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MSK > Lecture 4: UE Injuries Part 1 > Flashcards

Lecture 4: UE Injuries Part 1 Flashcards

1
Q

Rotator cuff muscles and their action

A
  • Teres Minor: external rotation
  • Infraspinatus: External rotation
  • Supraspinatus: Shoulder abduction
  • Subscapularis: Internal rotation, partial adduction
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2
Q

What is the most common CC in regards to shoulders?

A

Pain or instability

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3
Q

What is the MC CC for a shoulder complaint in someone < 30? 30-50? > 50?

A
  • < 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.

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4
Q

What is the MC form of instability in a shoulder?

A

Anterior instability

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5
Q

Where do you begin palpation on the shoulder joint?

A

Sternoclavicular joint and move laterally.

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6
Q

What position should the shoulder be in to assess the subacromial bursa?

A

Humerus extended back

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7
Q

What are the 6 ROM for a shoulder exam?

A
  • Flexion
  • Extension
  • ABduction
  • ADduction
  • Internal rotation
  • External rotation
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8
Q

how do you test for weakness of the deltoid muscle

A

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

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9
Q

What test is for the supraspinatus?

A

Empty can test

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10
Q

What test checks the infraspinatus and teres minor?

A

Hornblower test

External rotation against resistance. Support elbow.

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11
Q

What test checks the subscapularis?

A

Gerber lift-off test

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12
Q

How do you test the serratus anterior?

A
  1. Stabilize scapula
  2. Flex shoulder > 90d
  3. Depress ar posteriorly, other hand palpates scapula
  4. Winging indicates muscle weakness

Have them do a pushup on the wall

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13
Q

How do you test the rhomboid?

A

Winging = muscle weakness

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14
Q

What is the Neer impingement test and what does it test for?

A
  • 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
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15
Q

What is the Hawkins-Kennedy Test and what does it assess for?

A
  • Forward flex shoulder 90d
  • Elbow flex to 90d
  • Internal rotation of shoulder
  • Pain = impingement of supraspinatus tendon
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16
Q

What is a crossover test?

A
  • discomfort = AC joint pathology or arthritis
  • elevate shoulder to 90 degrees and adduct arm across the body in horizontal plane
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17
Q

What does the apprehension sign test for?

A

Anterior instability with a sense of impending dislocation

Crank arm until they sense it

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18
Q

What is the sulcus sign?

A

Test for inferior instability of the shoulder joint

Inferior subluxation of the humeral head

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19
Q

What is the jerk test?

A
  • 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
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20
Q

What views are good for radiographs of the shoulder?

A
  • AP view (addon internal or external rotation)
  • Scapular Y view for shoulder dislocation, proximal humerus or scapula fx
  • Axillary view (humeral head and glenoid)
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21
Q

What muscle is MC damaged in the rotator cuff muscles?

A

Supraspinatus

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22
Q

What is the MCC of shoulder pain and disability?

A

Rotator cuff disorders

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23
Q

Image of rotator cuff damage

A
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24
Q

Where does shoulder impingement pain present?

A

60-120d abduction

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25
Q

What is impingement syndrome?

A

Inflammation of subacromial bursa + rotator cuff tendons

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26
Q

How does impingement syndrome present?

A
  • 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
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27
Q

What tends to be abnormal on PE for impingement disorder?

A
  • 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
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28
Q

What is the most sensitive and specific imaging for a shoulder eval?

A

MRI

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29
Q

How can you differentiate between impingement vs tear without imaging?

A
  1. Anesthetic injection
  2. Empty can test that shows improvement = impingement
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30
Q

Management of impingement disorder

A
  • 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
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31
Q

What causes rotator cuff tendonitis?

Stage after impingement

A

Repetitive overhead motions (pitching)

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32
Q

MC RFs for rotator cuff tendonitis

A
  • Pitching
  • Increased BMI
  • DM
  • HLD
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33
Q

How does stage 1 tendonitis present?

A
  • Aching and soreness with throwing
  • Athletes saying they have decreased speed and accuracy
  • Pain with ADLs
  • improves with rest
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34
Q

How does stage 2 tendonitis present?

