MSK III - Shoulder and Upper Extremity Flashcards
where does exam of the shoulder start?
at the sternocalvicular joint
what bone supports the shoulder?
clavicle
what forms glenohumeral joint?
proximal humerus articulation with glenoid
where does pectorals major insert?
on the proximal shaft of the humerus
where does deltoid muscle attach?
mid shaft of humerus
proximal humerus receives blood supply from what artery?
axillary artery - 2 branches
what are the 2 branches of the axillary artery?
anterior humeral circumflex artery
posterior humeral circumflex artery
what nerve should you be concerned about in mid shaft of humerus?
radial nerve
what are the 4 rotator cuff muscles?
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
what is the function of the supraspinatus?
Initiates and acts throughout abduction cycle
what 2 rotator cuff muscles do external rotation?
Infraspinatus and Teres Minor
what is the function of the infraspinatus?
External rotation with arm in neutral
what is the function of the teres minor?
External rotation in 90 degrees of abduction
what is the function of the subscapularis?
main internal rotator of the shoulder
what is the main internal rotator muscle of the shoulder?
subscapularis
where is the weak point in a clavicle?
midshaft
where do most clavicle fractures occur on the clavicle?
middle 3rd (in diaphysis of the clavicle)
how do people fall and break their clavicle?
fall with arm adducted to their side
where do pts with clavicle fx have pain?
pain on palpation over fx and region
pain with active/passive ROM, esp. abduction/flexion of shoulder
what movements do pts with clavicle fx have pain with? why?
abduction/flexion of shoulder
-b/c pectoralis mjaor originates on medial half of clavicle
most clavicle fx’s treated how to start?
in sling with glenohumeral ROM beginning w/in 1 week
how are non or minimally displaced clavicle fx’s treated?
sling to limit glenohumeral movement
ice, NSAIDs, PT
passive ROM at shoulder w/in 3 days
if pt is in sling, what is important for them to do?
get out of sling 3x/day and straighten/move elbow to elbow doesn’t become stiff
how are displaced clavicle fx’s treated?
ORIF with plate and screws (like internal cast)
sling
active ROM started when can tolerate
analgesics
PT
how does AC joint injury usually occur?
from direct force to lateral aspect of shoulder with adducted arm
which way is the acromion driven in AC joint injury?
inferiorly and medially with respect to clavicle
AC joint injury common in what sport?
hockey (get checked)
pts with AC joint injury are tender where?
tender to palpation over AC joint
what is Grade 1 of AC joint injury?
sprain of Acromioclavicular ligament
what is Grade 2 of AC joint injury?
tear of AC ligament í AC ligament is fully torn
Clavicle still being held down by coracoclavicular ligaments
what is Grade 3 of AC joint injury?
tear of AC and coracoclavicular ligaments
Clavicle is not being held down anymore -> shoulder pops up
tx of AC joint injury Grades 1 and 2?
RICE, sling, NSAIDs
what test is used to assess for AC joint injury?
cross-arm test
what is the cross-arm test? positive finding?
Patient elevates the affected arm to 90 degrees, then actively adducts it
Positive finding: pain in AC joint
AC Joint dislocation classified as?
Grade 3 AC joint injury with increased coracoclavicular distance and superior displacement of the distal clavicle
tx of AC joint injury Grade 3?
+/- surgery
tx of AC joint injury Grades 4, 5, 6?
surgery
mechanism of injury of sternoclavicular joint dislocation?
fall on abducted and extended arm
what may sternoclavicular joint dislocation initially present as?
sternocleidomastoid muscle pain/spasm
tx for sternoclavicular joint dislocation? (posterior and anterior)
Posterior - requires repair if damage to neuro structures
Anterior - rarely repaired surgically
at what age is proximal humerus fracture greatest?
73-78 y/o
> 70% occur in patient >60 y/o
what is the most common mechanism of injury for proximal humerus fracture?
fall from standing
what dislocation can occur with proximal humerus fx?
Anterior or posterior dislocations of humeral head
sx’s of proximal humerus fx
Moderate/severe shoulder pain that increases with shoulder movement
swelling and ecchymosis (arm swells up)
pts hold affected arm adducted against side
how do pts hold their arms when have proximal humerus fx?
hold affected arm adducted against side
suspect proximal humerus fx in elderly who have fallen and present with what?
