MSK III - Shoulder and Upper Extremity Flashcards
1
Q
where does exam of the shoulder start?
A
at the sternocalvicular joint
2
Q
what bone supports the shoulder?
A
clavicle
3
Q
what forms glenohumeral joint?
A
proximal humerus articulation with glenoid
4
Q
where does pectorals major insert?
A
on the proximal shaft of the humerus
5
Q
where does deltoid muscle attach?
A
mid shaft of humerus
6
Q
proximal humerus receives blood supply from what artery?
A
axillary artery - 2 branches
7
Q
what are the 2 branches of the axillary artery?
A
anterior humeral circumflex artery
posterior humeral circumflex artery
8
Q
what nerve should you be concerned about in mid shaft of humerus?
A
radial nerve
9
Q
what are the 4 rotator cuff muscles?
A
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
10
Q
what is the function of the supraspinatus?
A
Initiates and acts throughout abduction cycle
11
Q
what 2 rotator cuff muscles do external rotation?
A
Infraspinatus and Teres Minor
12
Q
what is the function of the infraspinatus?
A
External rotation with arm in neutral
13
Q
what is the function of the teres minor?
A
External rotation in 90 degrees of abduction
14
Q
what is the function of the subscapularis?
A
main internal rotator of the shoulder
15
Q
what is the main internal rotator muscle of the shoulder?
A
subscapularis
16
Q
where is the weak point in a clavicle?
A
midshaft
17
Q
where do most clavicle fractures occur on the clavicle?
A
middle 3rd (in diaphysis of the clavicle)
18
Q
how do people fall and break their clavicle?
A
fall with arm adducted to their side
19
Q
where do pts with clavicle fx have pain?
A
pain on palpation over fx and region
pain with active/passive ROM, esp. abduction/flexion of shoulder
20
Q
what movements do pts with clavicle fx have pain with? why?
A
abduction/flexion of shoulder
-b/c pectoralis mjaor originates on medial half of clavicle
21
Q
most clavicle fx’s treated how to start?
A
in sling with glenohumeral ROM beginning w/in 1 week
22
Q
how are non or minimally displaced clavicle fx’s treated?
A
sling to limit glenohumeral movement
ice, NSAIDs, PT
passive ROM at shoulder w/in 3 days
23
Q
if pt is in sling, what is important for them to do?
A
get out of sling 3x/day and straighten/move elbow to elbow doesn’t become stiff
24
Q
how are displaced clavicle fx’s treated?
A
ORIF with plate and screws (like internal cast)
sling
active ROM started when can tolerate
analgesics
PT
25
how does AC joint injury usually occur?
from direct force to lateral aspect of shoulder with adducted arm
26
which way is the acromion driven in AC joint injury?
inferiorly and medially with respect to clavicle
27
AC joint injury common in what sport?
hockey (get checked)
28
pts with AC joint injury are tender where?
tender to palpation over AC joint
29
what is Grade 1 of AC joint injury?
sprain of Acromioclavicular ligament
30
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
31
what is Grade 3 of AC joint injury?
tear of AC and coracoclavicular ligaments
Clavicle is not being held down anymore -> shoulder pops up
32
tx of AC joint injury Grades 1 and 2?
RICE, sling, NSAIDs
33
what test is used to assess for AC joint injury?
cross-arm test
34
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
35
AC Joint dislocation classified as?
Grade 3 AC joint injury with increased coracoclavicular distance and superior displacement of the distal clavicle
36
tx of AC joint injury Grade 3?
+/- surgery
37
tx of AC joint injury Grades 4, 5, 6?
surgery
38
mechanism of injury of sternoclavicular joint dislocation?
fall on abducted and extended arm
39
what may sternoclavicular joint dislocation initially present as?
sternocleidomastoid muscle pain/spasm
40
tx for sternoclavicular joint dislocation? (posterior and anterior)
Posterior - requires repair if damage to neuro structures
Anterior - rarely repaired surgically
41
at what age is proximal humerus fracture greatest?
