Lecture 4: UE Injuries Part 1 Flashcards
Rotator cuff muscles and their action
- Teres Minor: external rotation
- Infraspinatus: External rotation
- Supraspinatus: Shoulder abduction
- Subscapularis: Internal rotation, partial adduction
What is the most common CC in regards to shoulders?
Pain or instability
What is the MC CC for a shoulder complaint in someone < 30? 30-50? > 50?
- < 30y = traumatic injuries or joint instability (AC joint separation)
- 30-50: Rotator cuff tears or impingement syndrome
- > 50: Rotator cuff dysfunction/tear, impingement syndrome and degenerative arthritis
Athletes are more likely to get tears.
What is the MC form of instability in a shoulder?
Anterior instability
Where do you begin palpation on the shoulder joint?
Sternoclavicular joint and move laterally.
What position should the shoulder be in to assess the subacromial bursa?
Humerus extended back
What are the 6 ROM for a shoulder exam?
- Flexion
- Extension
- ABduction
- ADduction
- Internal rotation
- External rotation
how do you test for weakness of the deltoid muscle
abduct shoulder at 90 degrees w the elbow flexed @ 90 degrees and the forearm parallel to the floor
ask patient to resist downward pressure to elbow
What test is for the supraspinatus?
Empty can test
What test checks the infraspinatus and teres minor?
Hornblower test
External rotation against resistance. Support elbow.
What test checks the subscapularis?
Gerber lift-off test
How do you test the serratus anterior?
- Stabilize scapula
- Flex shoulder > 90d
- Depress ar posteriorly, other hand palpates scapula
- Winging indicates muscle weakness
Have them do a pushup on the wall
How do you test the rhomboid?
Winging = muscle weakness
What is the Neer impingement test and what does it test for?
- Compresses the rotator cuff tendons btween greater tuberosity & anterior acromion
- w patient seated, depress scapula w one hand and elevate arm w other
- Discomfort = rotator cuff tear or impingement syndrome
What is the Hawkins-Kennedy Test and what does it assess for?
- Forward flex shoulder 90d
- Elbow flex to 90d
- Internal rotation of shoulder
- Pain = impingement of supraspinatus tendon
What is a crossover test?
- discomfort = AC joint pathology or arthritis
- elevate shoulder to 90 degrees and adduct arm across the body in horizontal plane
What does the apprehension sign test for?
Anterior instability with a sense of impending dislocation
Crank arm until they sense it
What is the sulcus sign?
Test for inferior instability of the shoulder joint
Inferior subluxation of the humeral head
What is the jerk test?
- 90d flexion + max internal rotation + elbow flex 90d
- Adduct arm across horizontal while pushing humerus in posterior position
- Posterior instability shows up as posterior subluxation or dislocation
What views are good for radiographs of the shoulder?
- AP view (addon internal or external rotation)
- Scapular Y view for shoulder dislocation, proximal humerus or scapula fx
- Axillary view (humeral head and glenoid)
What muscle is MC damaged in the rotator cuff muscles?
Supraspinatus
What is the MCC of shoulder pain and disability?
Rotator cuff disorders
Image of rotator cuff damage
Where does shoulder impingement pain present?
60-120d abduction
What is impingement syndrome?
Inflammation of subacromial bursa + rotator cuff tendons
How does impingement syndrome present?
- Gradual onset of shoulder pain (anterior and laterally)
- Pain worsened by overhead activity
- Night pain and difficulty sleeping on side
- Prolonged: weakness and SITS atrophy
What tends to be abnormal on PE for impingement disorder?
- Tenderness on palpation over greater tuberosity and subacromial bursa
- Pain with abduction between 90-120 and when lowering arm
- Crepitus with movement
- + Neer and Hawkins-kennedy
What is the most sensitive and specific imaging for a shoulder eval?
MRI
How can you differentiate between impingement vs tear without imaging?
- Anesthetic injection
- Empty can test that shows improvement = impingement
Management of impingement disorder
- Rest & NSAIDs
- Gradual exercises (pain should not worsen)
- Ice after exercises
- Corticosteroids if no improvement after 4-6 weeks
- PT if no improvement after 3-4 weeks
- OT if PT fails
What causes rotator cuff tendonitis?
Stage after impingement
Repetitive overhead motions (pitching)
MC RFs for rotator cuff tendonitis
- Pitching
- Increased BMI
- DM
- HLD
How does stage 1 tendonitis present?
- Aching and soreness with throwing
- Athletes saying they have decreased speed and accuracy
- Pain with ADLs
- improves with rest
How does stage 2 tendonitis present?
- Posterior shoulder pain with activity and at night
- Loss of ROM: abduction & ext rot
- Does not improve with rest
What is abnormal on PE for rotator cuff tendonitis?
- Tenderness along affected muscles
- Pain above 90d abduction
- Passive ROM > Active ROM
- positive Empty can
- positive Neer and hawkins if associated impingement
How does rotator cuff tendonitis usually present on XR?
Normal, unless very chronic.
What can MSK US show on rotator cuff tendonitis?
