CLINICAL CARE OF THE SHOULDER Flashcards
1
Q
What results from a fall onto the tip of the shoulder resulting in variable degrees of ligamentous disruption?
A
Acromioclavicular (AC) Injury
2
Q
What type of AC injury is where the AC ligaments are partially disrupted and Coracoclavicular (CC) ligaments are intact and there is no superior separation of of the clavicle from the acromion?
A
Type 1 AC injury
3
Q
What type of AC injury is when the AC ligaments are torn and the CC ligaments are intact resulting in partial separation of the clavicle from the acromion?
A
Type 2 AC injury
4
Q
What type of AC injury is where the AC and CC ligaments are completely disrupted resulting in complete separation of the clavicle from the acromion?
A
Type 3 AC injury
5
Q
What type of AC injury is where the AC and CC ligaments are completely disrupted with superior and prominently posterior displacement?
A
Type 4 AC injury
6
Q
What type of AC injury is where the AC and CC ligaments are completely disrupted with CC interspace more than twice as large as the opposite shoulder?
A
Type 5 AC injury
7
Q
What type of AC injury is uncommon, the clavicular periosteum and/or deltoid and trapezius muscle are torn resulting in wide displacement, the clavicle lies in either the subacromial or subcoracoid space?
A
Type 6 AC injury
8
Q
What type of AC injuries will present with obvious deformities?
A
Type 3-6
9
Q
A patient presents supporting the arm in the abducted position and the distal clavicle is prominent and superior to the acromion, What type of AC injury would be suspected?
A
Type 2 AC injury
10
Q
True or False
AC Injury
Patients with have full range of motion (ROM) but any motion, especially abduction, causes pain
A
True
11
Q
Elevating the arm or depressing the clavicle will temporarily reduce the AC except in what type of AC injuries?
A
Type 4-5
12
Q
True or False
AP and axillary radiographs of bilateral shoulders confirm type 2-6 AC separations
A
True
13
Q
In what type of AC injuries are radiographs negative and they are primarily diagnosed with clinical presentation and history?
A
Type 1
14
Q
In what AC injury can some AC joint widening be seen on radiographs?
A
Type 3
15
Q
What is the treatment for Type 1-2 AC injuries?
A
- Sling 24-48 hours
- Ice
- Analgesics
- Home exercise program that focuses on ROM and strengthening
- Return to full duty as pain permits, usually within 4 weeks
16
Q
What is the treatment for a Type 3 AC Injury?
A
- Controversial for non-surgical vs. surgical intervention
- Ortho consult
- Sling 24-48 hours
- Ice
- Analgesics
- ROM and strengthening exercises
- LLD until ortho eval
17
Q
What is the treatment for Type 4-6 AC injuries?
A
- Ortho consult, will need surgery
- Sling until ortho eval
- Ice
- Analgesics
- LLD until ortho eval
- MEDEVAC
18
Q
What types of AC injuries require an ortho eval?
A
Type 3-6
19
Q
What is the most common bony injury?
A
Clavicle fracture
20
Q
Fractured clavicles are classified based on anatomic location; the middle third, distal third, and proximal third; What is the most common location?
A
Middle third
21
Q
A patient presents with a bony deformity over the left clavicle, drooping shoulder on the same side, as well as grinding noted when the patient attempts to move the affected arm/shoulder; What would the most likely diagnosis be?
A
Clavicle fracture
22
Q
True or False
Clavicle Fracture
Assess axillary, musculocutaneous, median, ulnar and radial nerve function distal to the fracture, additionally assess radial pulse and capillary refill
A
True
23
Q
A positive cross-body test with possible grinding may be noted in a patient with a possible clavicular fracture but is usually not required if what is noted?
A
Obvious deformity
24
Q
What radiographic views confirm most clavicle fractures?
A
- AP
2. 10 degree cephalic tilt
25
What is the treatment for clavicle fractures?
1. Ice
2. analgesics
3. ortho consult
4. mid-shaft fracture with minimal displacement and no neurovascular injury
a. figure-of-8 strap for 6-8 weeks
26
What is the disposition for patients with a clavicle fracture?