73-78 y/o
>70% occur in patient >60 y/o
42
what is the most common mechanism of injury for proximal humerus fracture?
fall from standing
43
what dislocation can occur with proximal humerus fx?
Anterior or posterior dislocations of humeral head
44
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
45
how do pts hold their arms when have proximal humerus fx?
hold affected arm adducted against side
46
suspect proximal humerus fx in elderly who have fallen and present with what?
Focal tenderness at proximal humerus
Motor function limited due to pain
47
what nerves can get injured in displaced proximal humerus fx?
axillary of suprascapular nerve
48
what is important to check for humerus shaft fx's?
radial nerve
49
what motion can pt's not do if radial nerve is affected?
wrist extension
50
how can 80% of proximal humerus fx's be treated?
conservative - if impacted or nondisplaced
51
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
52
how do pts like to sleep when have proximal humerus fx?
semi-recumbent - will be comfortable sleeping in a recliner
53
how are unstable humerus neck fx's treated?
ORIF
54
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
55
which direction are most shoulder dislocations?
anterior
56
how are posterior shoulder dislocations caused?
falls from a height, epileptic seizures, or electric shocks
57
what are atraumatic shoulder dislocations caused by?
ligament laxity/repetitive microtrauma leading to joint instability
seen in Swimmers, gymnasts, and pitchers
58
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
59
what nerves should be document in shoulder dislocation?
axillary nerve and radial nerve
60
what is frequently damaged and should be checked in shoulder dislocation?
rotator cuff
61
imaging for shoulder dislocation?
AP, axillary, and scapula Y views to determine relationship of humerus and glenoid and to r/o fx's
62
what x-ray view must you have to confirm if shoulder dislocation is anterior or posterior?
scapula Y view
63
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
64
if shoulder is closer to the acromion, then what type of shoulder dislocation is it? (anterior or posterior?)
posterior shoulder dislocation
65
main tx for acute shoulder dislocation?
reduce shoulder ASAP
66
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
67
impingement syndrome aka?
rotator cuff tendonitis
68
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
69
cause of pain in impingement syndrome?
compression of tissues b/w the humeral head and coracoacromial arch
Bursa and supraspinatous tendon are compressed
70
often hx of what with impingement syndrome?
hx of over activity
71
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)
72
pts with impingement syndrome have tenderness where?
pain over the anterolateral shoulder at the greater tuberosity
73
pts with impingement syndrome have ___ active ROM but ____ passive ROM
pts with impingement syndrome have decreased active ROM but preserved passive ROM
74
on inspection, pt with impingement syndrome may have atrophy of what muscles?
May have atrophy of the supraspinatus and infraspinatus muscles
75
what test is used for impingement syndrome?
HAWKIN'S IMPINGEMENT TEST (and Neer's test)
76
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
77
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
78
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
79
what can the Grashey (glenoid AP view) for impingement syndrome rule out?
glenohumeral joint arthritis
80
what can the AP acromioclavicular joint view for impingement syndrome evaluate?
Evaluates the acromioclavicular joint for inferior spurs
81
what does the scapular Y (lateral scapula) view for impingement syndrome evaluate?
the acromial shape
82
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)
83
when do you get MRI for impingement syndrome? what will MRI look for?
if pt fails PT
MRI will look for rotator cuff tears
84
what type of rotator cuff tears are one of the most common reasons for impingement syndrome?
partial rotator cuff tears
85
conservative tx for impingement syndrome?
- Activity modification
- ***PT with modalities for ROM and strengthening
- NSAIDs
- ***Corticosteroid injection
86
surgical tx for impingement syndrome?
