MSK Re-Up #4 (Shoulder)

Question 1

MC type of shoulder dislocation?

How will the patient be holding their arm with this type of dislocation?

Answer 1

-Anterior

-Arm held in abduction and external rotation (elbow pointing outward)
-Squared off shoulder, humeral head palpable inferiorly

Question 2

Shoulder radiographs are usually the initial test of choice for a suspected shoulder dislocation. What views distinguish the different types of dislocations?

What are two unique findings in an anterior dislocation that can be seen on X-rays (they have specific names)

Answer 2

-Axillary and scapular “Y” views

-Hill Sach Lesion: groove fracture of the humerus
-Bankart Lesion: glenoid rim fracture

Question 3

Management for an anterior shoulder dislocation includes reduction and immobilization. However, what should you also do (it is a common complication).

Answer 3

Check deltoid pinprick sensation for axillary nerve injury!

Question 4

On the other hand, posterior shoulder dislocations are MC associated with what events?

How is the patient usually holding their arm with this type of dislocation?

Answer 4

Seizures, electric shock, trauma

-Arm adducted and internally rotated
-Anterior shoulder appears flat

Question 5

Explain how a posterior shoulder dislocation looks on shoulder radiographs (AP and scapular Y views).

Answer 5

-Humeral head looks like a light bulb or ice cream cone (light bulb sign)

Question 6

Rotator Cuff Impingement Syndrome is entrapment of what muscle/tendon?

What motions exacerbate this condition?

What are some symptoms?

Answer 6

-Supraspinatus entrapment

-Overhead motions exacerbate

-Anterolateral (front) shoulder pain
-Decreased or painful abduction
-Night pain

Question 7

What are three tests that can diagnose impingement syndrome (name and describe them)?

Answer 7

-Hawkins: arm in front, IR (move down)
-Neer: IR and raise arm (gymnast arm in air)
-Empty Can: arm out, thumb down (IR), push down

Question 8

Treatment for Impingement syndrome

Answer 8

-Rest, PT, NSAIDs, steroid injections, surgery?

Question 9

What are the four muscles of the rotator cuff? Which one is MC injured?

What are some symptoms of a rotator cuff tear?

Answer 9

-SITS
–Supraspinatus (MC), Infraspinatus, Teres Minor, Subscapularis

-Anterolateral (deltoid) shoulder pain
-Decreased ROM especially with overhead activities, ER or abduction (combing hair, reaching for wallet)
-Can’t sleep on affected side
-Passive ROM > Active ROM
-Weakness, atrophy, continuous pain

Question 10

List and explain the rotator cuff muscles and their associated actions

Answer 10

-Supraspinatus: Abduction
-Infraspinatus: External Rotation
-Teres Minor: ER and Adduction
-Subscapularis: IR and Adduction

Question 11

Which physical exam test has a 90% specificity for evaluating the supraspinatus?

Answer 11

Empty Can Test

Question 12

You perform some of the same exam tests for a rotator cuff tear as you do for impingement. What are the main three?

Answer 12

-Hawkins Test, Neer Test, Drop Arm Test (pain with lifting arm above shoulder level or slowly lowering it)

Question 13

Rotator Cuff Tendinitis, is MC in what population?

Answer 13

Adolescents and < 40 years old

Question 14

For a rotator cuff TEAR, what is the management?

Answer 14

-Conservative: PT, NSAIDs, Corticosteroid injections
-Surgery: fail conservative treatment within 6 months or if a complete tear

Question 15

What is the best diagnostic study to get for a rotator cuff tear?

Answer 15

MRI

Question 16

Management for rotator cuff tendinitis

Answer 16

-Shoulder pendulum or wall climbing exercises, ICE, NSAIDs, stop offending activity

Question 17

How does an acromioclavicular joint dislocation (shoulder separation) occur?

The acromioclavicular ligament provides ______ stability whereas the coracoclavicular ligament provides______ stability.

Answer 17

Direct blow to an adducted shoulder

-AC: horizontal stability
-CC: vertical stability

Question 18

How does an acromioclavicular joint dislocation (shoulder separation) occur?

