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athletic injuries 2036 > Lecture 8: The athletes shoulder > Flashcards

Lecture 8: The athletes shoulder Flashcards

1
Q

The shoulder girdle

A
  • connects the upper limb to the axial skeleton on each side
  • contains 2 bones (clavicle and scapula)
  • clavicle attaches medially to the sternal manubrium and laterally to the acromion process of the scapula
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2
Q

what are the different terms used to describe injuries of the shoulder complex?

A

1: separations
2: dislocations
3: fractures
4: tendonitis/osis
5: strains

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3
Q

shoulder separations

A
  • acromioclavicular (AC) joint
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4
Q

shoulder dislocations

A
  • glenohumeral
  • sternoclavicular joint
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5
Q

shoulder fractures

A
  • clavicle, humerus, scapula
  • pretty much any shoulder bone
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6
Q

shoulder tendonitis/osis

A
  • common in over head athletes
  • rotator cuff
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7
Q

shoulder strains

A
  • rotator cuff
  • scapular stabilizers
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8
Q

the sternoclavicular joint

A
  • clavicle articulates with manubrium to form the sternoclavicular joint
  • only 25% of the clavicles surface area in contact
  • least bony stability in the chain
  • integrity of the joint comes from strong ligament attachment
  • disc between two surfaces-shock absorber
  • only direct connection between upper extremity and trunk (attached through thee SC joint)
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9
Q

what movements is the sternoclaviclar joint do?

A
  • important for all movements, but especially in abduction
  • clavicle should move freely forward and backwards, up and rotate
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10
Q

sternoclavicular movement

A
  • as the arm moves through flexion and or abduction the clavicle retracts, elevates and rotates posteriorly
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11
Q

sternoclavicular joint stability

A

there are 4 things that help with joint stability
1: sternoclaviucvlar
2: costoclavicular
3: interclavicular
4: articular disc

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12
Q

what does the sternoclavicular do for joint stability?

A

stops a lot with the popping up and popping forward

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13
Q

what does the costoclavicular help with in joint stability?

A

helps hold it to the clavicle

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14
Q

what does the interclavicular do in joint stability?

A
  • puts medial tension on the two clavicles
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15
Q

what does the articular disc do in joint stability?

A
  • provides a little bit of joint stability and works as a shock absorber
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16
Q

sternoclavicular injury

A
  • MVA and sports injuries most common cause on injury

can be:
- direct blow to the clavicle
- indirect through arm or shoulder

  • usually clavicle moves upward and forward
  • dangerous if posterior
    • because it can injury the subclavian vein and artery, trachea, esophagus
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17
Q

what is an example of a direct injury to the sternoclavicular

A
  • a goalie taking a shot right on the clavicle
  • direct trauma that causes an issue
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18
Q

what is an example of an indirect injury to the sternoclavicular

A
  • usually a fall on the tip of the shoulder
  • i.e. if you fall on your shoulder and then it pops out, it usually pops upwards and forwards
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19
Q

anterior dislocations of the SC joint

A
  • anterior dislocations rarely occur as a result of direct trauma
  • when an anterolateral force is applied to the clavicle and the shoulder is rolled backward
  • in three separate studies looking at SC joint dislocations, an indirect force was the most common mechanism of injury
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20
Q

posterior dislocations of the SC joint

A
  • posterior dislocations of the SC joint typically occur as the result of a direct force to the anteromedial clavicle
  • posterior dislocations can also occur when a force is applied to the posterolateral shoulder, causing the shoulder to roll forward
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21
Q

sternoclavicular injury grading

A
  • patient presents with local pain and swelling
  • can be graded 1-3

1: slight pain and tenderness, but no deformity
- pain, tenderness, no real laxity

2: sublux with deformity, swelling and pain. unable to abduct or bring arm across chest.
- pain (especially with abduction)
- laxity
- end point because it is not fully dislocated

3: complete displacement of clavicle
- pain if it just happens, variable afterwards
- will move all over the place (laxity)
- no endpoint

