Clinical Shoulder Flashcards
What is Scapulohumeral Rhythym
- Refers to the motion that occurs at the scapaulothoracic joint during elevation of the arm
- Normal Ratio is 2:1
- 2 deg of Glenohumeral motion for every 1 degree of Scapulothoracic
What Gliding Movement changes occur with surgical tightening of the Shoulder Joint Capsule?
- Obligate movement is said to occur whereby tightening of the posterior capsule or Rotator Interval increase Anterior Translation during forward elevation
- Excessive Anterior stability after repair can cause humeral head and joint contact posteriorly and can possibly lead to degenerative changes in the shoulder
What is the normal strength ratio of the shoulder in ER and IR?
External Rotators typically are about 66% as strong as the internal rotators
- Some (Davies, etc) have proposed during rehabilitation we should shoot for 75% to create a “Posterior Dominant” Shoulder
What ligament is typically contracted in shoulders with adhesive capsulitis?
- The Coracohumeral ligament
- This ligament prevents ER with arm at side and often needs to be released to regain full ER ROM
What is the rotator cuff interval?
- The capsular tissue in the interval between the Subscapularis and Supraspinaus Tendons
- It is composed of parts of the Subscapularis and Supraspinatus tendons as well as the Coracohumeral and Superior Glenohumeral ligaments
How can pathologic change to the rotator cuff interval affect the shoulder?
- If too tight, can limit ER and play a role in Adhesive Capsulitis
- If too lax, can play a role in Multidirectional Instability and Anteroinferior instability
What are the biomechanical effects of the Rotator Cuff?
- Depress the humeral head and counteract the Superior pull of the deltoid
- Maintain proper positioning of the humeral head within the glenoid
What is the Quadrangular Space, What Structures pass through it?
- Anatomic interval formed by shaft of the humerus laterally, long head of the biceps medially, teres minor superiorly and teres major inferiorly.
- It contains Axillary Nerve, Posterior Humeral Circumflex artery
What is the Triangular Space, What structures pass through it?
- Anatomic interval bordered by long head of biceps laterally, teres minor superiorly, and teres major inferiorly
- It contains the circumflex scapular artery and a branch of the scapular artery
Which ligaments provide static prevention of anterior translation of the humeral head, and in which positions do they perform this action?
- Anterior Band of the Inferior Glenohumeral ligament in the ER9090 position
- Middle Glenohumeral ligament in midrange shoulder elevation
- Superior Glenohumeral ligament prevents ER and Inferior Translation with arm at side
What is a Bankart Lesion?
- Detachment of the anchor point of the Anterior Band of Inferior Glenohumeral and middle Glenohumeral ligaments
- Often occurs as a result of traumatic Anterior Dislocation of the shoulder
What is a Hill Sachs Lesion?
- Impression fracture to the posterolateral margin of the humeral head
- Caused by impaction on the rim of the glenoid during Anterior Dislocation
- If lesion involves >30% of the articular surface of the humerus, can lead to recurrent instability
Where does the Suprascapular nerve sometimes become compressed and what deficits would be present?
- Suprascapular Notch and Spinoglenoid notch
- If at Suprascapular, Supraspinatus and Infraspinatus would be affected
- If at Spinoglenoid, Infraspinatus would be affected
Which nerve is at greatest risk during Anterior Shoulder Surgery?
- Axillary nerve
Which Nerve Superficial to the Posterior Cervical Triangle and is susceptible to injury?
- Cranial Nerve XI (Spinal Accessory Nerve)
Injury to which nerve causes Classic Medial Scapular Winging?
- Long Thoracic Nerve
What is Os Acromiale?
- An unfused acromial epiphysis. Failure of the distal end of the acromion to ossify
What are the Three Types of Acromion Shape?
- Type 1: Flat
- Type 2: curved downward
- Type 3: Hooked
- Much higher incidence of RTC tears in type 3 and 2 than type 1
What are the Four Stages of Neers Rotator Cuff Pathology Classification?
- Stage I: Edema and Hemmorhage
- Stage 2: Fibrosis and Tendinitis
- Stage 3: Bone Spur and Tendon Rupture
- Stage 4: Cuf Tear Arthropathy
What is the Coracoacromial Arch?
