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PassPMR - 07 Musculoskeletal Medicine > 2- Shoulder & Neck > Flashcards

2- Shoulder & Neck Flashcards

1
Q

List 4 internal rotators of the shoulder. 🔑🔑 MOCK

A
  1. Subscapularis (upper and lower subscapular nerves, posterior cord, C5,6)
  2. Pectoralis major (lateral and medial pectoral nerves, med and la cord, C5-T1)
  3. Teres major (lower subscapular nerves, posterior cord, upper trunk, C5, 6)
  4. Latissimus dorsi (thoracodorsal nerve, posterior cord, C6, 7, 8)
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2
Q

What muscles are considered the primary scapular stabilizers? 🔑🔑 Dr. Jamal

List exercises that are used to train and strengthen them

A
  1. Levator Scapula: Shrugs, press ups
  2. Trapezius: Scapular rotation, shrugs
  3. Rhomboids: Rows, Prone arm lifts
  4. Teres Major: Pull Down
  5. Serratus anterior: Push up, punches

PMR Secrets 3rd Edition Chapter 43 Shoulder pg342

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3
Q

Describe the importance of the scapula in shoulder function and rehabilitation.

A

The scapula is the platform of glenohumeral articulation and motion

After shoulder injury, serratus anterior and lower trapezius are reflexively inhibited, thus destabelizing the platform, producing retracted and downward rotation of scapula, which exacerbate shoulder pathology (impingement and rotator cuff disease).

Neuromuscular reeducation of the serratus anterior and lower trapezius and then strengthening are the initial rehabilitation steps for many shoulder disorders

PMR Secrets 3rd Edition Chapter 43 Shoulder pg342

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4
Q

Is posture a factor in evaluation shoulder pain?

A

Yes, exaggerated thoracic kyphosis causes scapula to rotate downward making impingement more possible

PMR Secrets 3rd Edition Chapter 43 Shoulder pg342

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5
Q

Name the three most common anatomic structures of the shoulder involved in shoulder impingement syndrome.

A

SUBACROMIAL SPACE

  1. Subacromial bursa
  2. Biceps tendon
  3. Rotator cuff (most commonly the supraspinatus)

Cuccurollo 4th Edition Chapter 4 MSK pg163-167

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6
Q

What is the mechanism of “drop arm test”

A

Patient cannot actively abduct his arm, passive abduction to horizontal level can be briefly held by deltoid muscle, but the arm drops gradually +/- minimal wieght.

PMR Secrets 3rd Edition Chapter 43 Shoulder pg343

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7
Q

Mention one test to determine the presence of a complete rotate cuff tear

A

In complete tear, active external rotation of the arm is not possible.

PMR Secrets 3rd Edition Chapter 43 Shoulder pg343

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8
Q

Describe common radiographic findings after a traumatic anterior shoulder dislocation 🔑🔑

A
  1. Bankart lesion: Injury and detachment of anterior inferior glenoid labrum
  2. Bony Bankart: fracture of anterior interior glenoid rim
  3. Hill Sachs lesion: compression fracture of posteriolateral aspect of humeral head

PMR Secrets 3rd Edition Chapter 43 Shoulder pg344

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9
Q

Describe the two types of shoulder impingement 🔑🔑 Dr. Jamal

A

Primary outlet impingement → Extrinsic compression

  1. Hooked acromion
  2. Subacromion osteophyte
  3. Thick coracoacromial ligament
  4. Thoracic kyphosis
  5. Protracted and downward rotated scapula