Focal tenderness at proximal humerus
Motor function limited due to pain
what nerves can get injured in displaced proximal humerus fx?
axillary of suprascapular nerve
what is important to check for humerus shaft fx’s?
radial nerve
what motion can pt’s not do if radial nerve is affected?
wrist extension
how can 80% of proximal humerus fx’s be treated?
conservative - if impacted or nondisplaced
what is conservative tx of proximal humerus fx’s?
sling or collar and cuff/swath
ice, analgesics
gentle ROM of shoulder after 2 weeks
ROM of elbow/wrist when can tolerate
how do pts like to sleep when have proximal humerus fx?
semi-recumbent - will be comfortable sleeping in a recliner
how are unstable humerus neck fx’s treated?
ORIF
what is the surgical tx of proximal humerus fx? when is it done?
Reverse Total Shoulder Replacement
Done b/c person had so much damage to rotator cuff that they no longer have abduction -> supraspinatus is gone
which direction are most shoulder dislocations?
anterior
how are posterior shoulder dislocations caused?
falls from a height, epileptic seizures, or electric shocks
what are atraumatic shoulder dislocations caused by?
ligament laxity/repetitive microtrauma leading to joint instability
seen in Swimmers, gymnasts, and pitchers
signs/sx’s of shoulder dislocation?
obvious deformity with humeral head dislocated anteriorly
pt holds affected arm at side of body in external rotation
shoulder loses roundness and full anteriorly to palpation
what nerves should be document in shoulder dislocation?
axillary nerve and radial nerve
what is frequently damaged and should be checked in shoulder dislocation?
rotator cuff
imaging for shoulder dislocation?
AP, axillary, and scapula Y views to determine relationship of humerus and glenoid and to r/o fx’s
what x-ray view must you have to confirm if shoulder dislocation is anterior or posterior?
scapula Y view
what is the placement of the cricoid and acromion in posterior shoulder dislocation?
Coricoid is always anterior
Acromion is always on the posterior aspect of the scapula
if shoulder is closer to the acromion, then what type of shoulder dislocation is it? (anterior or posterior?)
posterior shoulder dislocation
main tx for acute shoulder dislocation?
reduce shoulder ASAP
tx for shoulder dislocation
reduce
sling for 2 weeks w/ pendulum exercises
early PT to maintain ROM and strengthen rotator cuff muscles
benzo’s/valium, morphine
impingement syndrome aka?
rotator cuff tendonitis
what is the key difference b/w a rotator cuff tear and rotator cuff tendonitis (impingement syndrome)?
have weakness in rotator cuff tear, not in tendonitis
cause of pain in impingement syndrome?
compression of tissues b/w the humeral head and coracoacromial arch
Bursa and supraspinatous tendon are compressed
often hx of what with impingement syndrome?
hx of over activity
main signs and sx’s of impingement syndrome?
Shoulder pain with over-head motion
Night pain with sleeping on shoulder
Pain on internal rotation (e.g. putting on a jacket or bra)
pts with impingement syndrome have tenderness where?
pain over the anterolateral shoulder at the greater tuberosity
pts with impingement syndrome have ___ active ROM but ____ passive ROM
pts with impingement syndrome have decreased active ROM but preserved passive ROM
on inspection, pt with impingement syndrome may have atrophy of what muscles?
May have atrophy of the supraspinatus and infraspinatus muscles
what test is used for impingement syndrome?
HAWKIN’S IMPINGEMENT TEST (and Neer’s test)
what is Hawkin’s impingement test? when is it positive?
Used to evaluate impingement of RC and subacromial bursa
Brings the greater tuberosity of the humerus underneath the acromiom -> if pain in anterior shoulder then is positive sign for impingement
what is the maneuver of the Hawkin’s impingement test?
Patient seated or standing with shoulder forward flexed to 90 degrees and elbow flexed to 90 degrees
Stabilize top of the shoulder while internally rotating the arm at the forearm
what are the 4 x-ray views for impingement syndrome? what do they often look like?
AP, Lateral, Grashey (glenoid AP view), scapular Y
often look unremarkable
what can the Grashey (glenoid AP view) for impingement syndrome rule out?
glenohumeral joint arthritis
what can the AP acromioclavicular joint view for impingement syndrome evaluate?
Evaluates the acromioclavicular joint for inferior spurs
what does the scapular Y (lateral scapula) view for impingement syndrome evaluate?
the acromial shape
what does the axillary lateral view for impingement syndrome visualize?
Visualizes the glenohumeral joint and the presence of os acromiale (failure of fusion of the acromial process)
when do you get MRI for impingement syndrome? what will MRI look for?
if pt fails PT
MRI will look for rotator cuff tears
what type of rotator cuff tears are one of the most common reasons for impingement syndrome?
partial rotator cuff tears
conservative tx for impingement syndrome?
