MS1: Affectations of Shoulder Flashcards
what are the functions of the shoulder
position hand
suspend UE
provide sufficient fixation for motion of UE and trunk
fulcrum for arm elevation
what are the 3 bones of shoulder joint
humerus, clavicle and scapula
what are the 3 true joints of the shoulder
SC - plane
AC - plane
GH - ball nd socket
what is the pseudojoint of the shoulder
scapulothoracic
- elev/depress
- protract/retract
- up/down rotation
describe the clavicle
s-shaped; strut bone that connects UE to trunk
last bone to ossify - starts at 5 months ends at 22-25 sa sternal end
most commonly fractured
- FOOSH: impact straight to shoulder
- fall on point of shoulder; most common
what is the allman classification of clavicular fracture
group 1: fracture of medial third
- most common; 80%
group 2: fracture of distal third
- disrupts CC or AC ligaments
- 12-28%
group 3: proximal third; sternal end
- 3-6%
what are the signs and symptoms of clavicular fracture
pain and swelling
tenderness
deformity
affected extremity is splinted close to the body and supported by contralateral UE
- tucked shoulder
what is the diagnosis and management for clavicular fractures
diagnosis: xray and CT scan
non-surgical: immobilize w sling for 6-8 wks
surgical: pinning and plating
- open fracture
- neurovascular affectation
- skin tenting > puncture
- midshaft displacement or shortening is 1-2 cm
- type 2 fractures
- non union symptomatic
describe the scapula
insertion site for 17 muscles
coracoid and acromion
fracture is uncommon bc muscles protect it
- 76%: thoracic SCI
- 54%: pulmonary contusion
what is floating shoulder
2 or more fractures in SSSC
naiiwan yung scapula
what is SSSC composed of
glenoid process
coracoid process
CA ligament
distal clavicle
AC joint
acromion process
what are the SSx of floating shoulder and scapular fractures
pain and swelling
UE tucked and supported by other UE
painful ROM
comolli sign - triangular swelling of posterior thorax over scapula > hematoma > compartment psi
what is the management of scapular fractures
non-surgical: most common; sling for 4-6 wks
surgical: ORIF
- displaced fracture
- intraarticular fracture and displacement
- acromion fracture > impingement
- floating shoulder
describe proximal humeral fracture
most common at surgical neck; neer’s 3
least common at anatomical neck; neer’s 2
what are the complications of PHF
vascular injury: axillary a.
nerve injury: axillary n.
myositis ossificans: bone forms in muscle > pain in abd/add
shoulder stiffness from immob
osteonecrosis common in anatomical neck fracture
non union or malunion
what is the management for PHF
non-operative: for minimally displaced
- sling > early ROM from 7-10 days if fracture is stable to prevent stiffness
surgical: ORIF or arthroplasty
describe the glenoid fossa
surrounded by fibrocartilage - LABRUM
- deepens socket by 50%
- retroverted to 5 deg
- pear shaped
what are the ligaments found at anterior scapula
superior GH
> foramen of rouvier
middle GH
> foramen of weitbrech
inferior GH
- most important; primary restraint for ant/post dislocation and sublaxation
what are the supporting ligaments of humerus and scapula
CC: conoid and trapezoid
- primary support of AC joint
CA: roof of shoulder
- prevents separation of AC
CH: restrains biceps tendon w/in the groove
TH: perpendicular to biceps tendon
what are the scapular pivoters
traps
rhomboids
serratus anterior
levator scapula
what are the humeral propellers IR
- subscapularis
- anterior deltoid
- pec major
- lats
- teres major
what are the humeral propellers ER
infraspinatus
teres minor
posterior deltoid
what are the shoulder protectors
fine tunes HH position during arm elevation
SITS muscles
discuss the insertions and functions of the rotator cuff muscles
SIT: greater tuberosity
subscap: lesser
supraspin - intitates abd
infra and teres minor: ER
subscap: IR
what are the static restraints of the shoulder
glenoid labrum
articular version nd conformity
neftive intra articular psi
capsule
ligaments
what are the dynamic restraints of the shoulder
SITS
biceps tendon
scapulothoracic motion
describe supraspinatus tendinitis
most common inflammatory problem in shoulder
from chronic wear nd tear of supraspinatus tendon as it passes under acromion
what are the subacromial syndromes
DD for supraspinatus tendinitis
- rotator cuff degeneration
- calcific tendinitis: ca deposits
- subacromial and subdeltoid bursitis
- adhesive capsulitis
- AC joint degeneration
what is the etiology of supraspinatus tendinitis
35-50 yo
women > men; sedentary individuals
young pitchers and swimmers
what is the pathogenesis of supraspinatus tendinitis
chronic wear and tear during overhead activites
circulation is impaired during shoulder abd
painful arc on resisted abd; 60-120 deg
