Shoulder 1 Flashcards
What are the 2 ligaments that stabilize the acromioclavicular joint?
- AC joint ligament
- Coracoclavicular ligament complex
T/F
- AC joint injuries occur in males in their 20’s
True
Mechanism of Injury of AC joint injury?
Direct Force
- Falls on AC joint w/ arm at side (collision sport)
- Force applied to superior aspect of acromion which forces acromion inferior & medial
Type 1, 2, or 3 AC injury?
- Sprain of AC ligament
- AC joint intact
- Coracoclavicular ligaments intact
- Pain w/o deformity
Type 1
Type 1, 2, or 3 AC injury?
- Sprain of coracoclaviular ligament
- AC joint disrupted
- <50% vertical displacement
- Pain & deformity ++
Type 2
Type 1, 2, or 3 AC injury?
- AC & coracoclavicular ligaments all disrupted
- AC joint dislocated & shoulder complex displaced inferiorly
- Coracoclavicular interspace greater than the uninvolved shoulder
- Pain w/ deformity
Type 3
AC joint injury rarely occurs from what mechanism?
FOOSH
Inspection/Palpation of AC joint separation
- Elevated distal clavicle (deformity called what?)
- Which 3 grades?
- Swelling
- Spasm of which muscle?
- “step” deformity
- 2, 3, 5
- Trapezius
What 2 tests to eval AC joint separation?
- Cross-arm ADDuction
- Traction test
Tx for which Type of AC joint injury?
- Non-operative
- Ice and protection until pain subsides (7 to 10 days)
- Return to sports / Activities of Daily Living (ADLs) as pain allows (1-3 weeks)
- No apparent benefit to the use of specialized braces
Types 1 & 2
Tx for which type of AC joint injury?
Non-operative treatment
- Sling and harness (10-14 days) to approximate alignment
- Return to sports / ADLs 3-4 weeks
Need for acute surgical treatment remains controversial
- Conservative treatment recommended except in the throwing athlete or overhead worker
- Repair generally avoided in contact athletes because of the risk of re-injury
Type 3
3 complications of AC joint injuries
- Osteoarthritis (OA) of the AC joint
- Osetolysis of the distal clavicle
- Inability to return to optimal functional level
What is the most common direction of dislocation of Shoulder (Glenohumeral) dislocations?
Anterior (95%)
Least common = inferior
Which type of shoulder dislocation?
- Associated with seizures or electrical shock
- Commonly missed on X-ray
- High incidence of associated lesser tuberosity fracture
Posterior
(relatively uncommon)
Which type of shoulder dislocation?
•ABD/ER (abduction/extended) most common mechanism
Complications
- Up to 20-40% neurologic injury
- Hills Sachs lesion
- Bankart tear
Anterior
(most common)
4 PE findings of Shoulder Dislocation
- Flattened deltoid
- Fullness of anterior chest
- Prominence of acromion
- Guarding / protecting
3 x-ray views for Shoulder Dislocation
- AP view (A&B)
- Axillary view (C&D)
- “Y” view
What 2 things should be given to patient during Anterior Shoulder Dislocation reduction procedure?
- Apply oxygen by mask or nasal cannula throughout the procedure
- Fentanyl 100 micrograms IV over 1 minute and then repeated every 3-5 minutes until adequate sedation is achieved
What 2 things should be done prior to reduction of Ant Shoulder Dislocation?
- Prior to reduction, a neurovascular exam should be performed and documented
- Obtain radiographs to document the dislocation and r/o any fractures
Tx for Shoulder Dislocations?
- What 3 things?
Immediate reduction
- Hippocratic technique
- Stimson technique
- Hennipen Technique
- Which technique?
- For what injury?
- Hippocratic Technique
- Shoulder Dislocation
- Which technique?
- Which injury?
- Stimson Technique
- Shoulder Dislocation
- Which technique?
- Which injury?
- Hennepin
- Shoulder dislocation
What are the 4 provocative tests to eval Shoulder Dislocation?
- Apprehension
- Jobe Relocation (Differentiate pain versus instability)
- Surprise (aka Release test)
- Sulcus sign
Shoulder Dislocation Aftercare
- Confirm reduction w/ radiographs
- Immobilize arm in sling
- Remove sling & extend elbow several times daily to prevent elbow stiffness
- Consult ortho
3 complications of Ant Shoulder Dislocation
•Bankart lesion (Glenoid labral avulsion (anterior/inferior))
•Hill-Sachs lesion (Impression fracture to posterolateral portion of the humeral head)
•Capsular laxity
What is this? / Which injury?
- Detachment of the anterior-inferior portion of the labrum from the glenoid.
- The most common cause of recurrent instability after an injury.
Bankart Lesion
- Anterior Shoulder Dislocation
What is this?
- A posterolateral compression fracture of the humeral head
- Caused by collision of the humeral head with the anterior ring of the glenoid.
- May destabilize glenohumeral joint & may predispose to further dislocation
Hill-Sachs Lesion
- Recurrence of shoulder dislocation after traumatic anterior dislocation is high in patients of what age?
- Recurrence is less common in what age?
- First time dislocation in pts older than 40 yrs may be associated w/ what?
- Traumatic, high recurrence: <30 y/o
- Less common recurrence: >45 y/o
- rotator cuff tear
2 complications of shoulder dislocations
Brachial Plexus Injury
•Carefully document pre- and post-reduction neuro exam in all patients!!
Recurrent dislocation
- Common in more active patients
- Treated with anterior shoulder reconstruction and Bankart repair
What is the most freq cause of shoulder pain??
Subacromial Impingement Syndrome (SAIS)
SAIS
- What is root of problem?
- What are the 2 types?
- Decreased subacromial space
- Primary / Secondary
Which type of SAIS?