- Activity modification
- ***PT with modalities for ROM and strengthening
- NSAIDs
- ***Corticosteroid injection
surgical tx for impingement syndrome?
Arthroscopic acromioplasty with coracoacromial ligament release (shave down the acromium)
Bursectomy
Debridement or repair of rotator cuff tears
what tx is FIRST LINE for impingement syndrome?
conservative
are ice and NSAIDs effective as prolonged therapy for impingement syndrome?
NO!!! - there is no evidence that ice and NSAIDs are effective as prolonged therapy for impingement syndrome
causes of acute rotator cuff tear?
fall on an outstretched arm
pulling on shoulder
causes of chronic rotator cuff tear?
repetitive injuries with overhead movement and lifting
what type of rotator cuff tear is more symptomatic and may require surgical tx?
full thickness RC tears
what is a common cause of shoulder pain after age 40?
rotator cuff tear
sx’s of rotator cuff tear
***Weakness or pain w/overhead movement
Night pain/inability to sleep on affected side
obvious weakness with light resistance testing of specific rotator cuff muscles
trouble lifting arm with limited active ROM
weakness with resisted strength testing suggests?
full thickness tear
what rotator cuff tendon is the most commonly torn?
supraspinatus
what rotator cuff muscle is a superior stabilize of the shoulder? what does it prevent?
supraspinatus - prevents humerus from banging off acromion
what strength tests are done on pt with suspected rotator cuff tear?
“Empty can” test - for supraspinatus
Infraspinatus test
“Lift-off” or “belly-press” tests - for subscapularis
what will MRI show for suspected rotator cuff tear?
full or partial RC tear (or tendinosis)
what is the BEST METHOD for visualizing rotator cuff tears?
MRI
imaging for rotator cuff tears?
4 x-ray view:
-AP, Lateral, Grashey, scapular Y
MRI (best way to see tear)
partial rotator cuff tear tx
may heal with scarring
Most partial RC tears can be treated conservatively with PT
- PT can strengthen remaining muscles to compensate for loss of strength
- PT also an option for older sedentary patients with full RC tears
- Have to start with bands, before moving on to weights
full-thickness rotation cuff tear tx
don’t heal well and increase in size with time
Surgery if young and active, PT after surgery
pt must be in sling after sugery for 6 weeks
what process progresses in full-thickness rotator cuff tears?
Fatty infiltration - degenerative process where muscle is replaced with fat following injury to rotator cuff tendons
this is IRREVERSIBLE
what is SLAP lesion?
Superior labrum, anterior and posterior
Injuries of the glenoid labrum at point of attachment of long head of biceps (injury to labrum in glenoid cavity)
Pulls labrum away -> starts to get in joint -> causes instability of shoulder
SLAP lesion most frequently seen in?
FOOSH
Throwing sports athletes
dx study of choice for SLAP lesion?
MR arthrogram
when is MR arthrogram positive for SLAP lesion?
if GAD gets out of the joint
tx of SLAP lesions (type 1 and type 2 and 3)?
Type 1 - asx’s, no tx
Type 2 and 3 - require surgical reattachment
what is Adhesive Capsulitis
Frozen shoulder
what is the pain like compared to clinical findings in adhesive capsulitis?
pain out of proportion to clinical findings during the inflammatory phase
clinical findings of adhesive capsulitis?
inflammation/thickening of the joint capsule
what phases does stiffness occur and when does resolution occur in adhesive capsulitis? how long can it last? hurts less when?
Stiffness during the “freezing” phase and resolution during the “thawing” phase
Can last up to two years
Hurst less during freezing phase -> BUT can’t move it
adhesive capsulitis common in what women? pts with what disorders?
perimenopausal women
patients with endocrine disorders, such as DM or thyroid disease
sx’s of adhesive capsulitis?
Pain with decreased ROM in both passive and active movements
Strength usually normal but can appear diminished when patient in pain
what is the reason pts with adhesive capsulitis can’t move their shoulder?
b/c the capsule doesn’t stretch -> PAIN
nothing structurally wrong with joint
are there calcium deposits in adhesive capsulitis? when do you have calcium deposits?
NO!!! - have calcium deposits in calcific tendonitis
tx of adhesive capsulitis?
NSAIDs
***PT to maintain motion
Intra-articular corticosteroid injection
Surgical tx’s (manipulation) - followed by PT
pts with what disease commonly get calcific tendonitis?
