Ch 5 MDT Shoulder Flashcards by Chris Weber

Results from a fall onto the tip of the shoulder resulting in variable degrees of ligamentous disruption

Classified into six types

Acromioclavicular (AC) Injury

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AC ligaments partially disrupted, and coracoclavicular (CC) ligaments are intact. No superior separation of the clavicle from acromion

Type 1

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AC ligaments are torn and CC ligaments are intact resulting in partial separation of the clavicle from the acromion

Type II

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AC and CC Ligaments are completely disrupted resulting in complete separation of the clavicle from acromion

Type III

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AC and CC ligaments are complete disrupted with superior and prominently posterior displacement

Type IV

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AC and CC ligaments are completely disrupted with CC interspace more than twice as large as opposite shoulder

Type V

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Uncommon. Clavicular periosteum and/or deltoid and trapezius muscle are torn resulting in wide displacement. Clavicle lies in either the subacromial space or subcoracoid space

Type VI

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Pain over AC joint

Pain on lifting affected arm

Type III-VI presents with obvious deformity

AC injury

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Patient supports arm in adducted position

Distal clavicle prominent

Full range of motion. Abduction especially causes pain.

Decrease in muscle strength due to pain

AC injury

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Diagnostic tests for AC injury

Anterior-posterior (AP) and axillary radiographs

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Treatment for I and II AC injuries

Sling x 24-48 hours

Ice

Analgesics

Home ROM exercises

Return to full duty in 4 weeks

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Treatment for type III AC injury

Orthopedic consultation

Sling x 24-48 hours

Ice

Analgesics

Home ROM exercises

Light duty until evaluation by orthopedics

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Treatment for type IV-VI AC injuries

Orthopedic consultation, will require surgery

Sling until evaluation by ortho

Ice

Analgesics

MEDEVAC

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What AC injuries require orthopedic consultation?

Type III-VI

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Typically results from falling on shoulder or being struck over clavicle

Most common bony injury

Clavicle Fracture

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Most common location for a clavicle fracture

Middle Third

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Bony deformity, bump, with shoulder droop

Pain/Tenderness

Decreased ROM due to pain. Grinding when patient moves arm.

Positive Cross-Body

Clavicle Fracture

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Diagnostic tests for Clavicle fracture

AP and 10-degree cephalic tilt radiographic views

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Treatment for Clavicle Fracture

Ice

Analgesics

Orthopedic Consult

Figure 8 Strap for 6-8 weeks

MEDEVAC

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Red flags of Clavicle Fractures

Painful nonunion after 4 months of treatment

Widely displacement lateral or mid-shaft fractures or segmental fractures

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Provides multiple and extreme degrees of functional motion that greatly depend on the rotator cuff muscles to properly seat the humeral head into the glenoid fossa to provide stability

Glenohumeral Joint

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Combination of shoulder symptoms, exam findings, radiologic signs attributable to compression of structures around the glenohumeral joint that occur with shoulder elevation

Shoulder Impingement Syndrome (SIS)

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Common structures impinged in the subacromion space

Subacromial bursa

Tendon of the supraspinatus

Tendon of the infraspinatus

Long head of the biceps tendon

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Different types of acromion morphology that vary in different individuals

Flat

Curved

Hooked (Greatest association with impingement)

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Tenderness over greater or lesser tuberosity Tenderness over bicipital groove Full Active ROM but possible limited due to pain Pain worsens between 90-120 degrees of abduction and when lowering arm

Shoulder Impingement

Shoulder impingement positive tests

Neers and Hawkins

Diagnostic tests for shoulder impingement syndrome

AP and axillary X-Rays (usually NORMAL) -Narrowing of subacromial space suggests long standing rotator cuff tear MRI with gadolinium

Treatment for Shoulder Impingement Syndrome

NSAIDs Ice Light duty for offending activities Home exercise Program

Shoulder Impingement Syndrome Ortho consult if failed conservative management for ___ months or other pathology is discovered

2-3 months

Rotator cuff tears usually originate in what muscle?

Supraspinatus

Rotator cuff full thickness tears are uncommon in patients younger than 40, but are present in ___% of patients older than 60

25%

Chronic shoulder pain for several months Specific injury that triggered pain Night pain and difficulty sleeping on the affected side Complaints of weakness, catching and grating especially overhead activities

Rotator Cuff Tear

Shoulder may appear sunken, indicating atrophy Tenderness over greater tuberosity Grating sensation felt at tip of shoulder Usually, Full ROM

Rotator Cuff Tear

Tests that may be positive for Rotator Cuff Tear

Abduction, forward flexion, and external rotation may be limited Positive Drop Arm Test Positive Empty Can Test

Tests needed to evaluate subacromial space for spurring and malalignment for Rotator Cuff Tears

Radiographs

Diagnostic testing that confirms Rotator Cuff Tears

MRI

Treatment for Rotator Cuff Tear

NSAIDs Ice Light duty with no overhead activity Home exercises/Physical Therapy

Rotator Cuff Tear Orthopedic consult if failed rehabilitation over ___ months

3-6 months

Rotator Cuff Tears Acute traumatic tears should be surgically repaired immediately or no later than __ weeks post-injury

6 weeks

Rotator Cuff Tear Patients younger than __ years old should be considered for surgical repair as tears could enlarge with time

55 years old

Bicep tendon injury occur most commonly along which part of the bicep tendon?