Secondary (internal or glenoid) impingement → Intrinsic compression

  1. Overhead throwing athletes, related to shoulder stability

PMR Secrets 3rd Edition Chapter 43 Shoulder pg344

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10
Q

What are the mechanism, diagnosis and management of shoulder subluxation 🔑🔑

A

Mechanism

  1. Glenohumeral capsule → Injury or laxity
  2. Rotator cuff weakness → Stroke

Management

  1. Positioning to avoid downward traction
  2. Increase supraspinatous muscle contraction mechanically or electrically

PMR Secrets 3rd Edition Chapter 43 Shoulder pg345

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11
Q

What is the optimum treatment of a frozen shoulder? 🔑🔑

A

NON-PHARMA

  1. Avoid splinting
  2. Early mobilization with pendulum exercises
  3. Aggressive passive then active-assisted range of motion
  4. Daily stretches 2-3 times

PHARMA

  1. Medication for pain relief prior to stretching
    1. NSAID
    2. Oral steroid
    3. Intraarticular injection

SURGICAL

  1. Manipulation under anasthesia
  2. Surgical release of adhesion

PMR Secrets 3rd Edition Chapter 43 Shoulder pg346

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12
Q

Suggest a convenient way for initiating active-passive shoulder movement

A

Pendulum (Codman’s) exercises: patient bend forward, arm pendular position and body actively moving to passively move the arm.

PMR Secrets 3rd Edition Chapter 43 Shoulder pg349

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13
Q

Contracture management in any patient. 4 marks. 🔑🔑

A

Non-Pharmacological

  1. Passive ROM and stretching exercises
  2. Proper positioning
  3. Maintain the maximally corrected position with rigid AFO
  4. Effective management of spasticity

Surgical

  1. Tenotomy
  2. Tendon-lengthening
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14
Q

Anatomical Classification of Contractures List 3 intrinsic and 3 extrinsic causes of myogenic contracture 🔑

A
  1. SKIN
    • Trauma, burns, infection, systemic sclerosis
  2. BONE & TENDON
    • Immobilization, capsular fibrosis, infection, trauma, degenerative joint disease
    • Tendinitis, bursitis, ligamentous tear, and fibrosis
  3. MUSCLE
    • Intrinsic: Traumatic (e.g., bleeding, edema), Inflammatory (e.g., myositis, polymyositis), Degenerative (e.g., muscular dystrophy), Ischemic (Compartment)
    • Extrinsic: Spasticity, Flaccid paralysis,Mechanical/Positional, Immobilization
  4. MIXED

DeLisa 5th Edition Chapter 48 Physical Inactivity pg1255 Table 48.2

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15
Q

What are the 5 stages of rehabilitation in sports injury? 🔑🔑 Dr. Jamal

A
  1. Management of PAIN and inflammation with relative rest.
  2. ROM exercises, goal is to restore painless full motion
  3. STRENGTH exercises and fixing muscle imbalance
  4. PRIOPRIOCEPTION training.
  5. Sports/task SPECIFIC activities.

Delisa pg 1414.

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16
Q

List 6 reasons for non-union of a fracture (delayed fracture healing).

A

ALIGMENT

  1. Bone - poor fixation.

BLOOD

  1. Smoking.
  2. AVN (poor blood supply).

NUTRIENTS

  1. Nutrition (Vit D deficiency, calcium deficiency)
  2. Endocrine (Vit D deficiency, calcium deficiency, occult hyper PTH, HypoTSH, poor DM control, Pagets disease).

INFLAMMATION

  1. Meds (anti-inflammatory i.e. Corticosteroids, NSAIDs).
  2. Infection.
17
Q

GHJ Instability: Classification, Presentation, Directions, Xray, Complications, Tx 🔑🔑 (OSCE)

A

DEGREES OF INSTABILITY

Instability

Translation of the humeral head with respect to the glenoid fossa.

  • Anterior (most common): abduction & external rotation (ie throwing)
  • Posterior: adducted & internal rotated (fall on flexed arm) → during seizure
  • Multi-Directional: generalized laxity (Ehlers-Danlos syndromes (EDS) & Marfan)

Subluxation

Incomplete separation of the humeral head from the glenoid fossa with immediate reduction and partial intact joint capsule.