Diabetics
what does calcific tendonitis result from?
deposition of calcium hydroxyapatite w/in the substance of a tendon
most common location for calcific tendonitis?
Supraspinatus
sx’s of calcific tendonitis?
Very painful shoulder triggered by minimal or no trauma
Appear with crazy amount of pain, these people look super worn down and don’t want to move anything
Acute onset
-Pain comes on VERY FAST, but patient has had deposits for a long time
Vs. adhesive capsulitis which comes on slower
what is pts ROM like in calcific tendonitis?
have basically no ROM - passive ROM hurts bad
tx for calcific tendonitis?
Analgesic/anti-inflammatory medication
***Subacromial local anesthetic/steroid injection (good response)
PT with U/S therapy
Arthroscopy with aspiration of mineralized material
what is the bimodal age distribution of humerus fx?
1st: seen in males in 3rd decade (20’s); often associated with high-velocity trauma (drunk driver)
2nd: in females in 7th decade (60’s) and is associated with low velocity falls
mechanism of injury of humerus fx?
trauma such as a direct blow or bending force
mid shaft humerus fx’s also result from?
strong muscle contractions
ex: high-velocity throwing or arm wrestling
sx’s of humerus fx’s
severe pain in mid-arm
referred pain to shoulder or elbow (assess for other injuries)
swelling and ecchymosis shortly after injury
significant tenderness to palpation and crepitus at fx site
shortening of the upper arm suggest the presence of what in humeral fx?
significant humeral shaft displacement
tx of humeral fx in older pts?
non-surgical
tx of humeral fx?
Functional bracing (splinting)
-PREFERRED tx for transverse shaft fractures and most other midshaft fractures)
what must be checked before and after splinting for humeral fx?
axillary and radial nerve status
humeral fx big one for radial nerve palsy
what type of palsy occurs in humeral fx?
radial nerve palsy
tx of severe displacement/young pts with humeral fx?
ORIF
when is ORIF required in humeral fx?
Adequate alignment not maintained
Open fractures
Presence of vascular injury
Segmental fracture
Floating elbow
Presence of significant other injuries (poly-trauma, brachial plexus injury)
Non-union
Pathological
what nerve is MOST COMMONLY injured by mid shaft humerus fx’s?
radial nerve
injury to radial nerve results in what?
weakness of wrist, finger, and thumb extension and some weakness of elbow supination
how can motor fxn of radial nerve be tested?
by giving “thumbs up” sign and testing resisted extension of the thumb
if radial nerve injured, where is there sensory loss? where is it tested?
dorsum of the hand
tested at dorsal web space b/w thumb and index finger
most common cause of elbow fx?
FOOSH
FOOSH causes what fx’s?
Radial head fx:
-decreased pronation/supination at wrist
Supracondylar humer fx
Olecranon fx
elbow fx is marked by what? and where is decreased ROM?
Marked by pain, decreased ROM in the elbow
what sign is positive for elbow fx?
Positive anterior fat pad or “sail sign” and posterior fat pad sign
if can’t see anterior/posterior fat pad sign in suspected elbow fx, what do you do?
put them in a sling -> do another scan in 9-10 days
how is radial head fx caused?
FOOSH with abudcted arm and minimal or moderate flexion of the elbow joint (0-80 degrees)
if can’t identify radial head fx but see joint effusion in adults, how should it be treated?
as non-displaced radial head fx
how are elbow effusions best seen on imaging?
on lateral projection as fluid in joint capsule elevates pericapsular fat
tx of radial head fx?
Long arm positive splint for 3-4 days
Sling for 1-2 weeks
-but take off 3-4 times a day for a little ROM
Analgesics
Gentle ROM
Serial radiographs (2 weeks)
PT
In general, don’t need to be repaired unless its more than 50% of the articular surface
what is a supracondylar elbow fracture?
Extra-articular fracture of distal humerus at elbow
at what ages does supracondylar elbow fx occur?
children 5-9 y/o
why is supracondylar elbow fx uncommon in adults?
b/c olecranon fossa is bigger
what is supracondylar elbow fx due to?
FOOSH from a moderate hiehght (bed/monkey-bars)
how does kid fall and get supracondylar elbow fx?
fall onto hyper-extended elbow
if kid has hyperextension or hyper flexion injury to elbow, what is the tx?
surgery
what does imaging show for supracondylar elbow fx?
extra-articular fx line
posterior displacement of the distal component
what is conservative tx for supracondylar elbow fx?
long-arm posterior splint (only if non-displaced)
sling
analgesics
serial radiographs (2 weeks)
surgical tx for supracondylar elbow fx?