- Driven by degenerative changes
- > 35 y/o
- Bone spurs &/or calcific deposits
- “true” or “classic” impingement
Primary
Which type of SAIS?
•Hooked acromion = increased subacromial pressure
- Decrease subacromial space
- More contact with RC tendons
- Increased risk of SAIS → increased risk of RC tear
Primary
Degenerative Calcification is seen with what?
Primary Impingement (SAIS)
Which type of SAIS?
- Due to repetitive overhead movement (ABDuction and ER)
- <35 y/o
- Overhead athlete (volleyball)
- Faulty scapular posture
Secondary Impingement
- 2 contributing factors to Secondary Impingement?
- Leads to adaptive muscle imbalances such as?
- Forward head / Increased thoracic kyphosis
- Tight pec minor –> anterior tilting & protraction
- ↓ subacromial space → impingement → inflammation and gradual degeneration of subacromial structures
SAIS is due to inflammation affecting volume in subacromial space –> increased compression.
- Repetitive microtrauma occurs in what 3 structures?
- Supraspinatus tendon
- Subacromial bursa
- Long Head of Biceps
SAIS
- Gradual or sudden onset of pain?
- Where is pain located (2 places)
- Night pain / diff sleeping on affected side
- TTP over what 3 areas?
- Gradual
- Anterior & Lateral shoulder = deltoid tuberosity, exacerbated by overhead activity
- greater tuberosity / subacromial bursa / biceps tendon (long head)
3 strength tests for SAIS?
- External rotation/Infraspinatus Strength Test
- Empty can Supraspinatus Test
- Lift-off Subscapularis Test
3 components of conservative care for SAIS?
- NSAIDS
- Avoid offending activities / Sleep position modified
- Therapy program for postural correction (PT or home therapy)
SAIS
- If no improvement in how many weeks of conservative care can you progress to corticosteroid injection in combo w/ conservative?
6 weeks
Under what circumstances with SAIS would you do surgery (subacromial decompression)?
- Failure with conservative care
- Evidence of calcifications &/or bone spur
Rotator Cuff Tear
- MC etiology? 2nd MC?
- Originate where?
- Full thickness tears uncommon < __ yrs
- Incidence of full thickness tears increases >___ yrs
- Incidence ESP. increases > ___ yrs
- # 1: overuse
- # 2: traumatic
- uncommon <40 yrs
- common >40 yrs
- very common >60 yrs
Clinical Px of which injury?
- Recurrent shoulder pain for several months (overuse)
- Specific injury that triggered the onset of the pain (traumatic)
- Subacromial pain and pain localized to deltoid tuberosity
- Night pain and difficulty sleeping on affected side
- Weakness, catching, and grating especially when lifting the arm overhead
Rotator Cuff Tear
PE of Rotator Cuff Tear
- TTP of subacromial space
- What ROM is decreased?
- What ROM is normal?
- What test is positive?
- Dec: Active (shoulder shrug w/ abduction)
- Normal: Passive
- “drop arm” test is positive
4 muscles of the rotator cuff
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
What is the gold standard imaging of Rotator Cuff tear
MRI
- If chronic injury and concern is for partial tear order arthrogram
- If traumatic injury and pt most likely has full thickness tear arthrogram is optional
Nonsurgical Tx for Rotator Cuff Tear
- <__% thickness tears
- PT
- Avoidance of overhead activities
- 2 meds?
- <50%
- NSAIDs
-
Steroid Injection
- •May decrease inflammation of an associated subacromial bursitis and provide short-term pain relief
- May also weaken tendon/accelerate propagation of tear
- Patients should never receive > 3 subacromial injections/year
Surgery for Chronic Injury of RC tear
- Significant sxs and failed ____ for > how many months?
- rehab
- > 3-6 months
Surgery for Acute Traumatic RC tear
- Best done acutely or no later than within ___ weeks of injury
6 weeks
Condition?
- Idiopathic loss of BOTH active & passive motion***
- Most commonly affects pts 40-60 y/o
- MC risk factor?
- Other related condiitons:
- hypothyroidism
- dupuytren contracture
- cervical disk herniation
- Parkinson’s disease
Adhesive Capsulitis (Frozen Shoulder)
- MC RF: DM type 1
Adhesive Capsulitis (Frozen Shoulder)
- Inflammatory process involving what structure?
-
Gradual ROM loss
- mechanical restriction
- pt commonly unaware
- What are the 3 common primary motions involved?
- Glenohumeral capsule (idiopathic)
- External rotation (most pronounced)
- Abduction
- Flexion
Adhesive Capsulitis - Evaluation
-
Significant (at least __%) reduction in BOTH active & passive ROM
- What motion is most pronounced?
-
Pain
- Dull/achy pain over what structure w/ what motion?
- Sharp pain when?
- Diffuse shoulder tenderness may be present
- 50%
- Most pronounced: external rotation
- Dull at rest: deltoid tuberosity
- Sharp: at end range of restricte movements (GH joint)
An MRI in a pt w/ Adhesive Capsulitis will reveal what 2 things?
- Contracted capsule
- Loss of inferior pouch
Which phase of adhesive capsulitis?
- Pain and progressive loss of motion
“Freezing” phase
Which phase of adhesive capsulitis?
- Decreasing discomfort associated w/ slow but steady improvement in ROM
“Thawing” phase
- How long does it take for Adhesive Capsulitis to resolve?
- Most pts experience what?
- 6 months - 2 years
- minimal long term pain or functional deficit
Tx of Adhesive Capsulitis
- What “may” be considered?
- PT will perform what? Consider what tx prior to PT visit?
- If no improvement in how long will surgery be considered?
- Intra-articular injection of steroid
- PT: aggressive ROM, consider pain control prior to PT therapy
- 9 - 12 months