- The Coracoacromial Ligament. It acts as the roof of the Glenohumeral joint and can compress tissue when humeral elevation and internal rotation occurs.
What are the two types of Subacromial Decompression?
- Open and Arthroscopic
- Some doctors prefer one or the other, but if a massive RTC tear is found during the procedure it is more easily repaired when open.
What is a Mumford Procedure?
- Distal Clavicular Excision/ Removal
- Removal of distal 2cm
Describe Primary vs. Secondary Shoulder impingement
- Primary is mechanical and caused by joint space overcrowding
- Secondary is typically due to instability
What is Posterior (Internal) Impingement?
- Pinching of the Infraspinatus and Supraspinatus between the posterior superior aspect of the glenoid
- Typically seen in throwers, symptomatic when in the cocking position or phase of throwing
Describe how the size of a rotator cuff tear is classified
- Small < 1 cm
- Medium is 1-3 cm
- Large is 3-5 cm
- Massive > 5 cm
What Special Tests are most predictive of Rotator Cuff Tear?
- Supraspinatus Weakness
- External Rotation Weakness
- Impingement sign
What is the most common direction and mechanism of injury for Dislocation of the Shoulder?
- Subcoracoid Anterior Dislocation
- Typically occurs with indirect force with arm Abducted, Extended, and Externally Rotated.
What is the most common nerve injury after Anterior Dislocation of the Shoulder?
- Axillary Nerve (30%)
What is the most common Mechanism of Injury for Posterior Shoulder Dislocations?
- Axial Loading of the arm in and Adducted, Flexed, and Internally Rotated Position.
- Blow to front of the shoulder, FOOSH
Describe the Acronym TUBS
Shoulder Instability T - Traumatic Onset U- Unidirectional (anterior) B - Bankart Lesion (usually present) S - Surgery (success rate higher with surgery)
Describe the Acronym AMBRI
Shoulder Instability
A - Atraumatic Onset
M - Multidirectional
B - Bilateral (usually)
R - Rehabilitation (success rate is high with conservative management)
I - Inferior Capsular Shift (procedure of choice if conservative treatment fails)
What is an ALPSA Lesion?
ALPSA stands for Anterior Labroligamentous Periosteal Sleeve Avulsion. Often accompanies an anterior dislocation, the labrum and periosteal sleeve of the anterior glenoid are avulsed and displaced medially.
What is a HAGL Lesion?
HAGL stands for Humeral Avulsion of the Glenohumeral Ligament. Occurs with traumatic dislocation when the arm is forced into a hyperabducted position.
What are common special tests for Shoulder Impingement?
- Neers
- Hawkins Kennedy
- Jobes
What are common special tests for Rotator Cuff Tear?
- Drop Arm Test (ER)
- Lift Off Sign
- IR and ER Lag Test
- Hornblowers Sign
- Belly Press
What are common special tests for Shoulder Instability?
- Ant Load and Shift
- Sulcus Sign
- Apprehension Test
- Relocation and Anterior Release
What grading scheme is used to describe glenohumeral translation?
Grade 1 - Humeral head to rim of glenoid but not past, 50% translation
Grade 2 - Humeral head subluxes beyond the glenoid rim but self reduces upon release
Grade 3 - Head remains dislocated on release, clinical dislocation
What are Hill Sachs and Reverse Hill Sachs Lesions?
Hill Sachs - Compression fracture of the posterolateral humeral head, occurs with Anterior dislocation.
Reverse Hill Sachs - Compression fracture of Anteromedial humeral head, Occurs with Posterior Dislocation
What is a Bankart Lesion?
- An Avulsion of the Anterior Portion of the Inferior Glenohumeral Ligament and Glenoid Labrum off the Anterior Rim of the Glenoid
- Often contributes to recurrent instability of the shoulder
What are common complications when managing a traumatic anterior dislocation
- Recurrent Dislocations
- Can also include fractures of the Humerus, Vascular Injuries, Neural Injuries, and Rotator Cuff Tears
With Anterior Dislocation, is an associated Rotator Cuff Tear Common?
- In young populations, no
- Age > 40 it ranges from 35-86%
What are some common surgical Procedures to correct Shoulder Instability?