- Thickening > 5-6 mm
- Hypoechogenicity
- Heterogenicity
When is MRI shoulder indicated for eval of rotator cuff tendonitis?
- Unclear presentation
- Inadequate response to conservative therapy
- Shows edema and inflammation
How do we manage stage 1 rotator cuff tendonitis? Stage 2?
- Stage 1: Rest and no training for 10 days. Intermittent activity after 10 days
- Stage 2: Rest and refer to PT. (No activity)
What age is rotator cuff tear NOT common in?
< 40, unless you’re in baseball chucking fastballs
How does a rotator cuff tear present?
- Chronic shoulder pain worse with activity and night
- Weakness, catching, and crepitus when lifting
- inability to fully perform ADLs
- Older people might be asymptomatic
They can get used to it, no need to treat unless symptomatic
What ADLs are common to ask about in rotator cuff tears?
- Washing/styling hair
- Putting on shirt/bra
- Reaching for items on shelves
What is abnormal on PE for a rotator cuff tear?
- Tenderness along grater tuberosity
- Limited, painful weak AROM
- Full PROM
- + Drop arm
- positive Empty can, neer’s, hawkin’s
Best image for Rotator cuff tear?
MRI
XRay really only to r/o other causes
What is US good for in terms of rotator cuff tear?
Determining full-thickness vs partial thickness
What is seen on XRAY for a chronic rotator cuff tear?
Shallow space between acromion and humerus indicative of chronic tear
How do we manage a rotator cuff tear?
- Rest
- NSAIDs
- PT for 6 weeks or more
- Glucocorticoid if non-surgical, 3-4 injections MAX
When is surgery indicated for a rotator cuff tear?
- < 55 y/o
- Acute, full-thickness
- Acute on chronic tear with loss of function
- Failure to improve after 3-6months
What is adhesive capsulitis MC known as?
Frozen shoulder
What is characteristic of adhesive capsulitis?
- Freezing phase: Progressive loss of ROM and pain
- Thawing phase: Gradual improvement in ROM and discomfort
Demographics and RFs for adhesive capsulitis
- MC in women 40-60
- RFs: (T1DM is MC)
- Hypothyroidism
- Dupuytrens
- Cervical disc dz
- Parkinsons
- Cerebral hemorrhage
How does XRAY look for adhesive capsulitis?
Normal.
Primarily used to r/o other DDx
What MRI finding is suggestive of adhesive capsulitis?
Contracted capsule and loss of inferior pouch
Management of adhesive capsulitis
- NSAIDs
- Moist heat compresses
- Home stretching program
- Intra-articular steroid injection (3-6 MAX)
- PT with TENS unit
When is surgery indicated for adhesive capsulitis and what is the surgery?
- Indicated when there is no improvement in symptoms after 3 months of consistent rehab
- Arthroscopic Capsular Release
1-2 years to fully recover
Define subluxation
Humeral head partially slips out of glenoid cavity
Define dislocation
Complete dislodging of humeral head from glenoid cavity
MC direction of shoulder instability
Anterior
How does anterior shoulder dislocation present?
- Arm slightly abducted with external rotation
- Prominent acromion
- Loss of rounded appearane
- NO ROM
Blocking a shot in basketball
How does posterior shoulder dislocation present?
- Adducted and internally rotated with no ability to externally rotate
- Shoulder prominence posteriorly with flattening anteriorly
- Prominent coracoid process
What is the mechanism of injury for an inferior shoulder dislocation?
Axial loading with arm fully abducted or forceful hyperabduction of the arm.
Overhead grasp of object to keep from falling
How does an inferior shoulder dislocation tend to present?
- Arm above head
- Inability to adduct arm
What tests are good for assessing shoulder instability?
- Apprehension (anterior)
- Jerk (posterior)
- Sulcus (inferior)
What is the concerning nerve near the shoulder?
Axillary nerve
Always do a neurovascular exam!
What is a hills sach lesion?
Depression fx of humeral head 2/2 dislocation.
MC in anterior dislocations.
What is a bankart lesion?
Glenoid labrum disruption, common in patients < 30 y/o
May result in bone fragment avulsion
What part of the humerus is sometimes fractured in shoulder dislocations?
Greater tuberosity fractures
10%
When is MRI indicated for shoulder instability?
- If we suspect soft tissue injury
- After reduction, to check for bankarts in people < 30
- Check rotator cuff muscles if traumatic and < 40
What are the two ways to do an anterior dislocation reduction?
- Stimson technique (prone)
- Longitudinal traction
How do you reduce an inferior shoulder dislocation?
Axial traction
How do you reduce a posterior shoulder dislocation?
Traction-countertraction
After reduction, how do we manage a shoulder dislocation?
- Reassess NV status
- Obtain post-reduction films to verify
- Immobilize in sling for 3 weeks
- Refer to PT
How does an AC injury tend to occur?
Falling directly on an ADducted shoulder
How is an AC injury graded?
I-VI
Describe a Type I AC injury
- Sprain
- MC type of AC injury
- Partial disruption of joints
- No separation of clavicle from acromion
Describe a type 2 AC injury
- AC ligament torn CC ligament intact
- Partial separation of clavicle from acromion
Describe a type 3 AC injury
- Both AC and CC ligament completely disrupted
- Complete separation of acromion and clavicle
How do type 4-6 AC injury present?
