Shoulder & Elbow

INTRODUCTION &

BACKGROUND

The History is usually the most important step to a

correct Diagnosis

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HISTORY

EXAMINATION

INVESTIGATIONS

DIAGNOSIS

60%

90%

100%

• Be Systematic:

– Pain

– Function

• Loss of Movement (stiffness/weakness)

• Instability

– Swelling

– Systemic History

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Traumatic / Non-traumatic

The importance of understanding the mechanism

of injury can not be underestimated - it gives clues to the

personality of the fracture and the treatment required:

• When and how did the incident occur?

• What exactly happened to the limb?

• How much force was applied?

• Has the joint ever been injured before?

Trauma Mechanism of Injury

Non-Trauma Onset

• When and how did the symptoms start?

• How has it changed?

• Have you had this before?

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Introductions

1. How ya doin’? - Introduction

2. What are you doing here? - Main Complaint

3. Have you been before? – Past Medical History

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4. Anything else?

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IntroductionHow ya Doin’?

Patients are People Too!!

• Shake Hands

• Introduce yourself Clearly and your Position

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Main Complaint Why are you here?

1. Pain

2. Function – Loss of movement – Instability / Locking

3. Swelling / Lump

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PAIN

• Site – where exactly is the pain?

• Radiation – Does it go anywhere else?

• Nature – Can you describe the pain?

• Severity – How bad is the pain?

• Duration – How long have you had the pain?

• Frequency – How often do you get the pain?

• Aggravating factors – What makes the pain worse?

• Relieving Factors – What makes the pain better?

• Related Features – do you get any other symptoms?

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PAIN

• Localised

• Referred

• Radicular

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PAIN

• Nociceptive Pain – Local Tissue damage – Worse with movement – Opiates or NSAIDs

• Neurogenic Pain – Peripheral Nerve or Nerve Root damage – Pain >> Tissue damage – Often Sensory changes – Poor response to Opiates or NSAIDs

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Function

• Activities of Daily Living – ADL

• Sports / Recreation • What can’t you do that you used to be able to do? • Why?

– Stiffness – Weakness – Pain

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Function

1. Loss of Movement

2. Instability

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Loss of Movement

• Time of Loss of Movement

• Was there a dislocation?

• Are Active and Passive movements the same? • Stiff or Loose

• Symptoms of Neurological deficit?

• Symptoms of Tendon rupture?

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Instability

• Does the joint ‘Give Way’? – Has it ever given way?

• Does the joint lock? – What does the patient mean by this?

• Does the joint click or clunk?

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SWELLING

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• Has there been swelling?

• How much?

• How soon / how long?

• Has it changed?

• Related Features – Pain

– Function

Past Medical HistoryHave you been before?

• Musculoskeletal – Previous similar symptoms – Other joints – Arthritides – Rheumatic Fever – TB

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• Systemic – Cardiac – Respiratory – GIT – GUT – Drugs – Alcohol – Tobacco

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Past Medical HistoryHave you been before?

• Social – Work – Sports / Hobbies – Driving – Live Alone – Stairs – Walking Aids – Assistance

• Family History – Musculoskeletal

• Anaesthetic – Previous – Problems

Mnemonic

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M OI/ onset

P ain

F unction

F eeling / Sensation

W eakness

S welling

S tiffness & Stability

M ust

P ass

F ***ing

F inals

W ith

S ome

S tudying

20 year old male Dislocated his left shoulder playing rugby Ongoing Instability …

20 year old male Dislocated his left shoulder playing rugby Ongoing Instability …

1. Onset: 1. Exact

Mechanism of Injury

2. Able to continue playing?

3. Management - relocated on pitch/hospital

4. Ease of relocation

2. Pain: 1. when

2. where 3. Nature of pain 4. Associated

symptoms (clicking, locking, instability)

3. Function: 1. Able to play? 2. Able to train

(what training)?

3. If not, why? (pain,

weakness or instability)

4. ADL 4. Instability:

1. When 2. What position(s) /

Activity 3. Disloc / Sublux /

Loose 4. Clicking / Locking 5. Associated pain?

Considerations: Labral tear; capsular tear; fracture; rotator cuff tear; laxity; other joints

58 year old Female Insidious onset shoulder pain 2 months ago Pain extremely severe and unable to sleep

58 year old Female Insidious onset shoulder pain 2 months ago Pain extremely severe and unable to sleep

1. Onset: 1. Gradual /

Sudden 2. Worsening /

improving / no change

3. Previous similar?

2. Pain: 1. when 2. where 3. Nature of pain 4. Associated

symptoms (clicking, locking, instability)

5. Relieving factors

3. Function: 1. ADL 2. Sleep 3. Work 4. Recreation

Considerations: Calcific tendonitis (most likely); Frozen Shoulder; ACJ Arthritis; Degenerative cuff tear; Tumour;

Infection; Radicular origin

58 year old Female Fell 3 months ago injuring shoulder Normal x-rays, but still painful and

struggling with gardening & housework

58 year old Female Fell 3 months ago injuring shoulder Normal x-rays, but still painful and struggling with gardening

& housework

Considerations: Rotator cuff tear; Greater tuberosity fracture; Post-traumatic Frozen Shoulder

NOT Labral injury!

1. Onset: 1. Exact

Mechanism of Injury

2. Able to continue with ADL?

3. Management at the time

2. Pain: 1. when 2. where 3. Nature of pain

4. Associated symptoms

3. Function: 1. ADL 2. Sleep 3. Recreation 4. Work

72 year old Farmer Elbow pain for 2 years Increasing in severity

72 year old Farmer Elbow pain for 2 years Increasing in severity

Considerations: Arthritis (most likely); Epicondylitis; Biceps/Triceps Tendonitis

1. Onset: 1. Gradual /

Sudden 2. Worsening /

improving / no change

3. Previous similar?

2. Pain: 1. when 2. where

(lateral/medial)

3. Nature of pain 4. Associated

symptoms (clicking, locking, instability)

5. Relieving factors

3. Function: 1. ADL 2. Sleep 3. Work 4. Recreation

Case 5

21 year old Rugby player Fell onto outstretched hand Felt a clunk Very painful medial side of elbow

Case 521 year old Rugby player Fell onto outstretched hand Felt a clunk Very painful medial side of elbow

1. Onset: 1. Exact

Mechanism of Injury

2. Able to continue playing?

3. Management - ? dislocated / subluxed - ?relocated on pitch/hospital

4. Ease of relocation

2. Pain: 1. when 2. where 3. Nature of pain 4. Associated

symptoms (clicking, locking, instability)

3. Function: 1. Able to play? 2. Able to train

(what training)?

3. If not, why? (pain, weakness or instability)

4. ADL 4. Instability:

1. When 2. What position(s) /

Activity 3. Disloc / Sublux /

Loose 4. Clicking / Locking 5. Associated pain?

Considerations: Traumatic instability; fractures

Case 6

18 year old female Right handed Keen tennis player Painful & clicking right scapula No recollection of injury

Case 6 18 year old female Right handed Keen tennis player Painful & clicking right scapula No recollection of injury

1. Onset: 1. Gradual /

Sudden 2. Worsening /

improving / no change

3. Previous similar?

2. Pain: 1. when 2. where 3. Nature of pain 4. Associated

symptoms (clicking, locking, instability)

5. Relieving factors

3. Function: 1. ADL 2. Sleep 3. Work 4. Recreation

4. Other: 1. Other joints 2. Family Hx 3. Spinal

Considerations: Snapping Scapula; Scapula Dyskinesis; Secondary to GHJ Instability; Hyperlaxity; Overhead Athlete

Thank You Lennard Funk, 2015