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Acute & Chronic Shoulder Pain Flashcards

1
Q

What attaches to the deltoid tubercle of the humerus?

A

Deltoid

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2
Q

What attaches to the Intertubercle groove of the humerus?

A

Pectoralis major, Teres major & latissiumus dorsi

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3
Q

What attaches to the Greater tubercle of the humerus?

A

Infraspinatus & Teres minor

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4
Q

What attaches to the lesser tubercle of the humerus?

A

Subscapularis

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5
Q

What are the Rotator Cuff mucles & their innervations?

A
  • Supraspinatus (suprascapular n)
  • Infraspinatus (suprascapular n)
  • Teres minor (axillary n)
  • Subscapularis (subscapular n)
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6
Q

What attaches to the Coracoid process?

A
  • Pectoralis minor
  • Biceps bracii
  • Coracobrachialis
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7
Q

What are the 2 clavicular joints?

A

Sternoclavicular & Acromioclavicular

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8
Q

What is the glenoid labrum?

A

Fibrocartilaginous rim attached around the margin of the glenoid cavity in the shoulder blade

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9
Q

Hx of Glenohumeral Joint Dislocation

A
  • Severe pain
  • Does not want to move shoulder
  • Felt like it popped out of place
  • Flaccid UE too painful to move
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10
Q

What causes an Anterior shoulder dislocation?

A

ER or ABDuction force to humerus

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11
Q

How does a pt hold their arm w/ an Anterior shoulder dislocation?

A

Externally rotated & slightly abducted

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12
Q

What causes a Posterior shoulder dislocation?

A

Fall, seizure, electrocution

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13
Q

How does a pt hold their arm w/ a Posterior shoulder dislocation?

A

IR & ADDucted

Exhibiting flattening of the anterior shoulder & a prominent coracoid process.

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14
Q

What 3 X-ray views are needed for a GH dislocation?

A

AP, axillary & scapular-Y

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15
Q

What are CT scans good for?

A

Boney fractures

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16
Q

When should you get an MRI in a GH dislocation?

A

After reduction to check for labral tears

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17
Q

What is a Bankart lesion?

A

Anterior capsule & labrum tear d/t repeated shoulder dislocations

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18
Q

What is a Hill Sachs lesion?

A

Compression fracture of posterolateral humeral head

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19
Q

What causes a Hill Sachs lesion?

A

Forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly

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20
Q

What are the assoc injuries w/ GH dislocation?

A
  • Greater tuberosity fractures
  • Rotator cuff tears (especially over 40 yo)
  • Axillary nerve injury
  • Recurrent dislocations in younger patients
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21
Q

How does an Axillary n injury present?

A

Paralysis of Deltoid→ loss of ABDuction from 18-90°

(0-18° abduction by supraspinatus)

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22
Q

What is the management of a GH dislocation?

A
  • Sling
  • ROM
  • PT
  • Hold out of sports until stabilize & full ROM/ strength
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23
Q

Who should have surgery for GH dislocation?

A
  • <25 yo 1st time dislocation is relative indication
  • Younger the patient the higher risk of recurrence
  • Recurrent dislocation despite nonop tx
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24
Q