The acromioclavicular ligament provides ______ stability whereas the coracoclavicular ligament provides______ stability.

Answer 18

Direct blow to an adducted shoulder

-AC: horizontal stability
-CC: vertical stability

Question 19

Symptoms of an AC joint separation

Answer 19

-Pain with lifting arm
-Unable to lift arm at the shoulder
-Step-off at AC joint

Question 20

Explain the four grades of an AC dislocation (shoulder separation)

Answer 20

Grade I: Normal XR (ligamental sprain)
Grade II: AC ruptured, CC sprained
Grade III: Both ruptured/torn
Grade IV: AC and CC rupture, displacement of clavicle through trapezius

Question 21

Nonoperative and Surgical Treatment for an AC dislocation

Answer 21

-Nonoperative: ice, sling ,rest, early PT to keep ROM
-Surgical: Grade IV or more with < 2 cm clavicular displacement

Question 22

Adhesive Capsulitis (Frozen Shoulder) is shoulder stiffness due to inflammation. What are two common conditions associated with it?

Symptoms of adhesive capsulitis?

Answer 22

-DM and Hypothyroidism

-Shoulder pain/stiffness
-Decreased ROM (especially ER)
-Pain worse at night
-Resistance to passive ROM on affected side
-Insidious onset over months - years

Question 23

Treatment for adhesive capsulitis

Answer 23

-Rehab ROM (mainstay)
-Do NOT immobilize
-Codman Exercises: dangle arms –> circumduction
-NSAIDs, PT, Steroid injections, manipulation under anesthesia

Question 24

What is the MC fractured bone in children, adolescents, and newborns during birth?

There are three “Groups” or classifications of this fracture. Explain them.

Answer 24

-Clavicle fracture

-Group 1 (Midshaft): Middle 1/3 MC
-Group 2 (Lateral): Distal 1/3
-Group 3: (Proximal): Medial 1/3

Question 25

If no history of high energy impact to the area or a FOOSH, what should you suspect with a clavicle fracture?

Answer 25

Malignancy, rickets, child abuse (if <2 years old)

Question 26

Symptoms of a clavicle fracture

What are the treatments based on the different types of clavicle features?

Answer 26

-pain with ROM, deformity (tenting of skin), crepitus. May hold arm against chest to protect it.

-Mid 1/3: Nonoperative (sling immobilization) in adults. Figure of 8 splint in children. Operative (open fractures, displaced with tenting of skin, shortening)

-Proximal 1/3: Ortho consult

Question 27

A proximal humerus/humeral head fracture occurs due to a FOOSH or direct blow. However it is a common site for pathologic fractures due to _________

What is the treatment for this type of humerus fracture?

Answer 27

-metastatic breast cancer

-Sling immobilization, analgesics, PT for rehab

Question 28

On the other hand, a humeral shaft fracture also occurs from a FOOSH or direct trauma. What must you do first here?

Answer 28

Rule out radial nerve injury (may develop wrist drop)!

Question 29

Treatment for humeral shaft fracture

Answer 29

-Nonoperative: coaptation splint or sling and swathe with prompt ortho follow up

-Operative: ORIF for open fractures or brachial plexus injury

Question 30

Thoracic Outlet Syndrome is what?

Answer 30

Compression of the brachial plexus (MC), subclavian vein, or subclavian artery as they exit shoulder girdle to the 1st rib

Question 31

Symptoms of Thoracic Outlet Syndrome (think nerve and vascular compression both)

Answer 31

-Nerve compression: ulnar neuropathy, pain and paresthesia to forearm and arm

-Vascular Compression: swelling of arm especially with abduction of arm, decreased pulses

Question 32

What is one unique exam test you can do to diagnose Thoracic Outlet Syndrome (it has a specific name)?

Answer 32

Adson Test: loss of radial pulse with head tilted toward affected side

Question 33

How to confirm Thoracic Outlet Syndrome?

What is the treatment?

Answer 33

-MRI confirms

Joint protection, PT, ortho consult