A
  • Posterior shoulder pain with activity and at night
  • Loss of ROM: abduction & ext rot
  • Does not improve with rest
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35
Q

What is abnormal on PE for rotator cuff tendonitis?

A
  • Tenderness along affected muscles
  • Pain above 90d abduction
  • Passive ROM > Active ROM
  • positive Empty can
  • positive Neer and hawkins if associated impingement
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36
Q

How does rotator cuff tendonitis usually present on XR?

A

Normal, unless very chronic.

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37
Q

What can MSK US show on rotator cuff tendonitis?

A
  • Thickening > 5-6 mm
  • Hypoechogenicity
  • Heterogenicity
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38
Q

When is MRI shoulder indicated for eval of rotator cuff tendonitis?

A
  • Unclear presentation
  • Inadequate response to conservative therapy
  • Shows edema and inflammation
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39
Q

How do we manage stage 1 rotator cuff tendonitis? Stage 2?

A
  • Stage 1: Rest and no training for 10 days. Intermittent activity after 10 days
  • Stage 2: Rest and refer to PT. (No activity)
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40
Q

What age is rotator cuff tear NOT common in?

A

< 40, unless you’re in baseball chucking fastballs

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41
Q

How does a rotator cuff tear present?

A
  • 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

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42
Q

What ADLs are common to ask about in rotator cuff tears?

A
  • Washing/styling hair
  • Putting on shirt/bra
  • Reaching for items on shelves
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43
Q

What is abnormal on PE for a rotator cuff tear?

A
  • Tenderness along grater tuberosity
  • Limited, painful weak AROM
  • Full PROM
  • + Drop arm
  • positive Empty can, neer’s, hawkin’s
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44
Q

Best image for Rotator cuff tear?

A

MRI

XRay really only to r/o other causes

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45
Q

What is US good for in terms of rotator cuff tear?

A

Determining full-thickness vs partial thickness

46
Q

What is seen on XRAY for a chronic rotator cuff tear?

A

Shallow space between acromion and humerus indicative of chronic tear

47
Q

How do we manage a rotator cuff tear?

A
  • Rest
  • NSAIDs
  • PT for 6 weeks or more
  • Glucocorticoid if non-surgical, 3-4 injections MAX
48
Q

When is surgery indicated for a rotator cuff tear?

A
  • < 55 y/o
  • Acute, full-thickness
  • Acute on chronic tear with loss of function
  • Failure to improve after 3-6months
49
Q

What is adhesive capsulitis MC known as?

A

Frozen shoulder

50
Q

What is characteristic of adhesive capsulitis?

A
  • Freezing phase: Progressive loss of ROM and pain
  • Thawing phase: Gradual improvement in ROM and discomfort
51
Q

Demographics and RFs for adhesive capsulitis

A
  • MC in women 40-60
  • RFs: (T1DM is MC)
  • Hypothyroidism
  • Dupuytrens
  • Cervical disc dz
  • Parkinsons
  • Cerebral hemorrhage
52
Q

How does XRAY look for adhesive capsulitis?

A

Normal.

Primarily used to r/o other DDx

53
Q

What MRI finding is suggestive of adhesive capsulitis?

A

Contracted capsule and loss of inferior pouch

54
Q

Management of adhesive capsulitis

A
  • NSAIDs
  • Moist heat compresses
  • Home stretching program
  • Intra-articular steroid injection (3-6 MAX)
  • PT with TENS unit
55
Q

When is surgery indicated for adhesive capsulitis and what is the surgery?

A
  • Indicated when there is no improvement in symptoms after 3 months of consistent rehab
  • Arthroscopic Capsular Release

1-2 years to fully recover

56
Q

Define subluxation

A

Humeral head partially slips out of glenoid cavity

57
Q

Define dislocation

A

Complete dislodging of humeral head from glenoid cavity

58
Q

MC direction of shoulder instability

A

Anterior

59
Q

How does anterior shoulder dislocation present?

A
  • Arm slightly abducted with external rotation
  • Prominent acromion
  • Loss of rounded appearane
  • NO ROM

Blocking a shot in basketball

60
Q

How does posterior shoulder dislocation present?