- Bankart Repair - Suturing of the Anterior Capsule and Labrum to the Glenoid Rim
- Capsular Shift - Tightening of the joint capsule
- Staple or Thermal Capsulorrhaphy - Shrinking the capsule either by stapling it down or thermally shrinking it
- Putti-Platt Procedure- Subscapularis and Capsular Shortening
What are SLAP Lesions?
- Superior Labrum Anterior to Posterior Lesion
- Usually occurs from downward force on a supinated outstretched arm or a fall on the lateral shoulder
What are the 4 types of SLAP Lesions?
Type 1- Degenerative Fraying of the Labrum
Type 2- Avulsion of the superior labrum and biceps tendon
Type 3- Bucket Handle tears of the Superior Labrum
Type 4- Same as 2 or 3 with extension into the Biceps Tendon
What are some common special tests to evaluate SLAP Lesions?
- Obriens (Active Compression)
- Crank
- Biceps Load at 90 and 110
Define Primary and Secondary Adhesive Capsulitis
- Primary- Stiff shoulder with insidious onset
- Secondary- Stiff Shoulder with onset after some type of trauma
What MRI findings are assocaiated with Adhesive Capsulitis?
- Thickening of the Coracohumeral Ligament > 4 mm
- Thickening of the capsule in the Rotator Interval > 7 mm
What are some predisposing factors of adhesive capsulitis?
- Cervical Spine Disorders
- Autoimmune Disorders
- Tendonitis
- Hypothyroidism
- Diabetes
- Hormonal Disorders
- Poor Posture
What are some surgical options to increase ROM in Adhesive Capsulitis?
- Manipulation under Anasthesia
- Arthroscopic capsular release
- Manipulation is preferred and usually has better outcomes, but release can be performed if pnt has not responded to conservative management or MUA
What is the difference between unconstrained, constrained and reverse Total Shoulder Arthroplasty?
Unconstrained- Shallow ball and socket much like the original
Constrained- Deeper ball and socket more similar to the hip, Slight decrease in ROM with this
Reverse- Ball is on the glenoid side and socket on humerus, good for people with deficient cuff
What is a Hemiarthoplasty of the Shoulder?
- Replacement of humeral head but not glenoid
- Good option when humeral head necrosed or damaged, but glenoid intact
How long will a TSA Last?
- Typically > 20 years
Describe the Neer Phased Rehab phases for Total Shoulder Arthroplasty
- Phase 1- Passive ROM
- Phase 2- AROM
- Phase 3- Resistive Exercise
What are typical mechanisms of injury to AC Joint?
- Direct force to tip oc shoulder with arm adducted at side
- Indirect force such as a FOOSH
What are the main ligaments of the AC Joint and what are their primary roles?
- Superior and Inferior AC Ligaments- Prevent horizontal movement
- Coracoclavicular Ligament (Trapezoid and Conoid)- Give Vertical Stability
Describe the classification system for AC joint injuries
Type 1- Sprain of AC ligament
Type 2- Complete Disruption of AC, sprain of CC
Type 3- Complete Disruption of AC and CC
Do Type 1 or Type 2 AC injuries require a sling?
- Not for Type 1, early return to function with several days of RICE and relative rest
- Type 2 injuries usually require a sling, RICE and Return to ROM as tolerated
What is the surgical procedure to correct Arthritic AC Disability?
- Distal Clavicular Resection or Mumford
- Removes approx .5-2.0 cm
What is the typical MOI for Sternoclavicular Injuries?
- Someone lying on their side and rolls over their shoulder (wrestling)
- Blow to the Anterior Shoulder
What Ligaments support the SC Joint?
- Anterior and Posterior Sternoclavicular Ligaments
- Costoclavicular Ligament
- Interclavicular Ligament
What are grades of SC Joint sprains?
- Similar to that of the AC
- Type 1- Ligaments intact
- Type 2- Ligaments partially disrupted
- Type 3- Total Disruption of ligaments
- Anterior dislocation of SC joint more common than Posterior, 9:1
What is Sprengels Deformity?
- Failure of the scapula to descend during normal development
- Seen in Infancy,usually along with other musculoskeletal deformities
What is SICK Scapula?
