Shoulder 1 Flashcards
What is the musculature of the shoulder
Rotator cuff (Supraspinatus, Infraspinatus, Teres minor, Subscapularis)
Deltoid
Stabilizers: Trapezius, levator scapulae, rhom major/minor, pec minor, serratus anterior
What do the muscle of the rotator cuff do
Supraspinatus: Abduction
Infraspinatus: External rotation
Teres minor: External rotation
Subscapularis: Internal rotation
What are the bursas of the shoulder
Subacromial bursa
Subdeltoid bursa
What specific MSK questions are important to ask when evaluating shoulder pain
Sensation of instability weakness popping, crepitus stiffness numbness/tingling
What specific MOI indicate specific injured structures
- Fall directly onto anterior/superior shoulder= AC joint injury (shoulder separation)
- Arm forcefully abducted and ext. rotated= Sublux/anterior dislocation
MOI can help you
determine radiologic needs
Age helps differentiate likely injury (complete rotator cuff tear more likely if >45 y/o)
What does this clinical scenario sound like
56 y/o male presents of R shoulder pain since yesterday when he was playing football. He jumped for a ball when someone tackled his legs and he landed on his shoulder. Pain when he lifts his arm overhead. No radiating pain, numbness, or weakness. No prior injuries
AC joint tear AKA shoulder separation
Presents with focal ttp at AC joint and superior coracoid
Pain limits abduction and forward flexion past 90 deg.
Pain reproduced with passive flexion and horizontal adduction
Increased deformity if you pull down on arm
Neurovascular intact!
What are the aspects of the AC joint
AC joint ligament
Coracoclavicular ligament complex
Delto-trapezial complex
AC joint injuries are MC in
Men
44% in 20 y/o patients
Common AC joint injuries include
*Direct force: falls on AC joint w/ arm at side
Force applied to superior acromion forcing acromion inferior and medial
-rarely can be 2/2 indirect force, like FOOSH, in which force may send humeral head superior into acromion and cause a tear
How do you classify AC joint tears
I: AC ligament sprain, but AC and CC joint intact
II: AC ligament ruptured, CC joint intact but sprained
III: AC and CC ligaments ruptured
IV-VI are less common and involve clavicle
What PE is associated with different grade AC joint injuries
I: Pain w/o deformity
II: Pain and deformity. <50% vertical displacement (downward?)
III: AC joint dislocation, shoulder displaced inferiorly. CC space >uninvolved shoulder. Pain and deformity
Inspection of an AC joint separation shows
Elevated distal clavicle (no ligaments hold it down) Step deformity (grade I-III) Other deformities (grade IV-VI) Swelling
Palpation of an AC joint separation reveals
Local pain and swelling
Step deformity (I-III)
Trapezius muscle spasm
What functional tests can you use to assess AC joint separation
Cross-arm adduction (will have pain with passive horizontal adduction)
Traction test
How do you perform a traction test
Basically you put your hand on top of shoulder to stabilize scapula and clavicle
Apply downward force to humerus to see if you can separate it from scapula and clavicle
What tests can be used to assess impingement
Neers: put one hand over posterior shoulder and scapula. Passively forward flex the shoulder. + is pain in anterolateral shoulder
Modifies Hawkins-Kennedy: Flex shoulder 90, and elbow 90. Stabilize elbow and internally rotate arm. + is pain in anterolateral
What type of XR should you get for suspected AC joint sprain
Bilateral AC series w/ 10 degree cephalic tilt
Some clinicians like it w/ and w/o weights
How do you treat AC joint type I-II
Non-operative
Ice and protection until pain subsides (7-10 days)
Return to sports/ADL in 1-3 weeks (when no more pain)
Braces are not proven to help
How do you treat grade III AC joint sprain
Depends!
Non-op: Sling and harness 10-14 days. Return to sports in 3-4 weeks
Conservative Tx except in a throwing athlete or overhead worker.
Repair is avoided in contact sports 2/2 high re-injury
Operation is basically a little clip inserted that sits over superior clavicle and inferior coracoid
Complications of AC joint injuries are
OA of AC joint
Osteolysis of distal clavicle (loses blood supply)- fix w/ distal clavicle resection
Inability to return to optimal functioning
Where is it most common to fracture the clavicle
MC: Midshaft
Then lateral
LC: medial (closest to sternum)
Who is at risk for a clavicle fracture
Contact sports
M <25/40 or >55
Women >75
What is Allman classification
Basically just classifies where you can fracture a clavicle
Grade I: midline (MC)
Grade II: distal (or lateral)
Grade III: medial
What MOI can lead to clavicle fracture
Direct fall on shoulder with arm at side
Direct blow
FOOSH
Inspection of a clavicle Fx shows
Deformity at fracture site (grade with ROM)
Palpation of clavicle fracture shows
Local tenderness, crepitus, +/- can feel defect
What PE exams should you preform if you suspect clavicle fracture
Neuro and Lung auscultation!