Arthroscopic acromioplasty with coracoacromial ligament release (shave down the acromium)
Bursectomy
Debridement or repair of rotator cuff tears
87
what tx is FIRST LINE for impingement syndrome?
conservative
88
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
89
causes of acute rotator cuff tear?
fall on an outstretched arm
pulling on shoulder
90
causes of chronic rotator cuff tear?
repetitive injuries with overhead movement and lifting
91
what type of rotator cuff tear is more symptomatic and may require surgical tx?
full thickness RC tears
92
what is a common cause of shoulder pain after age 40?
rotator cuff tear
93
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
94
weakness with resisted strength testing suggests?
full thickness tear
95
what rotator cuff tendon is the most commonly torn?
supraspinatus
96
what rotator cuff muscle is a superior stabilize of the shoulder? what does it prevent?
supraspinatus - prevents humerus from banging off acromion
97
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
98
what will MRI show for suspected rotator cuff tear?
full or partial RC tear (or tendinosis)
99
what is the BEST METHOD for visualizing rotator cuff tears?
MRI
100
imaging for rotator cuff tears?
4 x-ray view:
-AP, Lateral, Grashey, scapular Y
MRI (best way to see tear)
101
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
102
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
103
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
104
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
105
SLAP lesion most frequently seen in?
FOOSH
Throwing sports athletes
106
dx study of choice for SLAP lesion?
MR arthrogram
107
when is MR arthrogram positive for SLAP lesion?
if GAD gets out of the joint
108
tx of SLAP lesions (type 1 and type 2 and 3)?
Type 1 - asx's, no tx
Type 2 and 3 - require surgical reattachment
109
what is Adhesive Capsulitis
Frozen shoulder
110
what is the pain like compared to clinical findings in adhesive capsulitis?
pain out of proportion to clinical findings during the inflammatory phase
111
clinical findings of adhesive capsulitis?
inflammation/thickening of the joint capsule
112
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
113
adhesive capsulitis common in what women? pts with what disorders?
perimenopausal women
patients with endocrine disorders, such as DM or thyroid disease
114
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
115
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
116
are there calcium deposits in adhesive capsulitis? when do you have calcium deposits?
NO!!! - have calcium deposits in calcific tendonitis
117
tx of adhesive capsulitis?
NSAIDs
***PT to maintain motion
Intra-articular corticosteroid injection
Surgical tx's (manipulation) - followed by PT
118
pts with what disease commonly get calcific tendonitis?
Diabetics
119
what does calcific tendonitis result from?
deposition of calcium hydroxyapatite w/in the substance of a tendon
120
most common location for calcific tendonitis?
Supraspinatus
121
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
122
what is pts ROM like in calcific tendonitis?
have basically no ROM - passive ROM hurts bad
123
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
124
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
125
mechanism of injury of humerus fx?
trauma such as a direct blow or bending force
126
mid shaft humerus fx's also result from?
strong muscle contractions
ex: high-velocity throwing or arm wrestling
127
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
128
shortening of the upper arm suggest the presence of what in humeral fx?
significant humeral shaft displacement
129
tx of humeral fx in older pts?
non-surgical
130
tx of humeral fx?
Functional bracing (splinting)
-PREFERRED tx for transverse shaft fractures and most other midshaft fractures)
131
what must be checked before and after splinting for humeral fx?
axillary and radial nerve status
humeral fx big one for radial nerve palsy
132
what type of palsy occurs in humeral fx?
radial nerve palsy
133
tx of severe displacement/young pts with humeral fx?
ORIF
134
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
135
what nerve is MOST COMMONLY injured by mid shaft humerus fx's?
radial nerve
136
injury to radial nerve results in what?
weakness of wrist, finger, and thumb extension and some weakness of elbow supination
137
how can motor fxn of radial nerve be tested?
by giving "thumbs up" sign and testing resisted extension of the thumb
138
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
139
most common cause of elbow fx?
FOOSH
140
FOOSH causes what fx's?
Radial head fx:
-decreased pronation/supination at wrist
Supracondylar humer fx
Olecranon fx
141
elbow fx is marked by what? and where is decreased ROM?
Marked by pain, decreased ROM in the elbow
142
what sign is positive for elbow fx?