MEDEVAC
All fractures require referral
27
The ________ 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
28
What refers to a combination of shoulder symptoms, exam findings, and radiologic signs attributable to the compression of structures and the glenohumeral joint that occurs with shoulder elevation?
Shoulder impingement syndrome (SIS)
29
These are all common structures impinged within what space?
1. subacromial bursa
2. tendon of the supraspinatus
3. tendon of the infraspinatus
4. long head of the biceps tendon
Subacromion space
30
What type of acromion morphology has a greater association with impingement?
Hooked
31
A patient presents with a 2 month course of gradual onset of anterior and lateral shoulder pain exacerbated by overhead activity, noting pain at night and difficulty sleeping on the affected side; what is the most likely diagnosis?
Shoulder impingement syndrome (SIS)
32
Patients with what syndrome will normally have tenderness to palpation over the greater or lesser tuberosity and the bicipital groove?
Shoulder impingement syndrome (SIS)
33
Typically patients with SIS typically have full ROM but can be possibly limited due to pain, but pain will be worse between what degrees of abduction and when lowering the arm?
90-120 degrees
34
True or False
SIS
Flexion and abduction will be limited by pain
True
35
What special tests would you perform for a patient with suspected SIS?
1. Neers
| 2. Hawkins
36
True or False
SIS
AP and axillary radiographs usually show abnormalities
False
| Radiographs are usually normal
37
In radiographs of the shoulder for a patient with suspected SIS narrowing of the sub acromial space suggests what?
Long standing rotator cuff tear
37
In radiographs of the shoulder for a patient with suspected SIS narrowing of the sub acromial space suggests what?
Long standing rotator cuff tear
38
What imaging is helpful in establishing the exact soft tissue pathology for a patient with suspected SIS?
MRI with gadolinium
39
What is the treatment for SIS?
1. NSAIDS
2. ice
3. LLD to avoid offending activities
4. Home exercises: stretches and strengthening
5. PT consult if failed local management
40
A patient with SIS should be referred where if conservative management is failed after 2-3 months or other pathology is suspected?
Ortho
41
Acute injuries to the rotator cuff do occur but most injuries are age related such as what?
1. tendon degeneration
2. chronic mechanical impingement
3. altered blood supply to the tendons
42
Rotator cuff tears generally originate with the what and may progress posteriorly and anteriorly?
Supraspinatus
43
Full thickness tears are uncommon in patients younger than ____, but are present in 25% of patients older than ____
1. 40
| 2. 60
44
A patient presents with chronic shoulder pain following an injury 4 months ago, complains of night pain and difficulty sleeping on the affected side, weakness, catching and grating especially with overhead activities; what would a likely diagnosis be for this patient?
Rotator cuff tear
45
True or False
Visual inspection for possible rotator cuff tear
Shoulder may appear sunken, indicating atrophy of the infraspinatus following a long-standing cuff tear
True
46
Tenderness over the greater tuberosity and a grating sensation felt at the tip of the shoulder is usually present with what?
Rotator cuff tear
47
True or False
Rotator cuff tears
Usually patients have full passive ROM, some patients may maintain active ROM, but patients with large tears cannot raise arms and can only shrug or hike the shoulder upward
True
48
True or False
Rotator cuff tears
Abduction, forward flexion and external rotation may be limited
True
49
What special tests should you perform for a patient with a possible rotator cuff tear?
1. Drop arm test (positive)
| 2. Empty cans test (positive)
50
Rotator cuff tears
Radiographs are needed to evaluate the subacromial space for spurring or malalignment due to long standing tears, but what imaging is needed to confirm the diagnosis?
MRI
51
What is the treatment for rotator cuff tears?
1. NSAIDS
2. Ice
3. Home exercise program for strengthening and stretching
4. LLD to include no overhead activity
5. PT consult if failed local management
6. Ortho consult if failed rehab over 3-6 months
52
Failure of how many weeks of nonsurgical treatment is an indication for further evaluation in rotator cuff tears?
6 weeks
53
Acute traumatic rotator cuff tears should be surgically repaired immediately or no later than how many weeks post-injury?
6 weeks
54
Patients younger than how old should be considered for surgical repair as tears could enlarge with time?