ORIF
flexion reduction maneuver for extension-type
3 lateral pin technique for more unstable patterns
bimodal distribution of olecranon fx?
High energy injuries in young
Low energy falls in elderly
2 mechanisms of olecranon fx?
Direct blow
-usually results in comminuted fracture
Indirect blow
- fall onto outstretched upper extremity
- usually results in transverse or oblique fracture
clinical presentation of olecranon fx
Pain localized to posterior elbow
Palpable defect
Inability to extend elbow (triceps muscle)
-triceps attach at the olecranon, thus no extension
olecranon fx tx
ORIF with tension band
ORIF with plate and screw fixation
which direction on elbow dislocation most commonly?
posterior
how does posterior dislocation of elbow occur?
occur following a fall onto an extended arm
- Hyperextension
- Posterolateral rotatory mechanism
what is elbow dislocation usually accompanied by?
small coronoid process fx or another fx
tx of elbow dislocation
Closed reduction for simple dislocations
ORIF for Complex fracture-dislocations
- these are far more likely to have poor outcome í because elbows love to stiffen
- Long-arm posterior splint/sling for 1-2 weeks
what is tennis elbow? affects what tendons in forearm?
lateral epicondylitis
Affects extensor tendons of the forearm
-Particularly ERCB; occasionally EDC
what is golfer’s elbow? affects what tendons in forearm?
medial epicondylitis
Affects flexor tendons of the forearm
-Particularly pronator teres and FCR muscles
sx’s of epicondylitis?
extra-articular lateral or medial elbow of insidious onset
Pain can range from minimal and annoying to debilitating severely affecting ADLs
sx’s of lateral epicondylitis?
EXTENSOR PAIN
Pain over lateral epicondyle and extensor tendon wad
Pain with resisted wrist extension
sx’s of medial epicondylitis?
FLEXOR PAIN
Pain over medial epicondyle and flexor tendon wad
Pain with resisted wrist flexion
tx of epicondylitis?
- Rest (avoid strenuous activity)
- Ice cube massages
- Brace
- NSAIDs (naproxen)
- PT
- Cortisone
both bones forearm fx more common in?
men
mechanisms of both bones forearm fx? (direct and indirect trauma)
Direct trauma
-while protecting one’s head
Indirect trauma
- MVAs
- Falls from height
- Athletic competition
sx’s of both bones forearm fx?
- Gross deformity
- Pain/swelling
tx of both bones forearm fx?
Sugar-tong splint in ED
Casting for non-displaced (no surgery needed)
ORIF for displaced
what is a greenstick fx? common in?
Incomplete fracture of long bone
Usually occurs in the forearm in a young child
what does greenstick fx result from?
bending force applied perpendicular to shaft
what does greenstick fx look like?
Incomplete, transverse fracture is produced on convex cortex, while concave cortex becomes bent, but without visible crack
tx for greenstick fx?
- Sugar-tong splint and refer to ortho
- Analgesics
- Casting x3-4 weeks
- Splinting if pt and family reliable and fracture stable
what type of fx is buckle fx (torus fx)? where does it occur? stable or unstable?
type of incomplete fx; very stable
occurs at metaphyseal diaphyseal junction after a FOOSH
tx of buckle fx (torus fx)?
***Volar splint and refer to ortho
Analgesics
Casting x 3-4 weeks
Splinting if pt and family reliable and fx stable
what is a colles fx?
Fracture of the distal radial metaphyseal region with dorsal angulation and impaction
extra-articular (doesn’t go into joint)
colles fx occurs as result of?
FOOSH
tx of colles fx? (conservative and surgical)
Conservative:
-closed reduction, sugar tong splint immobilization followed by long/short arm cast for 4-6 weeks
Surgical:
-ORIF followed by cast/splint immobilization for 4-6 weeks
what is a smith fx?
” Fracture of distal radius with associated volar angulation of distal fracture fragment
Extra-articular transverse fx’s
smith fx aka?
reverse colles fx
mechanism of smith fx?
Fall onto a flexed wrist
Direct blow to the back of the wrist
Smith’s lectures suck -> this fracture is the worst because its flexion -> cant bring wrist up
what is volar (cock-up) forearm splint for?
Injuries of the wrist
Carpal tunnel syndrome
Soft tissue injuries of the hand
how is volar (cock-up) forearm splint applied? position?
Applied from midpalmar crease almost to elbow ventrally
Position:
-neural forearm (thumb up), wrist at 20 degrees extension
