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Summer FDTN Exam 4 > Shoulder 1 > Flashcards

Shoulder 1 Flashcards

1
Q

What is the musculature of the shoulder

A

Rotator cuff (Supraspinatus, Infraspinatus, Teres minor, Subscapularis)
Deltoid
Stabilizers: Trapezius, levator scapulae, rhom major/minor, pec minor, serratus anterior

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2
Q

What do the muscle of the rotator cuff do

A

Supraspinatus: Abduction
Infraspinatus: External rotation
Teres minor: External rotation
Subscapularis: Internal rotation

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3
Q

What are the bursas of the shoulder

A

Subacromial bursa

Subdeltoid bursa

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4
Q

What specific MSK questions are important to ask when evaluating shoulder pain

A 
Sensation of instability 
weakness
popping, crepitus
stiffness
numbness/tingling
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5
Q

What specific MOI indicate specific injured structures

A
  • Fall directly onto anterior/superior shoulder= AC joint injury (shoulder separation)
  • Arm forcefully abducted and ext. rotated= Sublux/anterior dislocation
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6
Q

MOI can help you

A

determine radiologic needs

Age helps differentiate likely injury (complete rotator cuff tear more likely if >45 y/o)

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7
Q

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

A

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!

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8
Q

What are the aspects of the AC joint

A

AC joint ligament
Coracoclavicular ligament complex
Delto-trapezial complex

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9
Q

AC joint injuries are MC in

A

Men

44% in 20 y/o patients

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10
Q

Common AC joint injuries include

A

*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

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11
Q

How do you classify AC joint tears

A

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

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12
Q

What PE is associated with different grade AC joint injuries

A

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

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13
Q

Inspection of an AC joint separation shows

A 
Elevated distal clavicle (no ligaments hold it down)
Step deformity (grade I-III) 
Other deformities (grade IV-VI) 
Swelling
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14
Q

Palpation of an AC joint separation reveals

A

Local pain and swelling
Step deformity (I-III)
Trapezius muscle spasm

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15
Q

What functional tests can you use to assess AC joint separation

A

Cross-arm adduction (will have pain with passive horizontal adduction)
Traction test

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16
Q

How do you perform a traction test

A

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

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17
Q

What tests can be used to assess impingement

A

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

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18
Q

What type of XR should you get for suspected AC joint sprain

A

Bilateral AC series w/ 10 degree cephalic tilt

Some clinicians like it w/ and w/o weights

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19
Q

How do you treat AC joint type I-II

A

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

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20
Q

How do you treat grade III AC joint sprain

A

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

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21
Q

Complications of AC joint injuries are

A

OA of AC joint
Osteolysis of distal clavicle (loses blood supply)- fix w/ distal clavicle resection
Inability to return to optimal functioning

22
Q

Where is it most common to fracture the clavicle

A

MC: Midshaft
Then lateral
LC: medial (closest to sternum)

23
Q

Who is at risk for a clavicle fracture

A

Contact sports
M <25/40 or >55
Women >75

24
Q

What is Allman classification

A

Basically just classifies where you can fracture a clavicle
Grade I: midline (MC)
Grade II: distal (or lateral)
Grade III: medial

25
Q

What MOI can lead to clavicle fracture

A

Direct fall on shoulder with arm at side
Direct blow
FOOSH

26
Q

Inspection of a clavicle Fx shows

A

Deformity at fracture site (grade with ROM)

27
Q

Palpation of clavicle fracture shows

A

Local tenderness, crepitus, +/- can feel defect

28
Q

What PE exams should you preform if you suspect clavicle fracture

A

Neuro and Lung auscultation!

Subclavian vessels and brachial plexus

29
Q

What radiographs are necessary for clavicle Fx

A

AP clavicle
Cephalic tilt view
(is either one pref?)

30
Q

Standard of care for clavicle Fx is

A

Non-operative Tx!

+/- Simple sling or figure 8 brace

31
Q

What is the difference between simple sling and figure 8 brace

A

Functional and cosmetic results are the same

Figure 8 is a little more uncomfortable

32
Q

What situations would require surgical Tx of clavicle

A

Open Fx
Associated neurovascular injury
Skin tenting (clavicle sits so high up it looks like a tent)

33
Q

Relative indications for surgical Tx of a clavicle Fx are

A 
Widely displaced Fx 
Multiple fracture segments 
Displaced lateral 1/3 
Dominant extremity in overhead athlete 
Cosmetic concerns
34
Q

Relative indications for surgical Tx of a clavicle Fx are

A 
Widely displaced Fx 
Multiple fracture segments 
Displaced lateral 1/3 
Dominant extremity in overhead athlete 
Cosmetic concerns
35
Q

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

A

Shoulder dislocation!

Can be caused by traumatic or non-traumatic (Grand-Mal seizure)

36
Q

What directions can a shoulder dislocate

A

Anterior (subcoracoid)** Mc
Posterior
Inferior (subglenoid)

37
Q

Posterior shoulder dislocations are associated with

A

Seizure or electrical shock- Most have associated Fx of lesser tuberosity
they are commonly missed on XR

38
Q

With anterior dislocations, we are worried about this associated injury

A

Neuro injury! 20-40%
Radial, Medial, and Axillary injury
(axillary and brachial plexus basically)

39
Q

Anterior shoulder dislocations are associated with

A

Abduction and external rotation injuries

40
Q

Anterior dislocation complications are

A

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)

41
Q

Inspection of a shoulder dislocation shows

A 
Flattened deltoid 
Full anterior chest 
Prominence of acromion 
guarding 
Capsular laxity
42
Q

What imaging should you get for shoulder dislocation

A 
AP view 
Axillary view 
Y view (almost like a side view)
Articular Fx concern: CT scan 
Soft tissue patho: MRI arthrogram
43
Q

What provocative tests help assess shoulder dislocations

A

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)

44
Q

What is the MCC of recurrent instability after a shoulder dislocation

A

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

45
Q

Hill-Sachs lesion can cause

A

destabilized GH joint and predisposition to further dislocation

46
Q

What must you do prior to reducing a dislocated shoulder

A

Neuro testing! and document everything

AP and axillary radiographs to document dislocation and r/o fractures

47
Q

How do you reduce a shoulder

A

Apply O2 mask/nasal cannula

Fentanyl 100mcg IV over 1 minute, repeat q3-5 min until sedated

48
Q

Techniques for shoulder reduction are

A

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

49
Q

After shoulder reduction

A

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

50
Q

What are outcomes of a shoulder dislocation

A

<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

51
Q

Compliactions of shoulder dislocations are

A 
Brachial plexus injury 
Recurrent dislocation (common if more active)- Tx w/ anterior shoulder reconstruction and bankart repair

Summer FDTN Exam 4 (14 decks)

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