- Scapular Malposition
- Inferior medial border prominence
- Coracoid Pain
- Dyskinesis
- Often found in overhead athletes and noted by a unilateral drop in the affected shoulder
Describe the Lateral Scapular Slide Test
- Measure the distance from the T8 Vertebrae to the inferior angle of the scapula in 3 positions
1. Arm at Side
2. Hands on Waist
3. Arms Abducted to 90 deg with max internal rotation - Difference > 1.5 cm between sides indicates scapular muscle dysfunction
What is typical MOI of Long Thoracic Nerve Palsy?
- Idiopathic without history of Macrotrauma
- Surgical Complications
- Viral Illness
- Trauma
What nerve is commonly affected after a cervical lymph node or benign tumor resection?
- Spinal Accessory Nerve
- Usually affects Trapezius but spares the Sternocleidomastoid
Define Snapping Scapula
- Friction between mobilie scapula and thoracic wall
- If pathologically painful can be caused by thickened bursa, bone spur, or Osteochondroma
Describe locations of Suprascapular Nerve Entrapment and clinical findings
- Suprascapular Notch and Ligament - Supraspinatus and Infraspinatus weakness
- Spinoglenoid Ligament- Sparing of the Supraspinatus with weakness of the Infraspinatus
What nerve is most frequently injured with a fracture of the Clavicle?
- Ulnar Nerve as it passes between the first rib and the fracture clavicle
What nerves are commonly affected after a Proximal Humerus Fracture?
- Axillary Nerve
- Suprascapular Nerve
- Often temporary and resolves as tissue healing of fracture takes place
What Nerve is most commonly affected after Humeral Shaft Fracture?
- Radial Nerve
- Rare Brachial Plexus Injury
What treatment is required for radial nerve injury after humeral shaft fracture?
- Most heal on their own, but splinting and ROM is recommended to prevent contractures
How is the Spinal Accessory Nerve Usually Injured?
- Tumor
- Surgical Procedures to the posterior triangle
- Stretch and Whiplash Injuries
What is typical presentation of Spinal Accessory Nerve Palsy?
- Dropping shoulder or Flat Upper Trap
- Winging of scapula with ABduction of the arm
- If SCM is affected, rotation of the head toward opposite shoulder
What is the most commonly injured nerve after Anterior Shoulder Dislocation?
- Axillary Nerve
What clinical signs would be seen with Musculocutaneous nerve injury?
- Weakness in Elbow Flexion and Supination
- Numbness or Parasthesia to lateral forearm
What is Ruck Sack Palsy?
- Weight of a Ruck Sack compromises the upper trunk of the Brachial Plexus or Long Thoracic Nerve
What are signs and symptoms of an Upper Trunk Brachial Plexus injury?
- Affect the Suprascapular, Musculocutaneous, and Axillary nerves and parts of the Median and Radial Nerves
- Weakness in shoulder flexion, abduction, Extension
- Weakness in Elbow Flexion, Supination, Pronation and wrist flexion
- Parasthesias in lateral forearm, hands, thumb and index finger
What are signs and symptoms of a Lower Trunk Brachial Plexus Injury?
- Affect Ulnar, C8 part of Radial, Distal Median Nerve
- Weakness of hand intrinsics including thenar muscles and lumbricals
- Parasthesias to medial forearm, medial hand, entire ring and little fingers
Differentiate Lateral Cord and Upper Trunk Brachial Plexus Injuries
- Lateral Cord - Less Severe - Sparing of the Suprascapular Nerve and Upper Trunk parts of the Axillary and Radial Nerves
- Lateral Cord will have normal Shoulder Flexion, External Rotation, Abduction
- Lateral Forearm parasthesias but not into hand
Differentiate Medial Cord and Lower Trunk Brachial Plexus Injuries
- Medial Cord Similar to Lower Trunk - In Medial cored there will be Sparing of C8 Contribution of Radial Nerve
- Normal Strength to finger extension
Differentiate C5-6 root injury and Upper Trunk Injury
- Upper Trunk Spares the Dorsal Scapular Nerve to rhomboids and Long Thoracic nerve to Serratus Anterior
- C5-6 Lesion does not
Differentiate C5-6 root injury and Lateral Cord Injury
- Lateral Cord Lesion spares the suprascapular nerve to supraspinatus and infraspinatus
- C5-6 Lesion does not
What are some clinical tests used to evaluate Thoracic Outlet Syndrome?