Hx of AC Joint Separation

A
  • Fall directly onto POINT of shoulder**
  • Complain of lateral shoulder pain at “TIP” of shoulder**
  • Athlete will hold the arm at side
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25
PE of AC joint separation
* Pain over AC joint & w/ cross arm test * Prominent AC joint or distal clavicle elevation * Possible increased motion of AC joint
26
Imaging for AC joint separation?
3 X-ray views: AP, axillary & scapular-Y
27
What is the Classification of AC separations?
* **I:** sprain AC ligaments * **II:** tear AC & sprain CC ligaments * **III:** tear both AC & CC ligaments
28
What is the tx of a AC joint separation?
* **I, II, III nonop w/ sling & ROM**\*\* * IV, V, VI surgery * Return to sport when nonpainful (management) * **Reconstruct** when greater than 100% displaced or chronic pain\*\*
29
Proximal Humerus facture hx
* Fall onto shoulder or on outstretched hand * Shoulder pain, swelling, bruising, and inability to use shoulder
30
PE of Humerus fracture
* Swelling * Pain to palpation * Crepitus with ROM * Bruising * Loss of normal contour of shoulder * Possible loss of sensation to lateral side of shoulder (**axillary nerve**)\*\*
31
What imaging is used to dx a Proximal Humerus fracture?
* **X-ray**: 3 views: AP, axillary & scapular-Y * CT scan: preop planning & classification of fracture
32
How are Proximal Humerus fractures tx?
* Nonop if minimal displacement of parts * Sling and early passive ROM
33
What are the indications for surgery in a Proximal Humerus fracture?
Displacement, bone quality, age, activity level, and associated injuries to decide
34
What % of pts w/ Proximal Humerus fracture need surgery?
20%
35
What is the hx of a Clavicle fracture?
* Fall onto area of shoulder or fall directly onto clavicle * Pain over area of fracture * May complain of deformity or bump
36
What will be found on PE of a Clavicle fracture?
* Bump over fracture site from elevation of clavicle * Swelling * Bruising * Motion at fracture site/crepitus
37
What imaging is dx of a Clavicle fracture?
X ray: 3 shoulder views & AP 30° cephalad
38
What is the tx of a Clavicle fracture?
* Most are nonop * Sling * Immobilize 3-4 weeks * No return to sports until healed and full ROM and strength (management)
39
What are indications for surgery in a clavicle fracture?
* Large displacement or large bump * Open fracture (bone went through skin) * Tenting of skin—bone is about to protrude through skin
40
What is the hx of a Burner/stinger?
* Short duration * UE only! * Unilateral! * Pain free c-spine motion * Numbness and shoulder weakness
41
What will be found on PE of a Burner/stinger?
* Weakness w/ shoulder motion * Numbness/paresthesias in arm * NO pain to range of motion of c-spine * Unilateral UE symptoms
42
What imaging is needed w/ a burner/stinger?
Normally not needed CT scan of C-spine w/ shoulder pads & helmet if suspect C-spine injury
43
What is the tx of a burner/stinger?
Rest & hold out of game Must be seen by a spine specialist if sx bilateral or in LE!
44
When can a athlete return to play?
When pain free full ROM of shoulder, no paresthesias, and normal strength
45
What is the hx of a Proxmial Biceps tendon rupture?
* Patient may feel a pop in the proximal arm or shoulder region usually lifting something * Bruising in upper arm * "Popeye arm": bulge in their arm
46
What will be found on PE of Proximal Biceps Tendon rupture?
* Classic bulge of “Popeye” arm * Some weakness of elbow flexion or arm supination (us. d/t pain)
47
What imaging is used to dx a Proximal Biceps tendon rupture?
MRI: absent intra-articular biceps tendon
48
What is the tx of a Proximal Bicep Tendon rupture?
PT, ICE, Anti-inflammatories, rare surgery
49
What is the ddx based on age for chronic shoulder pain?
Young (\<30-40 years of age): Instability Older (\>40 years of age) * Impingement * Biceps tendonitis * Rotator Cuff Tear * Frozen Shoulder (Adhesive Capsulitis) * Arthritis * Glenohumeral Joint * AC Joint
50
What is the MC dislocated joint?
Shoulder Joint
51
What is shoulder instability?
Pathological cond manifesting as pain or feeling of slipping due to excessive translation of humeral head on glenoid during active motion
52
What is the hx of Shoulder instability?
* Assoc w/ gen laxity of ligamentous structures * Often following shoulder dislocation(s) * Could be just from repeated subluxations * Often feel shoulder slipping * Often will have pain or weakness
53
Who gets Shoulder instability?
Swimmers, gymnasts Female more commonly
54
What are the special tests for Shoulder instability?
``` Apprehension sign (anterior and posterior) Relocation test ```
55
Imaging for Shoulder Instability
* **X-ray**: 3 views * MRI: labral tears
56
What does TUBS stand for?
* Traumatic * Unilateral * Bankart fracture * Surgery
57
What does AMBRI stand for?
* Atraumatic * Multidirectional instability * Bilateral * Rehab * Inferior capsular shift if surgery necessary
58
Tx for Shoulder instability?
Rehab--Especially AMBRI Surgery * Failed rehab * Contact sports * Large Bankart * Open or arthroscopic
59