55 y/o
55
What kind of injuries range from mild tendinopathy to rupture and occurs most commonly along the long head of the biceps tendon?
Bicep tendon injury
56
Bicep tendon injuries are more common in what kind of people?
people who pull, lift, reach, or throw for work/recreation
1. rock climbers, weight lifters
2. degenerative tendinopathy of the tendon in older patients
57
Clinical presentation of what injury may include anterior shoulder pain that radiates distally down the arm over the bicep muscle?
(aggravated by lifting, pulling, or overhead activity)
Bicep tendon injury
58
Bicep tendon injury
What would be suspected if there was a single injury (a "pop") with ecchymosis and swelling
bicep tendon rupture
59
Patients with what may be tender to palpation in the bicipital groove of the humerus?
Bicep tendon injury
60
What special test should be performed for a possible bicep tendon injury?
Speeds
61
What is the mainstay of treatment for a possible bicep tendon injury?
1. NSAIDS
2. Ice
3. Duty/activity modification
4. PT
**if rupture is suspected consult to ortho**
62
A shallow glenoid and loose capsule allow for exceptional shoulder mobility while depending greatly on the rotator cuff muscles and other soft tissue structures to provide dynamic stabilization; laxity, trauma or overuse can create disruption in the dynamic stabilization of the glenohumeral joint resulting in what?
1. instability
2. subluxations
3. dislocations
63
What is known as anterior, posterior, inferior, or multidirectional glenohumeral laxity due to traumatic or atraumatic pathology?
Instability
64
What is it called when the humeral head partially slips out of the socket with spontaneous reduction?
Subluxation
65
What is it called when the humeral head completely slips out of the glenoid fossa with spontaneous reduction or sometimes requiring manual manipulation?
Dislocation
66
What are the two specific instability patterns that have been described in regards to shoulder instability?
1. TUBS
| 2. AMBRI
67
What instability pattern is this?
Traumatic unilateral dislocations with a Bankart lesion that can be successfully treated with surgery
TUBS
68
What instability pattern is this?
Atraumatic multidirectional instability that is commonly bilateral and is often successfully treated with rehabilitation and occasionally an inferior capsular shift (surgery)
AMBRI
69
True or False
Patients with anterior instability will describe the sensation of the shoulder slipping out of joint when arm is abducted and externally rotated.
True
70
True or False
Initial anterior dislocations are associated with trauma from a fall or forceful throwing muscle
True
71
True or False
Recurrent dislocations may occur simply by positioning the arm overhead
True
72
True or False
Patients with multidirectional instability may have vague symptoms but usually related to activity
True
73
Ability to voluntarily dislocate the shoulder is frequently associated with ______ instability and has a poor prognosis for surgical treatment
Multidirectional instability
74
What is the most common direction for shoulder dislocations?
anterior dislocation
75
In what direction of dislocation does the patient hold the arm in adduction and internal rotation?
posterior dislocation
76
True or False
Patient will have limited to no AROM or PROM if currently dislocated, but multidirectional instability will not limit ROM but humeral "clunking" is noted with flexion and abduction/adduction
True
77
Should a patient with multidirectional instability be check for generalized ligamentous laxity?
Yes
78
The following special tests and results may be seen in what?
1. Positive sulcus test with inferior laxity
2. Positive apprehension test with anterior instability
3. Anterior/Posterior drawer test - anterior/posterior laxity
4. Jerk test - posterior instability
Shoulder instability
79
Shoulder instability
Radiographs to include AP and axillary views are used to rule out what?
Hill-Sachs lesion with anterior dislocations
80
AP and axillary radiographs are needed if what kind of dislocation is suspected?
Posterior dislocation
81
What kind of imaging is needed to evaluate health of rotator cuff tendons, labrum (Bankart lesion) and other soft tissue structures?
MRI
82
What technique for reducing acute dislocations is gravity assisted with the patient lying on their stomach?
Stimson technique
83
What technique is used for reducing acute dislocations where the elbow is at 90 degrees flexion while longitudinal traction is applied to the humerus and gently rotating the arm?
Longitudinal traction
84
What medication may be used to relax muscle structures to allow for the reduction of acute dislocations?
Valium
85
After reducing acute dislocations what is the additional treatment for shoulder instability?