Classified on degree and direction of separation
I think we don’t really need to know these
How do AC injuries present?
- Pain in AC joint on ABduction
- Supports arm in an ADducted position
- Deformity only see in grade 3 or higher
- Tenderness over AC joint
What XRAY view is good for AC injury imaging?
AP shoulder or Zanca view (10-15 cephalic tilt of an AP view)
Only type 2 and higher have imaging separation
Management of Grade I and II AC injuries
- Ice compresses
- NSAIDs
- Sling with rest for 2-3d
- ROM exercises, full return within 2-4 weeks
Management of Grade III AC injury
- Conservative as in I and II
- Surgical consult if affecting career
- Acceptable deformity is likely without surgery
Management of Grade 4+ AC Injury
Ortho, emergent if NV compromise
How does an anterior sternoclavicular injury occur?
Anterolateral force applied to shoulder with rolling motion (Sports)
How does a posterior sternoclavicular injury occur?
- Crushing forces to chest
- Mediastinal injuries
How does a sternoclavicular sprain present?
- Mild-mod pain
- Tenderness/swelling
- No change in joint structure
How does a sternoclavicular dislocation present?
- Severe pain
- Swelling
- Ecchymosis
- Decreased ROM
- Anterior: medial clavicle is prominent
- Posterior: medical clavicle is less visible/palpable + Hoarseness, dysphagia, UE paresthesias
What imaging is good for dxing sternoclavicular injury?
CT Chest, usually with con to r/o mediastinal injury
Management of Grade I sternoclavicular injury (Sprain)
- Rest, sling, ice, NSAIDs
- Gradual return (same as AC Grade I)
Management of anterior sternoclavicular dislocation
- Reduction with posterior traction
- Sling/figure 8 harness
Management of posterior sternoclavicular dislocation
Consult ortho :)
MC clavicle fracture location out of the 3
Middle 1/3: diaphysis
How does clavicle fx present?
- Pain, swelling, deformity
- Skin tenting
- tenderness
- Decreased ROM with a grinding sensation when attempting ROM.
What imaging is used for clavicle fx?
- Clavicle XRAY + 10d cephalic view
- CT Chest w/ con if medial fx is suspected
Management of an uncomplicated clavicle fx
- Figure 8 strap, sling, ice, analgesics
- Sling for kids: 3-4 wks
- Sling for adults: 6-8 wks
- Gentle ROM after 2-3 weeks
When would we consult ortho for a clavicle fx?
- Medial fx
- Tenting of skin
- 100% displacement
- Displaced distal 1/3 fx
- Severe comminution
ORIF
MC MOI for biceps tendinopathy
Overuse (repetitive lifting)
Long head is the MC affected
What condition is MC associated with biceps tendinopathy?
Impingement syndrome (95%)
Presentation of biceps tendinopathy
- Pain reported in the anterior shoulder radiating to the elbow
- Worsened by activity
- Night pain is common
- Symptoms relieved with rest and ice
What is abnormal on PE for biceps tendinopathy?
- Tenderness along with bicipital groove
- Pain with both passive ROM and AROM
- Yergason’s test (pain with supination = +)
Management of biceps tendinopathy
- Rest
- Ice
- NSAIDs
- Glucocorticoid if failed conservative (risk of tendon rupture)
- PT
Where does a rupture of the long head of the biceps MC occur? MC demographic?
- Proximal end
- MC in older adults with chronic shoulder pain or impingement
How does a rupture of the LHBT present?
- Sudden onset of pain
- Audible snap
- Ecchymosis initially
- Bulge/popeye deformity
- Tenderness in the bicipital groove
Management of LHBT rupture
- Conservative
- Usually lose about 10% of strength
- Surgery indicated only for unacceptable deformity or young athlete/laborer
MC MOIs for humeral fx
- Direct blow to arm during MVA
- Falling on an outstretched hand (FOOSH)
Locations of humeral fx
- Proximal
- Shaft
- Distal (Supracondylar MC in children)
Presentation of a humeral fx
- Pain, swelling, ecchymosis
- Tenderness to gentle palpation
- Limited ROM of shoulder
- Assess NV status of axillary (proximal) or radial (shaft)
Management of a proximal humeral fx
Sling fulltime for 3 wks and then part time
When is ORIF indicated for a proximal humeral fx?
- Displacement of > 1 cm or > 45deg angulation
- Displacement of greater tuberosity > 0.5 cm (rotator cuff involved)
When is a prosthetic humerus for a proximal humeral fx indicated?
4-part fx due to risk of blood supply disruption to humeral head
How do we manage a humeral shaft fx with angulation < 20 deg?
- Splinting with U-shaped coaptation splint for 2 weeks, then humeral fx brace for 6 weeks
- Encourage ROM of distal upper extremity
When is surgery indicated for a humeral shaft fx?
- Open fx
- NV compromise
- Pathologic fx
- Ipsilateral forearm fx