Dislocation

Complete separation of the humeral head from the glenoid fossa without immediate reduction with injured joint capsule.

PRESENTATION

  • Generalized ligament laxity
  • Dead arm syndrome: Shoulder fatigue, pain, numbness, and paresthesias
  • Fear of re-dislocation in abduction and external rotation (ie throwing and vollyball)

DIRECTIONS

Anterior Instability

  • Most common, younger population, high recurrence rate
  • Mechanism: Arm abduction and external rotation (ie throwing)
  • Complication
    1. Axillary n. injury
    2. Bankart lesion
      1. Labral Tear of anterior glenoid
      2. Avulsion fracture off the glenoid rim (boney Bankart)
    3. Hill–Sachs lesion
      1. Compression fracture of posteriolateral humeral head
  • Provocative Tests
    1. Anterior load-and-shift test (modified anterior drawer test)
    2. Apprehension
    3. Relocation test
    4. Anterior drawer test

Posterior Instability

  • Provocative Tests
    1. Posterior load-and-shift test
    2. Jerk Test
    3. Posterior drawer test
  • Complications
    1. Reverse Bankart lesion
    2. Reverse Hill–Sachs lesion
  • Treatment
    1. Immobilize roughly 3 weeks
    2. Strengthening the posterior shoulder–scapula musculature (6 months)

Multidirectional

  • Provocative Tests
    1. Sulcus Sign
    2. Load-and-shift test

XRAY

  • AP, scapular-Y, and axillary lateral views

TREATMENT

💡 Higher mobility joint uses dynamic muscular control as its greatest stabilizer.

1. Non-Traumatic AMBRI

  • Atraumatic - Multidirectional - Bilateral - Rehabilitation - Inferior capsular shift
  • 80% of the patients obtain excellent results with rehabilitation
  • This highly mobile joint uses dynamic muscular control as its greatest stabilizer
  • Educating patients for avoid positions of known instability
  • Inferior capsular shift indicated surgical treatment

2. Traumatic TUBS

  • Traumatic - Unidirectional - Bankart - Surgical
  • Sling immobilization 2-3 weeks
  • Passive range of motion (PROM): Codman’s pendulum exercises
  • Isometric exercises early in the recovery course
  • ROM and strengthening the posterior shoulder–scapula musculature
  • After a third dislocation, surgical maybe considered

Cuccurollo 4th Edition Chapter 4 MSK pg159-162

18
Q

Labrum Tear: Presentation, Complication, Tx 🔑🔑

A

Presentation

  • Shoulder instability (clicking, locking, pain)

Etiology

  • Repetitive overhead sports (baseball, volleyball) or traumas

Pathophysiology

  • Tears may occur through the anterior, posterior, or superior aspect
  • Accompanied by rotator cuff or biceps tendon pathology, as they are insert on the labrum
  • Superior glenoid Labral tear in the Anterior-to-Posterior direction (SLAP)

Provocative Test

  • Load-and-shift test
  • O’Brien’s test

Treatment

  • Same as GHJ instability

Cuccurollo 4th Edition Chapter 4 MSK pg162-163

19
Q

Deltoid injury: Presentation & Treatment

A

ANATOMY

  • Origin: Anterior clavicle, the acromion, and the spine of the scapula.
  • Insertion: Deltoid tuberosity of humerus
  • Nerve: Axillary nerve (C5, C6)

STRAIN

  • Anterior deltoid can be injured during the acceleration phase of throwing.
  • Posterior deltoid can be injured during the deceleration phase of throwing.
  • Swelling, local tenderness, and limited shoulder motion

RUPTURE

  • Crush injuries or severe direct blows
  • Swelling, ecchymosis, palpable defect & weakness.
  • Grade V AC joint separations

IMAGING

  • Plain radiographs to r/o shoulder dislocation or AC separation
  • MRI suspected cases of deltoid rupture.