Long Head

More common in people who pull, lift, reach, or throw for work/recreation -Rock climbers, weight lifters

Bicep tendon injury

Clinical presentation with anterior shoulder pain that radiates distally down the arm over bicep muscle Aggravated by lifting, pulling, overhead activity

Bicep tendon injury

What is suspected if there was a single injury ("pop") with ecchymosis and swelling?

Bicep Tendon Rupture

Positive test in Bicep Tendon injury

Speeds test

Treatment for bicep tendon injury

NSAIDs Ice Duty/activity modification Physical therapy/Home Exercises

Treatment for Bicep tendon rupture

Ortho Consult NSAIDs, Ice, Activity Modification, Home exercises/Physical Therapy

Synonyms for Shoulder Instability

Dislocation Multidirectional instability Recurrent dislocation Subluxation

Anterior, posterior, inferior or multidirectional glenohumeral laxity due to traumatic or atraumatic pathology

Instability

Humeral head partially slips out of socket with spontaneous reduction

Subluxation

Humeral head completely slips out of glenoid fossa with spontaneous reduction or sometimes requiring manual manipulation

Dislocation

Shoulder Instability Two specific instability patterns

TUBS - Traumatic Unilateral dislocations with a Bankart lesion that can be successfully treated with Surgery AMBRI - Atraumatic Multidirectional instability, Bilateral, successfully treated with Rehab and occasionally Inferior capsular surgery

Patient with ______ instability will describe that sensation of the shoulder slipping out of joint when arm is abducted and externally rotated

Anterior instability

Initial anterior dislocation is associated with trauma from:

Fall Forceful throwing motion

Recurrent dislocations may occur simply by:

Overhead positioning

Patient with _______ dislocation will describe a force that is posteriorly directed

Posterior dislocation

Ability to voluntarily dislocate shoulder is frequently associated with:

Multidirectional instability

Most common direction of a shoulder dislocation

Joint disfigurement Patient supports arm in neutral position

Anterior dislocation

Joint disfigurement Patient holds arm in adduction and internal rotation

Posterior dislocation

Full ROM with humeral "clucking" with flexion and abduction/adduction Should be checked for generalized ligamentous laxity

Multidirectional instability

Special tests that are positive for inferior laxity

Sulcus test

Special tests that are positive for anterior instability

Apprehension test

Special tests that are positive for anterior/posterior laxity

Anterior/Posterior Drawer test

Special tests that are positive for posterior instability

Jerk test

Diagnostic tests for Shoulder Dislocation

AP and Axillary radiographs MRI

Treatment for shoulder dislocation

Reduce Sling in neutral position Light Duty, No active use of arm for 2-3 weeks Rotator cuff strengthening 2-3 weeks post reduction Physical Therapy Ortho Consult

Gravity assisted reduction with patient lying on stomach

Stimson technique

Reduction of dislocation Elbow at 90 degrees flexion while longitudinal traction is applied to the humerus. Gently rotate arm

Longitudinal Traction technique

What drug maybe required to relax muscle structures to allow for reduction?

Valium

What needs to be re-evaluated after a reduction?

Axillary nerve function

What dislocations require orthopedic evaluation for possible surgery and MEDEVAC?

First time dislocations Evidence of neurovascular compromise

Fibrocartilaginous ring attached to outer surface of glenoid Gives depth to shoulder joint Increases area of contact between the humeral head and glenoid Point of contact for several ligaments and tendons

Labrum

Lesions involve injury to the superior glenoid labrum and the biceps anchor complex

Superior Labrum Anterior Posterior (SLAP)

SLAP lesions are usually confirmed during:

Surgery

MOI: Falling back onto an outstretched arm Tries to prevent falling by grabbing hold of an object Suddenly lifts heavy object Forceful throwing, excessive overhead activity

SLAP lesion (Labrum tear)

Anterior shoulder pain from overuse Clicking/clunking of the shoulder in certain positions Swelling, paresthesia, severe night pain is UNCOMMON

SLAP Lesion (labrum tear)

What special tests are recommended for SLAP lesions?

O'briens and Speeds

A condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are absent

Adhesive Capsulitis

Referred to as "Frozen Shoulder" More common in older populations (50's-60's) Often associated with other diseases -Diabetes, thyroid disease, autoimmune, stroke, Parkinsons, HIV Medication use VERY common after shoulder injuries

Adhesive Capsulitis

Adhesive Capsulitis Diffuse, severe, and disabling shoulder pain -Increasing stiffness Lasts __ months

2-9 months

Adhesive Capsulitis Stiffness and severe loss of shoulder motion with pain less pronounced Lasts ___ months

4-12 months

Adhesive Capsulitis Recovery phase with stiffness and gradual return of shoulder motion that takes about ____ months to complete

5-24 months

Concern for adhesive capsulitis is raised when a patient with history of shoulder injury complains of:

Severe pain that is worse at night "Nagging pain"

Most significant finding during physical exam of Adhesive Capsulitis

ROM reduction

What is most affected in Adhesive Capsulitis?

External rotation and abduction

Diagnostic tests for Adhesive Capsulitis

Plain films (Usually Normal) MRI U/S

Treatment for Adhesive Capsulitis

Early Mobilization Shoulder motion exercises, Physical Therapy consult NSAIDs/Tylenol

When to refer Adhesive Capsulitis?

Patients who do not respond to conservative management - Sports medicine for steroid injection - Ortho for surgery (likely does not improve outcome)