- Adsons Maneuver
- Allen Test
- Roos Test
- Wright Test
- Costoclavicular Syndrome Test
- Halstead Maneuver
- To decrease False Positive Rate, Perform at least 3
What are signs and symptoms of a Middle Trunk Brachial Plexus Injury?
- Rarely injured in isolation
- Weakness in radial distribution involving Triceps and sparing the Brachioradialis
What Nerves/Roots does a Burner or Stinger affect?
- C5-6 Roots
- Upper Trunk Brachial Plexus
Describe Clinical Findings of Pancoast Tumor
- Sensory changes to medial hand
- Horners Syndrome
- Intrinsic Hand Muscle wasting
- Night Pain
What is Quadrangular Space Syndrome?
- Compression of the Axillary Nerve as it passes through the quadrangular space
- Sx include weakness of the Deltoid and Teres Minor
What is a Sprengels Deformity?
- The failure of the Scapula to caudally descend during fetal development
- Results in Small and Undescended Scapula and Scapular Winging in children
- If Surgery indicated (most cases), best to perform between 3 and 8 years. At 8 years, chance of nerve damage is greater.
What are Erbs and Klumpkes Palsy?
- Brachial Plexus Lesions that typically occur during birth
- Erbs - C5-6- Weakness in Axillary, Musculocutaneous, Radial, Suprascapular Nerve Patterns
- Klumpkes- C8-T1- Weakness of Median and Ulanar Nerves, Claw Hand
- Worse prognosis with Klumpkes
What are the normal strength ratios of the shoulder?
- IR > ER by 3:2
- ADD > ABD by 2:1
- Ext > Flex by 5:4
What is the role of the biceps in stabilizing the glenomumeral joint?
- Increases compression across the Glenohumeral joint and dynamically maintains coaptation of the humeral head within the glenoid
The shoulder girdle is primarily supplied by what cervical roots and Trunk of Brachial Plexus?
- C5-6
- Upper Trunk
Describe the differences in the Three grades of AC joint injury
- Grade 1- AC liagments partially disrupted but Coracoclavicular intact
- Grade 2- AC ligaments torn, Coracoclavicular partially disrupted
- Grade 3- AC and Coracoclavicular ligaments torn
What is the difference between primary and secondary adhesive capsulitis?
- Primary- Idiopathic progression
- Secondary- Traumatic in origin or related to disease process
Describe the pattern of motion loss most typically associated with Adhesive Capsulitis
ER more limited than ABduction which is more limited than IR
What are possible mechanisms of Glenohumeral Labral Tear?
- FOOSH
- Traction injury
- Peel Back Injury: arm abducted and maximally ER and twisting of biceps results in “peeling back” of labrum
In baseball pitchers reporting a “dead arm” what is a possible diagnosis?
- SLAP Tear
- Also RTC Tear or both
What is Subscapular Bursitis?
- Focal Inflammation caused by mechanical pressure and friction between superomedial angle of scapula and the second and third ribs
What are characteristic electrodiagnostic changes in Thoracic Outlet Syndrome?
- Prolonged latency of F Wave
- Reduced Amplitude of Ulnar Sensory Evoked Amplitude
What motion does the Superior Glenohumeral Ligament Restrain and in what position?
- Restrains Inferior translation of the humeral head when the arm is adducted at the side
What motion does the Middle Glenohumeral Ligament Restrain and in what position?
- Restrains Anterior Humeral Translation with arm in mid range of abduction up to 45 deg
- Also restrains ER with arm at side
What is the most important Ligament for the Stability of the Sternoclavicular Joint?
- Posterior Sternoclavicular Ligament
What are some Muscular Imbalances found in individuals with Impingement Syndrome?
- Decreased Serratus Anterior Activity
- Delay in Firing of the Middle and Lower Trapezius
- Dominance of Upper Trapezius and Levator Scapulae
What are the three categories of the Kibler Scapular Dysfunction classification system?