TREATMENT

  • For strains and contusions, ice and immobilize acutely. Then perform stretching and progressive strengthening exercises.
  • For complete rupture or avulsion, treatment is surgical reattachment.

Cuccurollo 4th Edition Chapter 4 MSK pg172

20
Q

Types of scapular winging. Nerve injury and muscles affected 🔑🔑 MOCK

A

Management

  • Electrodiagnostic studies → diagnose nerve injury and prognosis.
  • Scapular stabilization rehabilitation

Cuccurollo 4th Edition Chapter 4 MSK pg173-173

PMR Secrets 3rd Edition Chapter 43 Shoulder pg 342 Table 43-1

21
Q

What are the 3 stages of shoulder impingement (Neer’s staging) 🔑🔑 MOCK

Describe the classification of impingement syndrome 🔑🔑 Dr. Jamal

Why does impingement syndrome result in rotator cuff tears?

Shoulder impingement: Presentation, PEx, Management

A

NEER CLASSIFICATION

Stage 1: Edema or hemorrhage (age <25) → Reversible, conservative

Stage 2: Fibrosis and tendonitis (ages 25–40) → Less reversible, usually not surgical.

Stage 3: AC spur and rotator cuff tear (age >40) → Surgery

INTERNAL IMPINGEMENT

Primary

  1. Hooked acromion
  2. Thick coracoacromial ligament

Secondary

  1. Glenohumeral joint instability
  2. Weak scapular stabilizers
  3. Scapulothoracic dyskinesis

EXTERNAL IMPINGEMENT

  • Overhead athletes
    • Abduction and external rotation
    • Augmented by posterior joint instability capsular tightness

ROTATOR CUFF

Muscle

  1. Supraspinatus
  2. Infraspinatus
  3. Teres minor
  4. Subscapularis

Function

  1. Rotate the arm
  2. Stabilize the humeral head against the glenoid.

Why does impingement syndrome result in rotator cuff tears?

  • Because the critical zone of hypovascularity is about 1 cm from the insertion site

Inadequate scapula rotation during shoulder elevation

  • Weakness of the scapula stabilizers
  • Muscle incoordination

Tear

  1. Direct trauma
  2. The result from chronic impingement (older than 40 years old)
  3. Curved or hooked acromion has a higher risk of rotator cuff tears.

PRESENTATION

  • Pain in repetitive overhead activities (Flexion, abduction, internal rotation)
  • Crepitus, clicking or catching on overhead activities
  • Pain may be referred anywhere along the shoulder girdle
  • Nocturnal pain → Difficulty sleeping on the affected side.
  • Glenohumeral joint instability: numbness, tingling, feelings of subluxation, or previous “dead arm” episodes.

PHYSICAL EXAMINATION

  1. Atrophy (chronic tears)
  2. Strength testing of the rotator cuff muscles
  3. Tenderness: Over the greater tuberosity or inferior to the acromion on palpation
  4. Painful arc
    • Inability to initiate abduction may indicate a rotator cuff tear
    • pain occurring roughly between 60 degrees and 120 degrees.
  5. Impingement → Near Hawk
    • Neer’s impingement sign
      • Supraspinatus tendon being compressed between the acromion and greater tuberosity of the humerus
    • Hawkins’ impingement sign
      • Impingement of the tendon, most commonly the supraspinatus, under the acromion and the greater tuberosity occurs with arm abduction and internal rotation.
      • Supraspinatus tendon being compressed between the coracoacromial ligament and greater tuberosity of the humerus
  6. Supraspinatus → Drop the Can
    • Empty can (supraspinatus) test
    • Drop arm test
      • The arm is passively abducted to 90 degrees and internally rotated
      • Initially, the deltoid will assist in abduction but fails to indicate a complete tear of the cuff
  7. Apprehension test
    • Anterior apprehension → anterior instability of the glenohumeral joint and internal impingement → relieved with the relocation test