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22
Q

management of SC joint injury

A
  • with posterior injury - send the person to the E.R.
  • anterior injuries reduced with lateral traction (lateral poll)
  • POLICE! PEACE & LOVE
  • high incidence of re-injury
  • the injury will continue to occur because the ligaments are weakened every time that they stretch while they are dislocated
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23
Q

the clavicle

A
  • clacicle is an “S” shaped bone
  • functions: protect neurovascular bundle, for muscle attachment and bony attachment of shoulder
  • one of the most common fractures in sports
  • MOI
  • can be injured with any force that brings shoulder to midline or direct force from superior or anterior direction force from the superior or anterior direction
    (fall on point of shoulder)
    (fall on outstretched arm)
24
Q

clavicle fractures

A

signs and symptoms
- usually middle 1/3 with outer fragment dropping down, but can be distal tip
- pain +++
- localized tenderness and swelling

will have:
- loss of function
- spasm of trapezius and SCM
- arm held to body with shoulder elevated
- scapula assumes protracted position

25
Q

clavicle fractures management

A
  • provide pain relied
  • POLIce
  • sling (do the tube)
  • managed conservatively
  • usually heal in 4-6 weeks
  • keep arm moving below 90 degrees
26
Q

rehab for clavicle fractures

A
  • keep the muscles below the clavicle working
  • can keep doing cardio
  • be as involved as possible
27
Q

the acromioclavicular joint

A
  • stability provided by a number of strucutes

1: caracoclavicular ligaments
(conoid, trapezoid)
- run from the caracoid to the clavicle
- gives the vertical stability, stops the coracoid from going up and down

2: acromioclavicualr ligaments
- gives anterior-posterior stability
- stops it from popping forward and backward

3: capsule

28
Q

AC separations

A
  • injuries to AC joint termed separations
  • MOI can be
    • direct point of shoulder with arm adducted- most common
    • indirect, fall on outstretched hand (FOOSH)

grades: 1-6 (1-3 most common)

29
Q

grade 1 of AC injury

A
  • small tear of the capsule of the AC joint
  • no instability of joint
  • pain on palpation
  • you can get peoples pain down enough to put them back in the game
30
Q

grade 2 of AC injury

A
  • complete tear of the AC joint capsule.ligaments and a small tear of the coracoclavicular ligaments
  • slight Anterior - posterior spring (meaning they have laxity that way because the capsule is not holding them in place
  • do not let the patient continue to play as they can further injure themselves
31
Q

grade 3 injury of the AC joint

A
  • complete tear of the acromioclavicualr ligament and the coracoclavicular (CC) ligament
  • there will be no anterior posterior stability
32
Q

step deformity

A
  • happens in a grade 3 AC separation
    -happens because the CC ligaments are torn and so now the clavicle has popped up.
  • hall mark sign of a AC separation
33
Q

when is a AC injury surgical?

A

grades 4, 5, 6

34
Q

management of a grade 1 AC injury

A
  • clinically stable but very painful
  • can go back as soon as pain/function permits
  • get them out of sling
  • tape for comfort
  • palliate pain
  • POLICE/PEACE & LOVE
    -goal is to keep shoulder moving for return to play ASAP
    • maintain ROM, strength and fucntion
  • can work through some pain
35
Q

why put athletes on ICE?

A

because it knocks out the C fibers

36
Q

injury management for grade 2-3 AC injury

A

inflammation/destruction phase
- POLICE/PEACE & LOVE
- stabilize with tape

repair phase
- gentle AROM or AAROM progress to full ROM
- shoulder isometrics, progression to concentric
- scapular stabilizer strengthening (Rhomboids, Trapezius, serratus anterior)

remodelling stage:
- full stregnth at shoulder
- good scapulothoracis mechanics
- full function as per return to play criteria (replicate the demands of the sport in rehab)

37
Q

stages of mangement for a grade 2-3 AC injury

A

1: inflammation/destruction phase
2: repair phase
3: remodelling stage

38
Q

criteria for return from shoulder girdle injuries

A
  • medical clearance
  • full range of motion
  • strength within 90% of un-affected side
  • full function
  • able to protect themselves
  • protect the joint
39
Q

return time estimates for shoulder girdle injuries

A

grade 1: one week to ten days
- will heal nicely because everything is still intact

grade 2: two to three weeks
- can still heel across because it is still intact

grade 3: four to twelve weeks
- always going to have the step deformity

grade 4-6: surgical

40
Q

what does the shoulder complex consist of?

A
  • the humerus, scapula (gelnohumeral joint) articulation through the AC and SC joints
41
Q

what does the design of the shoulder complex allow for?