recurrent impingement > degenerative and inflammatory changes in the RC and subacromial bursa > subacromial syndromes
describe acute calcific tendinitis
DD - supraspin tendin; pag kita calcification sa xray edi ACT
acute - gradual onset over hours to days
- most painful in shoulder
what are the SSx of acute calcific tendinitis
preceded by strain or unaccustomed use of shoulder
pain over subacromial area radiates to deltoid insertion, localized pain distal to tip of acromion
sleep disturbed by pain
rotation or abd limited by pain
what is the diagnosis and treatment of ACT
xrays - amorphous calcium phosphate salt in supraspinatus
symptoms subside sponatenously after 5-10 days onset
- may lead to adhesive capsulitis
what are the treatments for supraspinatus tendinitis
rest and protection of shoulder w sling; short duration
axillary pillow; medj abd
early gentle ROM; avoid capsulitis
analgesics: 2-3 days
ice packs after 48 hrs heat
what is the treatment for ACT
ultrasound guided aspiration using saline + steroid; most effective
- yields milky white suspension of Ca salts
describe chronic degenerative tendinitis
sequelae of ACT; whole rotator cuffs
develops over months
pain less intense but interferes w arm use
awakened when turning to shoulder at night
painful arc: 60-90 deg
DD: 1sr few wks supraspin tendi > chronic degen
how to diagnose for CDT
MRI and CT scan: osteophyte formation and degen of AC joint
protracted course > adhesive capsulitis
wha are the treatments for subacromical syndromes
conservative
- avoidance of overhead use
- most heat and analgesics
- initial circumduction pendulum; passive = maintains elasticity
surgical: associated w impingement syndrome
- anterior acromioplasty
- resection of CA ligament
- RC tear reapir
- aspirate calcium
describe bicipital tendinitis
inflammation of tendon sheath from flex nd supinate; friction in bicipital groove
results in adhesion of the tendon to the bicipital groove and RC
may occur bilaterally
women > men
early 40s
what is the pathogenesis of bicipital tendinitis
inadequate depth of bicipital groove
abnormal ridges along groove
normal physiologic wear and tear
fraying, shredding and fasciculation of tendon > adhesions occur
associated w impingement syndrome
what is the SSx of bicipital tendinitis
insidous onset or precipitated by strenous activity
over more anterior and medial region of shoulder of biceps and forearm
tenderness over intertubercular sulcus when rolling biceps tendon w fingers; supinate to feel
how to test for bicipital tendinitis
speeds: pt arm at 90 shoulder flex and has to resist motion into extension while supinated
yergasons: pt elbow in 90 deg flexion; ER while supinating against resistance
what is the treatment for bicipital tendinitis
conservative
- rest, moist heat
- avoid painful ROM
- NSAID + therapy
- steroids + anesthetic
surgical: failed conservatice
- biceps tenodesis w reaatachment below bicipital groove or coracoid
describe adhesive capsulitis
starts w/ any of the subacromial syndromes
chronic; worsens over 3-12 moments > gradual improvement > normal or near
pain
LOM
women > men
> 40 yo
what is the pathogenesis of adhesive capsulitis
low grade inflammation from immob
- edema, fibrosis, round cell infiltration
LOM
head fixed at glenoid
ER LIMITED bc od CH and subscap contracture
articular surfaces are intact
what is the SSx of adhesive capsulitis
onset followed by direct or indirect trauma
associated w CVA, MI and cervical root affectations; any that causes immob
LOM > frozen shoulder
night time pain
dec active and passive ROM; ER and abd
what are the 3 phases of adhesive capsulitis
freezing: acute/painful
- lasts 3-9 mo.
- gradual onset of pain at rest, + stifness at all planes; unable to sleep
frozen: adhesive/stiffening
- 4-12 mo.
- pain subsides
- progressive loss of GH motion
- pain at extremes of movement
thawing: resolution
- 12-42 mo.
- motion gradually improves
- complete recovery may not occur
what is the conservative treatment of adhesive capsulitis
w/o treat > 2-3 yrs
conservative
- moist heat
- gravity free excerices w/in pain free range; pendulum
- AIF and analgesics
- steroids
- anti grav in later
what is the non conservative treatment of adhesive capsulitis
anesthetic block of suprascap nerve @ fossa ; temporary
manipulation while pt sleeps; contra in acute
hydrodilatation
surgical: failed non-op
- MUA
- arthrocscopic capsular release
- acromioplasty
- AC joint resection
describe rotator cuff tears
always trauma - esp young
sudden powerful arm elevation
elderly - extensive tears w minor trauma due to degeneration; incidence inc w age
partial thickness tears are more frequent; progression to full 28-53%
what is the etiology for rotator cuff occurs
laborers
> 40 yo.