INVESTIGATIONS

  1. Shoulder
    1. AP View
      • Subacromial sclerosis
      • Superior migration of proximal humerus (Acromiohumeral distance < 7 mm)
      • Flattening of the greater tuberosity
      • Superior and medial wear into the glenoid, coracoid, AC joint, and acromion
      • AC joint osteophytes
    2. “Y” view
      • Assess acromion morphology
  2. MRI
    • The gold standard (Full thickness tears and partial tears)
  3. Ultrasound (US)
    • Full thickness tears: non-visualization of the cuff
    • Thickened, heterogeneous appearing tendon: partial tear or tendinosis.

CONFIRM DIAGNOSIS

  • Elimination of the pain provoked by impingement testing after injection of 5 to 10 mL of 1% lidocaine into the subacromial space confirms the diagnosis of impingement.

CONSERVATIVE (REHABILITATION)

  1. Acute phase (up to 4 weeks) → Pain
    1. Reduce pain and inflammation
    2. Relative rest
    3. Reestablish nonpainful and scapulohumeral ROM.
    4. Minimize muscle atrophy of the entire upper extremity
    5. Extracorporeal shock-wave therapy
  2. Recovery phase (months) → ROM & Stabilize
    1. Proprioception
    2. Full pain-free ROM
    3. Improve scapular stabilizers (rhomboids, levator scapulae, trapezius, serratus anterior) → 1st priority
    4. To reduce impingement, pull the shoulder down
      1. Strengthen scapula stabilizer (serratus anterior)
      2. Strengthen scapula retractor, and depress (rhomboids and inferior trapezius)
      3. Stretching muscles that protract and elevate the scapula (e.g., pectoralis minor and upper trapezius)
    5. Improve rotator cuff (supraspinatus) → 2nd priority
      1. Closed chain exercises to promote stability and proprioception
      2. Open chain exercises can be used to correct strength imbalances, such as weakness of the shoulder external rotators relative to the internal rotators
    6. Re-establish normal scapulothoracic kinematics through neuromuscular retraining.
  3. Functional phase → Strength & Sport
    1. Strengthening exercises
    2. Increasing power and endurance (plyometrics)
    3. Perform activity-specific training

SURGICAL MANAGEMENT

  1. Ultrasound-guided percutaneous lavage and aspiration
    • Calcific tendinopathy is presented
  2. Corticosteroid injection
    • Only up to three injections yearly
  3. Surgery
    • Indicated in partial or full thickness tears that fail conservative treatment
    • Acute rotator cuff tears (i.e., athletes/trauma) → first 3 weeks
    • Acromioplasty, coracoacromial ligament lysis, repair rotator cuff tendon.
    • Restoration of abduction is less predictable than relief of pain.

Cuccurollo 4th Edition Chapter 4 MSK pg163-167

Braddom 6th Edition Chapter 35 UL Upper Limb Pain and Dysfunction pg717-718

22
Q

List diagnoses associated with rotator cuff impingement

A

NARROW SPACE

  1. Subacromial spurs
  2. Subacromial bursitis
  3. Bicipital tendonitis

STATIC & DYNAMIC STABILIZER

  1. Coracoacromial ligament degeneration
  2. Rotator cuff disease
  3. Scapular dyskinesis
  4. GH instability
  5. Labral tear

REFERRED

  1. Cervical radiculopathy
23
Q

Pain with shoulder abduction and overhead activities. Diagnosis & Management.

A

Diagnosis

  • Calcified tendonitis, Ca deposit in supraspinatous tendon
  • Size of the deposit has no correlation to symptoms

Management

  1. Physical therapy
  2. US-guided percutaneous needling, aspiration, and saline lavage
  3. Subacromial injection
  4. Surgical treatment for those who have failed more conservative treatments.

Cuccurollo 4th Edition Chapter 4 MSK pg168-169

24
Q

When do you suspect AC joint injury?