A
  • Adducted and internally rotated with no ability to externally rotate
  • Shoulder prominence posteriorly with flattening anteriorly
  • Prominent coracoid process
61
Q

What is the mechanism of injury for an inferior shoulder dislocation?

A

Axial loading with arm fully abducted or forceful hyperabduction of the arm.

Overhead grasp of object to keep from falling

62
Q

How does an inferior shoulder dislocation tend to present?

A
  • Arm above head
  • Inability to adduct arm
63
Q

What tests are good for assessing shoulder instability?

A
  • Apprehension (anterior)
  • Jerk (posterior)
  • Sulcus (inferior)
64
Q

What is the concerning nerve near the shoulder?

A

Axillary nerve

Always do a neurovascular exam!

65
Q

What is a hills sach lesion?

A

Depression fx of humeral head 2/2 dislocation.

MC in anterior dislocations.

66
Q

What is a bankart lesion?

A

Glenoid labrum disruption, common in patients < 30 y/o

May result in bone fragment avulsion

67
Q

What part of the humerus is sometimes fractured in shoulder dislocations?

A

Greater tuberosity fractures

10%

68
Q

When is MRI indicated for shoulder instability?

A
  • If we suspect soft tissue injury
  • After reduction, to check for bankarts in people < 30
  • Check rotator cuff muscles if traumatic and < 40
69
Q

What are the two ways to do an anterior dislocation reduction?

A
  • Stimson technique (prone)
  • Longitudinal traction
70
Q

How do you reduce an inferior shoulder dislocation?

A

Axial traction

71
Q

How do you reduce a posterior shoulder dislocation?

A

Traction-countertraction

72
Q

After reduction, how do we manage a shoulder dislocation?

A
  • Reassess NV status
  • Obtain post-reduction films to verify
  • Immobilize in sling for 3 weeks
  • Refer to PT
73
Q

How does an AC injury tend to occur?

A

Falling directly on an ADducted shoulder

74
Q

How is an AC injury graded?

A

I-VI

75
Q

Describe a Type I AC injury

A
  • Sprain
  • MC type of AC injury
  • Partial disruption of joints
  • No separation of clavicle from acromion
76
Q

Describe a type 2 AC injury

A
  • AC ligament torn CC ligament intact
  • Partial separation of clavicle from acromion
77
Q

Describe a type 3 AC injury

A
  • Both AC and CC ligament completely disrupted
  • Complete separation of acromion and clavicle
78
Q

How do type 4-6 AC injury present?

A

Classified on degree and direction of separation

I think we don’t really need to know these

79
Q

How do AC injuries present?

A
  • Pain in AC joint on ABduction
  • Supports arm in an ADducted position
  • Deformity only see in grade 3 or higher
  • Tenderness over AC joint
80
Q

What XRAY view is good for AC injury imaging?

A

AP shoulder or Zanca view (10-15 cephalic tilt of an AP view)

Only type 2 and higher have imaging separation

81
Q

Management of Grade I and II AC injuries

A
  • Ice compresses
  • NSAIDs
  • Sling with rest for 2-3d
  • ROM exercises, full return within 2-4 weeks
82
Q

Management of Grade III AC injury

A
  • Conservative as in I and II
  • Surgical consult if affecting career
  • Acceptable deformity is likely without surgery
83
Q

Management of Grade 4+ AC Injury

A

Ortho, emergent if NV compromise

84
Q

How does an anterior sternoclavicular injury occur?

A

Anterolateral force applied to shoulder with rolling motion (Sports)

85
Q

How does a posterior sternoclavicular injury occur?

A
  • Crushing forces to chest
  • Mediastinal injuries
86
Q

How does a sternoclavicular sprain present?

A
  • Mild-mod pain
  • Tenderness/swelling
  • No change in joint structure
87
Q

How does a sternoclavicular dislocation present?

A
  • Severe pain
  • Swelling
  • Ecchymosis
  • Decreased ROM
  • Anterior: medial clavicle is prominent
  • Posterior: medical clavicle is less visible/palpable + Hoarseness, dysphagia, UE paresthesias
88
Q

What imaging is good for dxing sternoclavicular injury?