- Inferior Angle Scapular Dysfunction
- Medial Border Scapular Dysfunction
- Superior Scapular Dysfunction
What conditions do you commonly see Scapular Dysfunction with and what types of Scapular Dysfunction?
- Inferior Angle- Rotator Cuff Impingement
- Medial Border- GH Joint Instability
- Superior - Rotator Cuff weakness and force couple imbalances
What are some special tests used to assess Scapular Dysfunction?
- Lateral Scapular Slide Test
- Scapular Assistance Test
- Scapular Retraction Test
- Flip Sign
With a Limitation in IR and Post Capsule Tightness, how will this affect the Humeral Head in Movement of the Shoulder?
- Anterior Superior Translation
What is the Optimal Testing Position for the Supraspinatus?
- Full Can
What is the Optimal Testing Position for the Teres Minor?
- Patte Test
What is the Optimal Testing Position for the Subscapularis?
- Gerber Lift Off
What is the Optimal Testing Position for the Infraspinatus?
- Patient Seated, Arm at side with 45 deg IR
Describe the Tests of the Beighton Hypermobility Scale?
- 9 Individual Tests, Assessed Bilaterally
- Passive Hyperextension of 5th MCP Joint
- Passive Thumb Opposition to Forearm
- Elbow Hyperextension
- Knee Hyperextension
- Standing Trunk Flexion (not bilaterally assessed)
What is the Typical ER/IR Strength Ratio?
- 66%
What are the 3 Stages of Neers Impingement?
- Edema and Hemmhorage
- Fibrosis and Tendonitis
- Spurs and Tendon Rupture
What are the 3 types of Acromion?
- Type 1- Flat
- Type 2- Curved
- Type 3- Hooked
What are the two types of Partial Thickness Tears?
- Bursal Side- Superior Surface Tears
- Articular Side- Under Surface Tears
What types of Shoulder Dysfunction are Bursal and Articular Side Tears Associated With?
- Bursal Side- Subacromial Impingement
- Articular Side- Increased Tensile Loads and Instability (capsular, labral, and muscular insufficiency)
How do you classify the size of a Rotator Cuff Tear?
- Small < 1 cm
- Medium 1-3 cm
- Large 3-5 cm
- Massive >5 cm
What are some Postoperative Milestones after RTC Repair?
- 4-6 weeks- Early PROM, Submaximal Isometric
- 5-6 weeks- Initiate Isotonics
- 8 weeks- Closed Chain Exercise
- 10 weeks- 90 deg Abducted ER and IR
- 12 weeks- Maximal Isokinetics
- 16 weeks- Return to Sport
What are some Postoperative Milestones after Bankart Repair?
- 4-6 weeks- Light Tubing Isotonics
- 6-8 weeks- Higher Level Strengthening
- 12-16 weeks- Sports Specific Activities
How many weeks after SLAP Repair should you wait until you begin ER ROM?
- Should wait 4 weeks until beginning ER ROM past 0 deg
What are some Postoperative Milestones after SLAP Repair?
- 5-6 weeks- GH ROM increased in all planes
- 10 weeks- Submaximal Isometrics in Elbow Flexion
- 12 weeks- Full Shoulder ROM should be achieved
Describe the Modified Weaver-Dunn Procedure
- Coracoclavicular Ligament Reconstruction at the AC Joint
Contracture of what structure is very common in patients with Frozen Shoulder?
- Rotator Cuff Interval
- RCI release can lead to dramatic improvement in ROM into ER
What Surgical Options are available in patients with Glenohumeral Osteoarthritis?
- Hemiarthroplasty (HA)
- Total Shoulder Arthroplasty (TSA)
- Reverse TSA (RSA)
How common is nerve injury with Proximal Humeral Fracture?
- 67% of patients with PHF had nerve injury
- Most common is Axillary Nerve
What are some Postoperative Milestones after TSA?
- Variable recommendations
- Perform AAROM for first 3 weeks, Begin Isometric at 3-5 weeks, Tubing at 10 weeks, Return to work 16 weeks
When is a Reverse TSA warranted?
- 3 Situations related to GH Joint Damage
- Massive or Irreparable RTC Tear
- Proximal Humeral Fracture Resulting in RTC Deficiency
- Revision of previous arthroplasty that has concurrent RTC Deficiency