List 2 Provocation Tests.

Mention 3 ligaments stabelize AC joint

Rackwood Classification of AC injury & their management. 🔑🔑

A

AC Joint:

  • Gliding joint

Stabilization (3)

  1. Acromioclavicular (AC) Ligament: horizontal stability
  2. Coracoclavicular (CC) Ligament: preventing vertical translation
  3. Coracoacromial (CA) Ligament

Presentation

  1. Soft tissue swelling
  2. AC joint displacement type III or greater.
  3. AC joint tenderness
  4. Severe shoulder droop & instability
  5. Cross-chest (horizontal adduction or scarf) test

Xray

  • Type III injuries may show a 25% to 100% widening of the CC space
  • Type V injuries may show a widening >100%.

Acute

  • Incomplete Tear (Types I & II): P.O.L.I.C.E., Return after 6 weeks
  • Complete Tear (Type III): Surgical for heavy laborers, athletes
  • Dislocation (Types IV, V, VI): (ORIF) or distal clavicular resection with reconstruction of the CC ligament

Chronic

  • Corticosteroid injection
  • Clavicular resection and CC reconstruction

Complications

  • Clavicular fractures and dislocations
  • AC joint arthritis
  • Distal clavicle osteolysis

Cuccurollo 4th Edition Chapter 4 MSK pg155-158

25
Q

Biceps Tendonitis & Rupture: Anatomy - Presentation - Name 3 Tests 🔑 - Management

A

ROTATOR CUFF AND BICEP TENDONITIS

  • Isolated bicipital tendonitis as the primary cause of shoulder pain is uncommon
  • It exists along the continuum of rotator cuff tendinitis secondary to its related proximity.
  • Impingement is a result of biomechanical dysfunction of the shoulder and itself is not a pathologic diagnosis.
  • This impingement causes pathology by repetitive compromise of the soft tissues of the shoulder girdle

ANATOMY

  • Long head of the biceps tendon: supraglenoid tuberosity
  • Short head of the biceps tendon: coracoid process
  • Insertion: radial tuberosity

IMAGING

  • MRI: tendinopathy or biceps tendon rupture.
  • Diagnostic US imaging (quick, in-office evaluation)

TENDONITIS

Examination

  1. Tenderness in the bicipital groove (long head)
  2. Positive impingement signs (associated with shoulder impingement syndrome)
  3. Yergason’s test
  4. Speed’s test

Treatment

  1. ROM
  2. Modalities
  3. Strengthening as tolerated
  4. Injection into the tendon sheath (controversial)

TENDON RUPTURE

Causes

  • Proximal Tear → Chronic impingement & Rotator cuff tears
  • Distal Tear → Heavy lifting → Sharp pain, audible snap

Examination

  1. Popeye sign
  2. Ecchymosis
  3. Ludington’s test

Surgical Correction

  • Patient requiring heavy lifting or cosmetic

Cuccurollo 4th Edition Chapter 4 MSK pg170-172

26
Q

Name 3 muscles that attach to the coracoid process. 🔑🔑

A
  1. coracobrachialis
  2. short head of the biceps
  3. pec minor (insertion)
27
Q

OA Shoulder: 1st Sign in PEx, 4 Xray findings, 3 Surgical Indication

Post OP precautions & Arthrtodesis position 🔑🔑

A

SHOULDER OA

Etiology

  • Posttraumatic lesions
  • Chronic rotator cuff pathology

Presentation

  • Pain affecting activities of daily living (ADLs)
  • Pain may be nocturnal and relieved by rest.