A
  • for great mobility due to articualr surface having minimal bony congruity
  • both the scapulothoracis articulation and gelnohumeral joints help with this mobility
  • must work together with musculature and ligaments/capsule to maintain the instantaneous center of motion (ICOM) of the GH joint
    • boney structures keep articulation in contact
    • scapular stabilizers help position for scapula for max stability
    • injury occurs with disruption one or more components
42
Q

glenohumeral joint

A
  • humeral head is roughly 3x the size of the laterally facing glenoid
  • labrum deepens the socket
  • must coordinate movement with scapula and scapular stabilizers
  • with movement, the scapula must rotate under to support humerus
  • there is not a ton of stability
43
Q

shoulder support

A

1: static
- labrum
-capsule
-gelnohumeral ligaments

2: dynamic
- rotator cuff
- scapular stabilizers (helps to position the other things)

44
Q

shoulder support post-ant-sup

A
  • to achieve the mobility, stability is compromised

posteriorly and superiorly support
- from spine of scapula and acromion
- thick capsule
-RC muscles crossing posterior joint

anteriorly
- minimimal bony support
- biceps
- joint capsule and ligaments

45
Q

static stabilizers capsule/ligaments

A
  • capsule around shoulder joint has thickenings
  • these thickenings are the ligaments
    • superior (SGHL), middle (MGHL), and inferior glenohumeral (IGHL) ligaments
  • these ligaments rotate with movement
  • when in abduction and external rotation, the anterior IGHL “fans-out” and rotates anteriorly and superiorly to prevent subluxation of the shoulder
46
Q

normal movement pattens of the shoulder complex

A
  • setting phase:
  • inital 30 degrees the scapula does not move as the scapula establishes a stable base (just the humerus will move)
  • following that there is aprrox. 2:1 degree ratio between the humerus and scapula
47
Q

0-90 degree shoulder abduction

A
  • upper fibers of trap and serratus anterior drive motion
48
Q

above 90 degrees of shoulder abduction

A
  • lower fibers of trap and seratus anterior drive motion
49
Q

the dislocated shoulder

A

1: traumatic - TORN LOOSE
- TUBS (traumatic, unilateral lesion with Bankart and requiring Surgery

2: astraumatic - BORN LOOSE
- AMBRI (Atraumatic, multidirectional, frequently bilateral, responds to rehabilitation and rarely requires an inferior capsular shift

50
Q

the dislocated shoulder (traumatic)

A
  • single force applies excessive overload to the passive restraints. Often damages the glenoid (Bankart) and the humerus (Hill-Sachs lesion)
51
Q

the dislocated shoulder (atraumatic)

A
  • multi-directionally (congenitally) lax individauls or functionally lax secondary to repetitive mictrotrauma - lead to loose capsule
52
Q

torn loose - anterior dislocation

A
  • 95% of dislocations occur anteriory (because there is 0 bony protection interior)
    -MOI
    • forced external rotation usually abducted or FOOSH

signs/symptoms:
- arm held slightly externally rotated and abducted
- restricted ROM
- altered contour of the shoulder

53
Q

why do you not put patients with torn loose- anterior dislocation into a sling?

A

because the head is just going to dig into the rib cage, instead you want to put the arm slightly out and rotated and you can pack in-between the arm and the persons chest for comfort

54
Q

apprehension test (for people with anterior laxity)

A

1: tell - tell you to stop
2: roll - roll their body towards the arm
3: fight - fight what you are doing
4: pull - pull the arm to the body

55
Q

inferior dislocations

A
  • accounts for 1%
  • MOI
  • arm is in excessive abduction and a force is taken pushing the head of the humerus inferiorly out of the glenoid
  • similar S/S as anterior dislocation
56
Q

posterior dislocation

A
  • it is easily missed
  • account for 4%
  • often due to seizure (34%) or electric shock

MOI
- the arm is in flexion and adduction
- force is taken on the hand, causing the head of the humerus to be pushed out the glenoid posteriorly
- elbow held at side with hand on stomach
- can not externally rotate or abduct

57
Q

Born loose - subluxing shoulder

A
  • often seen in individuals with chronic instability
  • AMBRI - multiple joint laxities in multiple directions, with frequent subluxations
    (can be acquired - from repetitive trauma/ motion and poor stretching through a joint)
  • may experience “dead arm” with a humeral sublxation
  • this is due to traction/impingement of neuromuscular structures causing transient weakness/numbess

athletic injuries 2036 (20 decks)

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