Positive anterior fat pad or "sail sign" and posterior fat pad sign
143
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
144
how is radial head fx caused?
FOOSH with abudcted arm and minimal or moderate flexion of the elbow joint (0-80 degrees)
145
if can't identify radial head fx but see joint effusion in adults, how should it be treated?
as non-displaced radial head fx
146
how are elbow effusions best seen on imaging?
on lateral projection as fluid in joint capsule elevates pericapsular fat
147
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**
148
what is a supracondylar elbow fracture?
Extra-articular fracture of distal humerus at elbow
149
at what ages does supracondylar elbow fx occur?
children 5-9 y/o
150
why is supracondylar elbow fx uncommon in adults?
b/c olecranon fossa is bigger
151
what is supracondylar elbow fx due to?
FOOSH from a moderate hiehght (bed/monkey-bars)
152
how does kid fall and get supracondylar elbow fx?
fall onto hyper-extended elbow
153
if kid has hyperextension or hyper flexion injury to elbow, what is the tx?
surgery
154
what does imaging show for supracondylar elbow fx?
extra-articular fx line
posterior displacement of the distal component
155
what is conservative tx for supracondylar elbow fx?
long-arm posterior splint (only if non-displaced)
sling
analgesics
serial radiographs (2 weeks)
156
surgical tx for supracondylar elbow fx?
ORIF
flexion reduction maneuver for extension-type
3 lateral pin technique for more unstable patterns
157
bimodal distribution of olecranon fx?
High energy injuries in young
Low energy falls in elderly
158
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
159
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
160
olecranon fx tx
ORIF with tension band
ORIF with plate and screw fixation
161
which direction on elbow dislocation most commonly?
posterior
162
how does posterior dislocation of elbow occur?
occur following a fall onto an extended arm
- Hyperextension
- Posterolateral rotatory mechanism
163
what is elbow dislocation usually accompanied by?
small coronoid process fx or another fx
164
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
165
what is tennis elbow? affects what tendons in forearm?
lateral epicondylitis
Affects extensor tendons of the forearm
-Particularly ERCB; occasionally EDC
166
what is golfer's elbow? affects what tendons in forearm?
medial epicondylitis
Affects flexor tendons of the forearm
-Particularly pronator teres and FCR muscles
167
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
168
sx's of lateral epicondylitis?
EXTENSOR PAIN
Pain over lateral epicondyle and extensor tendon wad
Pain with resisted wrist extension
169
sx's of medial epicondylitis?
FLEXOR PAIN
Pain over medial epicondyle and flexor tendon wad
Pain with resisted wrist flexion
170
tx of epicondylitis?
- Rest (avoid strenuous activity)
- Ice cube massages
- Brace
- NSAIDs (naproxen)
- PT
- Cortisone
171
both bones forearm fx more common in?
men
172
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
173
sx's of both bones forearm fx?
- Gross deformity
| - Pain/swelling
174
tx of both bones forearm fx?
Sugar-tong splint in ED
Casting for non-displaced (no surgery needed)
ORIF for displaced
175
what is a greenstick fx? common in?
Incomplete fracture of long bone
Usually occurs in the forearm in a young child
176
what does greenstick fx result from?
bending force applied perpendicular to shaft
177
what does greenstick fx look like?
Incomplete, transverse fracture is produced on convex cortex, while concave cortex becomes bent, but without visible crack
178
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
179
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
180
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
181
what is a colles fx?
Fracture of the distal radial metaphyseal region with dorsal angulation and impaction
extra-articular (doesn't go into joint)
182
colles fx occurs as result of?
FOOSH
183
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
184
what is a smith fx?
" Fracture of distal radius with associated volar angulation of distal fracture fragment
Extra-articular transverse fx's
185
smith fx aka?
reverse colles fx
186
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
187
what is volar (cock-up) forearm splint for?
Injuries of the wrist
Carpal tunnel syndrome
Soft tissue injuries of the hand
188
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