Xray

  1. Irregular joint surfaces
  2. Flattened glenoid
  3. Joint space narrowing (cartilage destruction)
  4. Subacromial sclerosis
  5. Osteophyte changes
  6. Cystic changes in the humeral head

Examination

  • Pain in internal rotation and abduction
  • Tenderness felt on palpation on the anterior and posterior aspects of the shoulder
  • Manual muscle testing (MMT) may or may not be affected

Conservative

  1. NSAID
  2. Corticosteroid injection
  3. ROM exercises
  4. Rotator cuff strengthening

TOTAL SHOULDER ARTHROPLASTY (TSA)

Goals

  • Relieve pain, protect joint, and restore function

Indication

  1. Pain
  2. Avascular necrosis
  3. Neoplasm

Precautions status post-TSA

  1. Sling immobilization
  2. No active ROM, nonweight bearing (NWB)
  3. Avoid active abductions and extension >0 degrees.
  4. No external rotation >15 degrees

Stage 1: 2 to 6 weeks

  1. Shoulder Sling
  2. Gentle PROM (Codman’s exercises)
  3. Active range of motion (AROM; wall-walking)
  4. Isometrics exercises (progressing)

Stage 2: 6 to 12 weeks

  1. Discontinue sling
  2. Active-assist ROM (AAROM), AROM
  3. Start isotonics exercises, start light weights.

Stage 3: >12 weeks

  1. Stretching
  2. Active ROM
  3. Progressive resistive exercises

SHOULDER ARTHRODESIS

Indications

  1. Severe shoulder pain secondary to osteoarthritis (OA)
  2. Mechanical loosening of a shoulder arthroplasty
  3. Joint infection

Position

  • 50-degree abduction
  • 30-degree forward flexion
  • 50-degree internal rotation

Cuccurollo 4th Edition Chapter 4 MSK pg167-168

28
Q

Adhesive Capsulitis: Presentation, 1st Sign in PEx, Investigation, Management

Stages & 6 Etiologies 🔑🔑 When to operate? 🔑🔑

A

ADHESIVE CAPSULITIS

  • Synovial tissue of the capsule and bursa become adherent

ETIOLOGY

  1. Trauma
  2. Immobilization
  3. Intracranial lesions: CVA, hemorrhage, tumor
  4. CRPS
  5. Clinical depression
  6. Parkinson’s disease
  7. Diabetes
  8. Hypothyroid
  9. Autoimmune

STAGES

  1. Painful stage: Progressive vague pain lasting roughly 8 months
  2. Stiffening stage: Decreasing ROM lasting roughly 8 months
  3. Thawing stage: Increasing ROM with decrease of shoulder pain

PRESENT

  1. Painful shoulder with restricted glenohumeral motion
  2. Painful ADLs

EXAM

  1. Significant reduction in both AROM and PROM
  2. External rotation and abduction ROM typically lost first.
  3. Contracture of the shoulder joint

INVESTIGATION

  1. Plain films (AP view)
    1. To rule out underlying tumor or calcium deposit
    2. Osteopenia → due to mechanical unloading
  2. MRI
    1. Thickened GHJ capsule and synovium

TREATMENT

Stages 1 and 2 → Reduce pain and inflammation

  • Pain modalities
  • Analgesics
  • Nonsteroidal anti-inflammatory drug (NSAID)
  • Oral steroids
  • Activity modification
  • Up to three intraarticular corticosteroid injections
    • To shorten the duration of the condition
    • Decrease pain to maximize therapy

Early ROM

  • Postural retraining to reduce kyphotic posture and forward humeral positioning
  • Passive joint glides
  • Passive and active assisted ROM exercises should be initiated.

Strength as Tolerate

  • Scapular stability exercises
  • Closed chain rotator cuff exercises
  • Active ROM along with open chain and proprioceptive exercises.