Subclavian vessels and brachial plexus
What radiographs are necessary for clavicle Fx
AP clavicle
Cephalic tilt view
(is either one pref?)
Standard of care for clavicle Fx is
Non-operative Tx!
+/- Simple sling or figure 8 brace
What is the difference between simple sling and figure 8 brace
Functional and cosmetic results are the same
Figure 8 is a little more uncomfortable
What situations would require surgical Tx of clavicle
Open Fx
Associated neurovascular injury
Skin tenting (clavicle sits so high up it looks like a tent)
Relative indications for surgical Tx of a clavicle Fx are
Widely displaced Fx Multiple fracture segments Displaced lateral 1/3 Dominant extremity in overhead athlete Cosmetic concerns
Relative indications for surgical Tx of a clavicle Fx are
Widely displaced Fx Multiple fracture segments Displaced lateral 1/3 Dominant extremity in overhead athlete Cosmetic concerns
What injury does this clinical scenario indicate:
26 y/o MMA fighter w/ R shoulder pain and loss of function. Injured 6 hrs ago when his arm was forced overhead while grappling and he felt a shift in his shoulder. No numbness, tingling, or radiation. Dominant RUE
Shoulder dislocation!
Can be caused by traumatic or non-traumatic (Grand-Mal seizure)
What directions can a shoulder dislocate
Anterior (subcoracoid)** Mc
Posterior
Inferior (subglenoid)
Posterior shoulder dislocations are associated with
Seizure or electrical shock- Most have associated Fx of lesser tuberosity
they are commonly missed on XR
With anterior dislocations, we are worried about this associated injury
Neuro injury! 20-40%
Radial, Medial, and Axillary injury
(axillary and brachial plexus basically)
Anterior shoulder dislocations are associated with
Abduction and external rotation injuries
Anterior dislocation complications are
Nerve injury
Hills sachs lesion (impression Fx to posterolateral humeral head from anterior rim of glenoid hitting it while injured)
Bankart tear (Ant/Inferior Glenoid labrum avulsion/detachment)
Inspection of a shoulder dislocation shows
Flattened deltoid Full anterior chest Prominence of acromion guarding Capsular laxity
What imaging should you get for shoulder dislocation
AP view Axillary view Y view (almost like a side view) Articular Fx concern: CT scan Soft tissue patho: MRI arthrogram
What provocative tests help assess shoulder dislocations
Apprehension
Jobe relocation (differentiate pain v instability)
Release (surprise test)
Sulcus sign (hold distal to elbow and pull down to see if you get a sulcus under acromion)
What is the MCC of recurrent instability after a shoulder dislocation
Bankart tear! B/c of the torn capsule, the shoulder will always slip in and out more easily
You can do a Bankart repair in which you drill holes and anchor sutures to labrum and glenoid ligament
Hill-Sachs lesion can cause
destabilized GH joint and predisposition to further dislocation
What must you do prior to reducing a dislocated shoulder
Neuro testing! and document everything
AP and axillary radiographs to document dislocation and r/o fractures
How do you reduce a shoulder
Apply O2 mask/nasal cannula
Fentanyl 100mcg IV over 1 minute, repeat q3-5 min until sedated
Techniques for shoulder reduction are
Hippocratic: old foot in the shoulder, now you put a towel under arm pit and have someone pull oppo as you pull the arm
Stimson: Pt lies prone, you put a weight on their wrist (but takes a long time)
Hennipen: Pt is supine, elbow flexion 90. Adduct arm and flex shoulder 20. Externally rotate arm, then internally rotate
After shoulder reduction
Confirm with radiograph
Immobilize arm in sling (but tell pt to remove sling and extend elbow a few times a day to prevent elbow stiffness)
Begin isometric exercises for rotator cuff
Consult ortho
What are outcomes of a shoulder dislocation
<30: High recurrence if traumatic anterior 2/2 Bankart lesion
>45: Recurrence less common
First time dislocation in pt older than 40 likely w/ rotator cuff tear
Compliactions of shoulder dislocations are
Brachial plexus injury Recurrent dislocation (common if more active)- Tx w/ anterior shoulder reconstruction and bankart repair
