pathology Rotator cuff disease –ImpingementSclerosis GT and Acromion –Cuff tearSuperior migration of humerus(+/-) –Cuff arthropathyHumero-acromial articulation InstabilityHill Sachs lesion Glenohumeral OADiagnosis ACJ dislocation/OADiagnosis Investigations – X-Rays

27 Page 27 Ultrasound (one stop clinic) MRI Arthrogram CT Scan EMG Bone Scan ARTHROSCOPY

28 Page 28 Impingement/ACJ Pathology ACJ ArthritisAcromial spur

29 Page 29 Calcific Tendonitis

30 Page 30 Metastatic Fracture

31 Page 31 Frozen Shoulder

32 Page 32 Rotator cuff tear HorizontalVertical Horizontal Retracted Vertical & Horizontal Inner Substance

33 Page 33 Surface replacement Total Shoulder Replacement

34 Page 34 Reverse Delta Shoulder replacement

35 Page 35 SLAP Lesion Superior Labrum Anterior Posterior

36 Page 36 Bankarts Lesion

37 Page 37 Activity modification NSAIDs / Analgesia Physiotherapy Steroid Injection Frozen shoulder Calcific tendinitis Impingement syndrome AC joint disease Glenohumeral arthritis

38 Page 38 Indications for Injection Diagnostic –Subacromial impingement –AC joint pain –Aspiration Therapeutic –Subacromial impingement –Rotator cuff tendinitis / Bursitis –Calcific tendinitis –Glenohumeral OA –Long head of biceps tendinitis –Frozen Shoulder –AC joint arthritis

39 Page 39

40 Page 40 When to Refer to a Shoulder Specialist Impingement not responding to conservative measures Frozen shoulder not showing any improvement despite physiotherapy for 6 months Suspected Rotator cuff tear. Cuff tear arthropathy Instability / SLAP lesions Osteoarthritis / Rheumatoid Arthritis Uncertainty of diagnosis. Red flag signs

41 Page 41 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.

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