NO PROGRESS IN 6 MONTHS

  1. Xray to rule tumor or calcium deposit
  2. Arthroscopic lysis of adhesions
  3. Manipulation under anesthesia

Cuccurollo 4th Edition Chapter 4 MSK pg169

Braddom 6th Edition Chapter 35 UL MSK pg720-721

29
Q

What are the shoulder stabilizers? Exercise prescription 🔑🔑 Dr. Jamal

A

STATIC STABILIZERS

  1. Glenoid
  2. Glenoid Labrum
    - Cup-shaped rim of cartilage that reinforces a ball-and-socket joint
    - Increases overall contact of the humeral head with the glenoid by 70%
    - Attachment site for the glenohumeral ligaments
    - Prevents anterior and posterior humeral head dislocation
  3. Shoulder capsule
  4. Glenohumeral ligaments
    - Superior glenohumeral ligament: Prevents translation in the inferior direction in a neutral position. Provides stability of the shoulder from 0 degrees to 90 degrees of abduction
    - Middle glenohumeral ligament: Prevents anterior shoulder translation
    - Inferior glenohumeral ligament: Stabilizer above 90 degrees. Prevent posterior subluxation
  5. Coracohumeral ligament (CHL)
  6. Negative intraarticular pressure

DYNAMIC STABILIZERS

  1. Rotator cuff muscles
  2. The long head of the biceps tendon → Curls
  3. Deltoid, and teres major
  4. Latissimus dorsi

SCAPULA STABILISERS

  1. Trapezius → Shrug, Press Up, Up Right Rows
  2. Serratus anterior → Push Up-Plus, Punches
  3. Rhomboid Major & Minor → Rowing, Scapula Retraction
  4. Levator Scapula → Shrug, Press Up, Up Right Rows

Cuccurollo 4th Edition Chapter 4 MSK pg149-154

30
Q

List 3 early and 3 late complications of fracture (6 local complications) 🔑🔑 MOCK 21

A

EARLY

  1. Muscle: Acute Compartment Syndrome
  2. Nerve: Nerve Injury
  3. Vessels: Hemarthrosis, Vascular Injury
  4. Bone: Fat Embolism
  5. Skin: Cellulitis

LATE

  1. Bone: Delayed, Non, Malunion, Shortening/Growth Disturbance
  2. Vessels: AVN
  3. Joint: OA, Contracture
  4. Nerve: Compression
  5. Muscle: Osteomyelitis, Weakness & Atrophy
31
Q

Spot diagnosis - Complication

Four-Part (Neer) classification for humerus fracture patterns. 🔑🔑

Management

A

PROXIMAL HUMERAL FRACTURES

Etiology

  • Occur primarily in older osteoporotic patients after a low-energy fall
  • Young patients that experience a high-energy trauma

Presentation

  • Pain, swelling, and ecchymosis in the upper arm
  • Exacerbated with the slightest motion
  • Loss of sensation is seen if there is neurologic involvement
  • Diminished radial pulse if the fracture compromises the vascular supply

Complications

  1. Avascular necrosis (AVN) of the humeral head (humeral circumflex artery)
  2. Brachial plexus injuries
  3. Axillary nerve injury
  4. Axillary artery compromise
  5. Radial and ulnar nerves may be affected as well.
  6. The median nerve is the least affected.

FOUR PARTS

  1. Humeral head / Anatomical neck
  2. Humeral shaft / Surgical neck (most common)
  3. Greater tuberosity
  4. Lesser tuberosity

NEER CLASSIFICATION

  1. One-part humeral fracture: Nondisplaced fractures, All parts still in alignment.
  2. Two-part humeral fracture: One fragment is displaced
  3. Three-part humeral fracture: Two fragments are displaced.
  4. Four-part humeral fracture: All fragments are displaced

IMAGING

  • X-ray (trauma series): AP view, scapular Y view, axillary view, apical oblique view, and west point axillary view

MANAGEMENT

One part (mean non-displaced and joint still in one unit structure)

  • Sling immobilization and early rehabilitation (6 weeks)
  • Early ROM: Codman’s exercises and AROM as early as tolerated

Surgical (ORIF)

  • Greater than one part (displaced >2 cm)

PassPMR - 07 Musculoskeletal Medicine (8 decks)

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