A

CT Chest, usually with con to r/o mediastinal injury

89
Q

Management of Grade I sternoclavicular injury (Sprain)

A
  • Rest, sling, ice, NSAIDs
  • Gradual return (same as AC Grade I)
90
Q

Management of anterior sternoclavicular dislocation

A
  • Reduction with posterior traction
  • Sling/figure 8 harness
91
Q

Management of posterior sternoclavicular dislocation

A

Consult ortho :)

92
Q

MC clavicle fracture location out of the 3

A

Middle 1/3: diaphysis

93
Q

How does clavicle fx present?

A
  • Pain, swelling, deformity
  • Skin tenting
  • tenderness
  • Decreased ROM with a grinding sensation when attempting ROM.
94
Q

What imaging is used for clavicle fx?

A
  • Clavicle XRAY + 10d cephalic view
  • CT Chest w/ con if medial fx is suspected
95
Q

Management of an uncomplicated clavicle fx

A
  • Figure 8 strap, sling, ice, analgesics
  • Sling for kids: 3-4 wks
  • Sling for adults: 6-8 wks
  • Gentle ROM after 2-3 weeks
96
Q

When would we consult ortho for a clavicle fx?

A
  • Medial fx
  • Tenting of skin
  • 100% displacement
  • Displaced distal 1/3 fx
  • Severe comminution

ORIF

97
Q

MC MOI for biceps tendinopathy

A

Overuse (repetitive lifting)

Long head is the MC affected

98
Q

What condition is MC associated with biceps tendinopathy?

A

Impingement syndrome (95%)

99
Q

Presentation of biceps tendinopathy

A
  • Pain reported in the anterior shoulder radiating to the elbow
  • Worsened by activity
  • Night pain is common
  • Symptoms relieved with rest and ice
100
Q

What is abnormal on PE for biceps tendinopathy?

A
  • Tenderness along with bicipital groove
  • Pain with both passive ROM and AROM
  • Yergason’s test (pain with supination = +)
101
Q

Management of biceps tendinopathy

A
  • Rest
  • Ice
  • NSAIDs
  • Glucocorticoid if failed conservative (risk of tendon rupture)
  • PT
102
Q

Where does a rupture of the long head of the biceps MC occur? MC demographic?

A
  • Proximal end
  • MC in older adults with chronic shoulder pain or impingement
103
Q

How does a rupture of the LHBT present?

A
  • Sudden onset of pain
  • Audible snap
  • Ecchymosis initially
  • Bulge/popeye deformity
  • Tenderness in the bicipital groove
104
Q

Management of LHBT rupture

A
  • Conservative
  • Usually lose about 10% of strength
  • Surgery indicated only for unacceptable deformity or young athlete/laborer
105
Q

MC MOIs for humeral fx

A
  • Direct blow to arm during MVA
  • Falling on an outstretched hand (FOOSH)
106
Q

Locations of humeral fx

A
  • Proximal
  • Shaft
  • Distal (Supracondylar MC in children)
107
Q

Presentation of a humeral fx

A
  • Pain, swelling, ecchymosis
  • Tenderness to gentle palpation
  • Limited ROM of shoulder
  • Assess NV status of axillary (proximal) or radial (shaft)
108
Q

Management of a proximal humeral fx

A

Sling fulltime for 3 wks and then part time

109
Q

When is ORIF indicated for a proximal humeral fx?

A
  • Displacement of > 1 cm or > 45deg angulation
  • Displacement of greater tuberosity > 0.5 cm (rotator cuff involved)
110
Q

When is a prosthetic humerus for a proximal humeral fx indicated?

A

4-part fx due to risk of blood supply disruption to humeral head

111
Q

How do we manage a humeral shaft fx with angulation < 20 deg?

A
  • Splinting with U-shaped coaptation splint for 2 weeks, then humeral fx brace for 6 weeks
  • Encourage ROM of distal upper extremity
112
Q

When is surgery indicated for a humeral shaft fx?

A
  • Open fx
  • NV compromise
  • Pathologic fx
  • Ipsilateral forearm fx

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