What should surgery for shoulder instability focus on?
Labral tear—reattach Capsule laxity—tightening the capsule
60
Impingement hx
* Dull ache worse in evenings * Pain location generalized or lateral upper arm/shoulder or at deltoid insertion * Worst with overhead activity * Hurts to sleep on * Hurts to get things out of cabinet—reach above head or behind back
61
What are the special tests for Shoulder Impingement?
* Hawkings * Neer sign * Neer test * Empty can test
62
What is shoulder impingement?
Anterior 1/3 of acromion undersurface causes irritation to the underlying cuff tendons causing sx
63
What acromion shape inc risk of impingement?
Curved or hooked
64
Tx of Shoulder Impingement
* Rest * Analgesics * Exercises * Stretching * Strengthen * Injection (cortisone may weaken tendon and lead to rupture so counsel patient and slow rehab)\*\* * Surgery: Persistent, Excise and/or smooth acromion
65
Hx of Biceps tendonitis?
* Proximal pain along anterior humerus * Hurts with overhead activity and with throwing or pushing
66
Where will the pain be on PE of Biceps Tendonits?
Along the proximal biceps in the intertubercular groove
67
What special tests are used for Bicep tendonits?
* **Yergason test**--resist supination of forearm * Speed test--resisted forward F of arm
68
Imaging for Biceps Tendonits
X-ray: normal MRI: shows inflam
69
Tx of Biceps tendonits?
NSAIDs, PT, Rest Must be careful with injections because intra-tendon injection can cause rupture Surgery with tenotomy (cutting the tendon) or tenodesis (bury the tendon in the bone) when nonop fails
70
Hx of Rotator Cuff Tear
* Pain in area under acromion * Inability to raise arm above head * Weakness of motion
71
Which Rotator Cuff muscle is affected if weak forward elevation/Empty can sign?
Supraspinatus
72
Which rotator cuff muscle is affected w/ weak ER?
Infraspinatus
73
What muscles is tested w/ Lift off sign or Belly press?
Subscapularis
74
Imaging for Rotator Cuff
X-ray: normal MRI: confirmatory
75
What is the Nonop tx for Rotator cuff tear?
* Chronic tears * Older patients * PT: ROM/pendulum * Strengthening muscles around shoulder * NSAIDS * Steroid shots
76
What are the indications for sugery in a Rotator cuff tear?
* Younger patients * Full thickness tears * Acutely retracted tears * Good tendons & muscles
77
Hx of Adhesive Capulitis (Frozen shoulder)
Pain & restricted GH joint motion Pt in tears on exam
78
What can Frozen shoulder be assoc w/?
* Trauma to chest * Breast surgery * DM * Thyroid dz
79
Imaging for Frozen shoulder
X-ray: normal (diff from OA) MRI arthrogram: dec joint filling & thickening of inferior capsule
80
Tx of Frozen Shoulder
* NSAIDs * Pain meds to sleep * PO or Injection Cortisone * PT * Usually burns out on own
81
What is done during surgery of Frozen shoulder?
Lysis of adhesions with arthroscope if fail nonop for several months
82
Who does the worst w/ all tx for Frozen shoulder?
Diabetics
83
Hx of DJD of Shoulder
* Progressive pain * Progressive dec active & passive ROM * Night pain * Motion makes pain worse * Crepitus\*
84
What will be found on the 3 X-ray views of DJD?
* Loss of joint space * Osteophytes/spurs * Subchondral sclerosis and cysts
85
What is the tx of DJD?
* NSAIDs * Avoid activities that hurt shoulder * Steroid shots
86
When should a pt w/ DJD get a joint replacement?
* Failed nonop * Severe pain affecting ADL * Quite limited activities after—good pain relief for ADLs but limited ROM often
87
What is the hx of AC joint DJD?
* Pain on top of shoulder or reaching across body * Complain of bump on top of shoulder
88
What will be found on PE in AC joint DJD?
* Pain to palpation over AC joint * Bump over AC joint from hypertrophy * Positive cross arm compression test
89
What % of pt have recurring GH dislocations in \<20yo?
90% 50% have major problems & do surgery
90
What % of pts 20-40yo have recurring GH dislocations?
60%
91
What % of pts \>40yo have recurring GH dislocations?
\<10%
92
In pts \>40yo what other assoc injury should one worry about after a shoulder dislocation?
Rotator Cuff tear
93
What will be shown on X-ray in a posterior dislocation?
Light bulb sign!!
94
What will a normal lateral X-ray of the GH joint show?
Golf ball on tee!!
95
What are the risks of surgery w/ a clavicle fx?
Large incision & risk of artery injury
96
Were is the Conoid lig located?
Medial
97
Where is the Trapezoid lig located?
Lateral
98
Where does the Long head of the biceps attach?
Supraglenoid tubercle
99
Where does the short head of the biceps attach?
Coracoid process
100
What is commonly assoc w/ proximal biceps tendon ruptures?
Subscapularis (MC) or supraspinatus tears
101
Besides impingement, what else can cause biceps tendonitis?
Subluxation of tendon when transverse humeral ligament or subscap tendon is torn
102
What can intra-tendon injections cause?
Rupture
103
What is the tx for AC joint DJD?
* Rest * NSAIDs * Cortisone shot in AC joint
104
When is surgery indicated in AC joint DJD?
* Failure of nonop treatment * Distal clavicle excision * Arthroscopic or open

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