transient sharp pain for days/months
tenderness below acromion
sulcus appreciated betw acromion nd RC tendon
what are the SSx of RC tear
weak abd
inability to initiate and maintains abd
painful arc
- GH: 60-120
- AC: 170-180
atrophy of supraspin and infra in later cases; drop arm test
what is the treatment of RC tear
MRI - gold standanrd
nonoperative
- avoid provocative motions
- splint in abd
- NSAIDs
- physical therapy
- corticosteroid injection
operative: arthroscopic
- failed non-op
- acute traumatic tears in young
- acute loss of strength and motion
- good quality of muscles w/o fatty infiltration and arthritis
describe the shoulder hand syndrome
shoulder pain w homolateral hand pain and swelling
- frozen shoulder
- hand: sudecks atrophy; pain, swell, vasomotor instability, trophic changes, patchy osteoporosis
sequelae of shoulder lesion, MI, CVA, trauma, cervical arthritis
what is the etiology of shoulder hand syndrome
5th decade or older
pain, tenderness, stiff shoulder
hand swelling and edema of hand
atrophy and finger flex deformity and extension contracture of MCP; may be permanent
SSx may occur together or may mauna
what is the pathogenesis of SHS
sympathetic dysfunction due to injury or compression
immobilized shoulder > frozen shoulder > swelling of hands > limited finger motion
reflex-like response to pain by sympathetic nerves > vasomotor reax that reduces blood flow to tissue in pain
what are the diagnosis and DD of SHS
xray: osteoporosis and normal/minimal joint changes
labs: ESR is normal
DD:
- RA
- thoracic outlet syndrome
- scleroderma
- post-infarct sclerodactyly
what are the stages of SHS
- burning hand pain, cold and clammy, sensitive tou touch/pressure
- hand appears white, creaseless, thick skin, inc cold and stiff
- hand is pale, thin, atrophied
discuss treatment and prognosis of SHS
conservative
- relieve provocative if known
- brief splint and PT ROM daily
- eliminate inflammation and relieve pain
- regain strength and encourage motion
- inc peripheral circulation: sympatholytic drugs, sympathetic ganglia block, ganglionectomy, periarterial sympathectomy
prognosis
- good
- recovery slow: some w permanent stifness
- psych factor: poorly motivated > poor recov
describe rupture of bicepsbrachii
infrequent
men 40-60 yo
involves dominant side
distal bicep tendon avulses from radial tuberosity
@ bicipital groove assoc w degenerative
where can rupture of biceps occur
at/near origin
bicipital groove
musculotendinous junction
via singe traumatic event; unexpected extension applied to 90 deg flexion
SSx of biceps tendon rupture
sharp pain and audible snap
local tenderness
popeyes sign
weakness in flexion and supination
insertion > loss of flexion strength
rupture of long head = 20% loss of flexion
diagnosis and treatment of biceps tendon rupture
xray: avulsion of glenoid rim
non-surgical: strength regained after 4-6 mo.
young - surgical repair
- tenodesis: fixed at coracoid or floor of bicipital groove
describe anterior dislocation of shoukder
most common; abd, ext, ER and force from back
traumatic and unilat; may injure axillary n.
describe posterior dislocation of shoulder
assoc w seizures or electrical shock bc pt is pushed dow or anterior force
what are usually assoc w shoulder disloc
bankart lesion - injury to the labrum due to repeated anterior dislocs
- leads to recurrent disloc in patients arnd 30 yo.
hill sachs lesion - humeral head gets impacted during anterior disloc
fracture of greater tuberosity
what is the epidemiology of reccurent SD
50-57%
high for acute disloc < 20 yo.
immob after reduction for 3 wks dec chance
more common anterior SD
describe RSD
succesive dislocs require lesser force; w/o movement
pain decs in mga sunod and reduction easier
atrophy will develop
sudden pain and audible click when abd and ER
what are risk factors for RSD
incomplete healed tears
relaxation of capsular ligaments
shoulder muscle weakness
congenital or acquired changes in head or glenoid fossa
what is shoulder arthroplasty
TSA is surgical typically reserved for elderly patients w/ cuff deficiency or arthritic shoulders
what are indications for TSA
tumors
RA
pagets
osteonecrosis of humeral ehead
fracture and recurrent disloc
unremitting pain more than LOM
loss of function
failure of conservative
what are the requirements for TSA
strengths of
- SITS
- deltoid
- traps
- rhomboids
- serratus ant
- lats
- pec major and minor
shoulder stretching before operation may improve postsurgical function
what are the two types of shoulder arthroplasty
partial: head of humerus replaced w metal head and stem
total: replacing both joint surfaces; metal head and stem w plastic glenoid
what are the contraindication for TSA
active sepsis of joint
severe osteoporosis
charcot joint
obesity >200 lbs.
bedfast
poor cognition
baka pwede lesser invasive; osteotomy
children; active growth plates
