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This arthrogram of the shoulder shows:
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Osteoarthritis of the glenohumeral joint
Para-articular ossification
Tuberculosis of the shoulder
Supraspinatus tendonitis
A tear of the rotator cuff Correct, This arthrogram shows extravasation of dye into the
subacromial space which must imply that there is a tear in the capsule and therefore of the
rotator cuff
This young man was knocked off his motorcycle by a car travelling at high speed. He landed on the point of
his left shoulder and the left side of his face. Which of the following injuries is the LEAST likely?
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Dislocation of the shoulder Correct, The injuries that are common are caused by the direct effect
of the impact and by the stretching effect of depressing the shoulder and pushing the neck in the
opposite direction. Therefore fractures of the clavicle, acromion and the first rib occur. The
brachial plexus may be stretched or avulsed. If there is complete avulsion of the plexus than the
cervical sympathetic chain may be damaged and a Horners syndrome results. Dislocation of the
shoulder is unlikely between the mechanism for a dislocation is an indirect injury, usually a fall
on the outstretched arm.
Fracture of the first rib
Fracture of the clavicle
Injury to the brachial plexus
Horners syndrome
This x-ray of the shoulder shows:
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Osteoarthritis of the glenohumeral joint
Para-articular ossification
Tuberculosis of the shoulder
Supraspinatus tendonitis Correct, The x-ray shows calcification in the line of the supraspinatus
tendon. This is therefore calcific supraspinatus tendonitis. Tuberculosis of the shoulder destroys
the joint. A rotator cuff tear cannot be shown on plain x-rays with any degree of certainty.
A tear of the rotator cuff
This man has:
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A dislocation of the shoulder Correct, This man has a chronic unreduced dislocation of the
shoulder. The alignment of the humerus if projected proximally is quite different from that of the
other side. There is secondary wasting of the deltoid.
A dislocation of the acromioclavicular joint
Paralysis of the suprascapular nerve
Paralysis of the nerve to serratus anterior
Sprengels shoulder
On clinical examination, this patient demonstrates a painful arc of movement. This painful arc is most likely to
be:
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From 0 - 90 degrees abduction
From 140 - 180 degress abduction
From 0 - 30 degrees extension
From 60 - 120 degrees abduction Correct, This man has calcification in the supraspinatus
tendon. This will give him a subacromial painful arc. The pain is produced by the rubbing of the
inflamed tendon under the acromion and under the coraco-acromial ligament. Once the arm is
abducted beyond 90 degrees, then the tendon is no longer under the leading edge of the coracoacromial complex and therefore further movement becomes painless. Therefore, the range of
movement which will be painful will be from 60 - 120 degrees. Painful arcs which show pain from
90 degrees onwards are the acromioclavicular painful arcs which are caused by pathology in the
acromioclavicular joint.
From 0 - 90 degrees forward flexion
This patient:
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Has a lesion of the nerve to latissimus dorsi
Has a posterior dislocation of the shoulder
Has lesions involving both the suprascapular and circumflex humeral (axillary) nerves Correct,
This man shows wasting of the supraspinatus, infraspinatus and the deltoid. Therefore his
suprascapular nerve and the axillary nerves are damaged or else he has damage to the superior
roots of the brachial plexus. Although there is muscle wasting, the overall contour of the
shoulder is not disturbed. Sprengels shoulder is an elevation of the scapular caused by a
persistence of a band between the angle of the scapula and the cervical spine. This scapula is
not normally elevated.
Has a Sprengels shoulder
Has a partial brachial plexus lesion involving the lower nerve roots
The appearance of this shoulder is most likely to be caused by:
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A C5 nerve root lesion from a cervical disc
A fractured clavicle
An acromio-clavicular dislocation
A fracture of the surgical neck of the humerus
Anterior dislocation of the shoulder Correct, This is an anterior dislocation of the shoulder and it
is a typical appearance with a 'squaring off' of the shoulder. The head of the humerus is now
anterior and below the level of the glenoid.
This radiograph of an injured shoulder shows:
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A fracture dislocation of the humerusCorrect, This radiograph shows a fracture dislocation of the
shoulder with the dislocation being posterior. The fractures are obvious with a fragment off the
metaphysis. There is a fracture through the surgical neck and another one through the head of
the humerus. The injury that is difficult to spot is posterior subluxation and this is a classic catch
in injuries of the shoulder. Nevertheless, one can see that the overlap between the glenoid and
the humeral head is only partial.
A fracture of the humerus
A fracture of the acromion
A fracture of the coracoid
The asymmetry in this man's shoulders:
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Indicates a dislocation of the left shoulder
Is caused by a scoliosis
Is a normal variant Correct, This man is asymptomic and therefore the asymmetry in the two
sides of his body must be looked upon as normal variants. There are quite significant differences
in the two sides of the body. The right shoulder is very commonly lower than the left in righthanded people. Leg length can vary up to an inch without producing any symptoms. Foot size
varies by half a shoe size. This man shows quite a significant hemihypertrophy on the right side.
However, because both limbs function normally it can not be regarded as pathological in any
way.
Needs further investigation
This patient has an obvious deformity of his right shoulder. You would expect to find:
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Paralysis of serratus anterior
Dislocation of the glenohumeral joint Correct, The appearance of this patient is consistent with a
dislocation of the glenohumeral joint. The acromion on the affected side is much more easily
seen than on the normal side due to the loss of normal shoulder contour. The long thoracic nerve
supplies the serratus anterior muscle and paralysis of this results in winging of the scapula. This
patient does not have this sign. Limb-girdle muscular dystrophy is a primary muscle disorder
and is bilateral.
Dislocation of the acromioclavicular joint
Neuropraxia of long thoracic nerve
Limb-girdle muscular dystrophy
This injury was sustained by a rugby player. You would:
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Send the patient home Correct, This x-ray shows a dislocation of the acromioclavicular joint. The
distal end of the clavicle is sitting above the medial edge of the acromium and the distance
between the calvicle and coracoid is increased. This signifies disruption of the coracoclavicular
ligaments. This injury is adequately managed with resting the elbow in a broad arm sling until the
pain settles down. Patients with this injury usually become asymptomatic and have return to
football within six weeks.
Remanipulate the elbow
Admit for observation
Arrange for surgery
Start physiotherapy within the next few days
This x-ray shows:
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A subluxation of the shoulder
A posterior dislocation of the shoulder
An anterior dislocation of the shoulder Correct, This is an anterior dislocation of the shoulder. In
this axial view it is possible to identify the spine of the scapula, the coracoid and the glenoid. The
head of the humerus is lying anteriorly, beneath the coracoid. The coracoid is normal.
Destruction of the coracoid
A normal shoulder in an axial projection
This patient sustained this injury playing football. Which of the following must have occurred:
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Rupture of the rotator cuff
Rupture of the coraco-acromial ligament
Rupture of the rhomboid ligament
Rupture of the coraco-clavicular ligament Correct, The radiograph demonstrates a dislocation of
the acromio-clavicular joint. One of the primary group of stabilising ligaments are the conoid and
trapezoid ligaments which run from the superior surface of the coracoid process to the
undersurface of the lateral third of the clavicle. These are also known therefore as the coracoclavicular ligaments. To enable the joint to dislocate, these ligaments must rupture.
Rupture of the coraco-humeral ligament