1. immobilize the arm in a sling in a neutral position
2. LLD to include no active use of arm for 2-3 weeks
3. Rotator cuff strengthening 2-3 weeks post reduction
4. PT consult
5. Ortho consult
86
True or False
First time dislocations or evidence of neurovascular compromise require ortho eval for possible surgery - MEDEVAC
TRUE get them off the ship
87
What is the fibrocartilaginous ring attached to outer surface of the glenoid?
Labrum
88
What has the following purposes?
1. give depth to the shoulder joint
2. increases area of contact between humeral head and glenoid
3. serves as point of contact for several ligaments and tendons
labrum
89
What involves injuries to the superior glenoid labrum and the biceps anchor complex?
Superior labrum anterior posterior (SLAP) lesions
Often difficult to diagnose and are often a diagnosis of exclusion, confirmed during surgery
90
The following may be the MOI of what injury?
1. falling back onto an outstretched arm
2. tries to prevent falling by grabbing hold of an object
3. suddenly tries to lift a heavy object
4. forceful throwing, excessive overhead activity
5. chronic overuse vs acute injury
Labrum tear and SLAP Lesion
91
These are all common symptoms of what shoulder injury?
1. Anterior shoulder pain (in overuse injury)
2. Clicking/clunking of the shoulder in certain positions
3. Swelling, paresthesia, severe night pain is uncommon
Labrum tear and SLAP Lesion
92
True or False
Patients with either a tear of the labrum or a SLAP lesion have a higher prevalence of other shoulder injuries as well
True
93
True or False
During the palpation of the shoulder for a possible labrum tear or SLAP lesion posterior shoulder tenderness is common but special attention should be paid to the biceps tendon
True
94
True or False
There are multiple special tests that have been shown to reliably diagnose a SLAP lesion
False
No single special test on exam has ever been shown to reliably diagnose a SLAP lesion
Recommend Obriens and Speeds
95
What is 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
96
What is adhesive capsulitis commonly referred to as?
Frozen shoulder
97
In what age group is frozen shoulder more common?
50-60 y/o's
98
What condition of the shoulder is often associated with the following diseases and conditions but also very commonly occurs after shoulder injuries?
1. Diabetes
2. Thyroid disease
3. Autoimmune disorders
4. Stroke
5. Parkinsons
6. HIV
7. Med use
Adhesive Capsulitis
99
What disorder of the shoulder is commonly described as going through three main phases of pain and injury?
Adhesive capsulitis
100
The first phase of adhesive capsulitis is usually marked by diffuse, severe, and disabling shoulder pain with increased stiffness that lasts about how long?
2-9 months
101
During the second phase of adhesive capsulitis, stiffness and severe loss of shoulder motion with pain is less pronounced and lasts about how long?
4-12 months
102
The recovery phase of adhesive capsulitis is marked with stiffness and gradual return of shoulder motion but can take how long to complete?
5-24 months
103
Concerns for frozen shoulder is raised when a patient with a history of shoulder injuries complains of what?
1. Severe pain that is worse at night
a. "nagging pain"
2. Dressing ROM in the shoulder
3. Issues with work or other activities of daily living
a. varying degrees of impaired function
4. History of shoulder injury and immobilization
104
What is usually the most significant finding on physical exam for a patient with possible adhesive capsulitis?
ROM Reduction
1. reduction in passive and active ROM in two or more planes
2. external rotation and abduction most affected
105
In adhesive capsulitis, plain films are most often normal, but in more challenging cases the provider should order an MRI which is not necessary for the diagnosis but often shows what?
Thickening of the joint capsule
106
True or False
Adhesive Capsulitis
UT is also useful in diagnosing the dynamic changes that occur in the shoulder
True
107
Evidence is lacking in the treatment of adhesive capsulitis but what are some viable treatment options?
1. early mobilization for those with injuries
a. avoid slings when possible
2. shoulder motion exercises
a. PT consult
3. NSAIDS
4. Tylenol
5. Consider referral for steroid injection
108
Where should patients with adhesive capsulitis not responding to conservative management by referred to?
1. sports medicine for steroid injections
2. ortho for surgery
a. likely does not improve outcomes
