Ch 5 MDT Shoulder Flashcards
Results from a fall onto the tip of the shoulder resulting in variable degrees of ligamentous disruption
Classified into six types
Acromioclavicular (AC) Injury
AC ligaments partially disrupted, and coracoclavicular (CC) ligaments are intact. No superior separation of the clavicle from acromion
Type 1
AC ligaments are torn and CC ligaments are intact resulting in partial separation of the clavicle from the acromion
Type II
AC and CC Ligaments are completely disrupted resulting in complete separation of the clavicle from acromion
Type III
AC and CC ligaments are complete disrupted with superior and prominently posterior displacement
Type IV
AC and CC ligaments are completely disrupted with CC interspace more than twice as large as opposite shoulder
Type V
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
Pain over AC joint
Pain on lifting affected arm
Type III-VI presents with obvious deformity
AC injury
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
Diagnostic tests for AC injury
Anterior-posterior (AP) and axillary radiographs
Treatment for I and II AC injuries
Sling x 24-48 hours
Ice
Analgesics
Home ROM exercises
Return to full duty in 4 weeks
Treatment for type III AC injury
Orthopedic consultation
Sling x 24-48 hours
Ice
Analgesics
Home ROM exercises
Light duty until evaluation by orthopedics
Treatment for type IV-VI AC injuries
Orthopedic consultation, will require surgery
Sling until evaluation by ortho
Ice
Analgesics
MEDEVAC
What AC injuries require orthopedic consultation?
Type III-VI
Typically results from falling on shoulder or being struck over clavicle
Most common bony injury
Clavicle Fracture
Most common location for a clavicle fracture
Middle Third
Bony deformity, bump, with shoulder droop
Pain/Tenderness
Decreased ROM due to pain. Grinding when patient moves arm.
Positive Cross-Body
Clavicle Fracture
Diagnostic tests for Clavicle fracture
AP and 10-degree cephalic tilt radiographic views
Treatment for Clavicle Fracture
Ice
Analgesics
Orthopedic Consult
Figure 8 Strap for 6-8 weeks
MEDEVAC
Red flags of Clavicle Fractures
Painful nonunion after 4 months of treatment
Widely displacement lateral or mid-shaft fractures or segmental fractures
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
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)
Common structures impinged in the subacromion space
Subacromial bursa
Tendon of the supraspinatus
Tendon of the infraspinatus
Long head of the biceps tendon
Different types of acromion morphology that vary in different individuals
Flat
Curved
Hooked (Greatest association with impingement)
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
Anterior
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)
