Shoulder 1 Flashcards
1
Q
What are the 2 ligaments that stabilize the acromioclavicular joint?
A
- AC joint ligament
- Coracoclavicular ligament complex
2
Q
T/F
- AC joint injuries occur in males in their 20’s
A
True
3
Q
Mechanism of Injury of AC joint injury?
A
Direct Force
- Falls on AC joint w/ arm at side (collision sport)
- Force applied to superior aspect of acromion which forces acromion inferior & medial
4
Q
Type 1, 2, or 3 AC injury?
- Sprain of AC ligament
- AC joint intact
- Coracoclavicular ligaments intact
- Pain w/o deformity
A
Type 1
5
Q
Type 1, 2, or 3 AC injury?
- Sprain of coracoclaviular ligament
- AC joint disrupted
- <50% vertical displacement
- Pain & deformity ++
A
Type 2
6
Q
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
A
Type 3
7
Q
AC joint injury rarely occurs from what mechanism?
A
FOOSH
8
Q
Inspection/Palpation of AC joint separation
- Elevated distal clavicle (deformity called what?)
- Which 3 grades?
- Swelling
- Spasm of which muscle?
A
- “step” deformity
- 2, 3, 5
- Trapezius
9
Q
What 2 tests to eval AC joint separation?
A
- Cross-arm ADDuction
- Traction test
10
Q
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
A
Types 1 & 2
11
Q
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
A
Type 3
12
Q
3 complications of AC joint injuries
A
- Osteoarthritis (OA) of the AC joint
- Osetolysis of the distal clavicle
- Inability to return to optimal functional level
13
Q
What is the most common direction of dislocation of Shoulder (Glenohumeral) dislocations?
A
Anterior (95%)
Least common = inferior
14
Q
Which type of shoulder dislocation?
- Associated with seizures or electrical shock
- Commonly missed on X-ray
- High incidence of associated lesser tuberosity fracture
A
Posterior
(relatively uncommon)
15
Q
Which type of shoulder dislocation?
•ABD/ER (abduction/extended) most common mechanism
Complications
- Up to 20-40% neurologic injury
- Hills Sachs lesion
- Bankart tear
A
Anterior
(most common)
16
Q
4 PE findings of Shoulder Dislocation
A
- Flattened deltoid
- Fullness of anterior chest
- Prominence of acromion
- Guarding / protecting
17
Q
3 x-ray views for Shoulder Dislocation
A
- AP view (A&B)
- Axillary view (C&D)
- “Y” view
18
Q
What 2 things should be given to patient during Anterior Shoulder Dislocation reduction procedure?
A
- 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
19
Q
What 2 things should be done prior to reduction of Ant Shoulder Dislocation?
A
- Prior to reduction, a neurovascular exam should be performed and documented
- Obtain radiographs to document the dislocation and r/o any fractures
20
Q
Tx for Shoulder Dislocations?
- What 3 things?
A
Immediate reduction
- Hippocratic technique
- Stimson technique
- Hennipen Technique
21
Q
- Which technique?
- For what injury?
A
- Hippocratic Technique
- Shoulder Dislocation
22
Q
- Which technique?
- Which injury?
A
- Stimson Technique
- Shoulder Dislocation
23
Q
- Which technique?
- Which injury?
A
- Hennepin
- Shoulder dislocation
24
Q
What are the 4 provocative tests to eval Shoulder Dislocation?
A
- Apprehension
- Jobe Relocation (Differentiate pain versus instability)
- Surprise (aka Release test)
- Sulcus sign
25
Shoulder Dislocation Aftercare
* Confirm reduction w/ radiographs
* Immobilize arm in sling
* Remove sling & extend elbow several times daily to prevent elbow stiffness
* Consult ortho
26
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**
27
**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
28
**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
29
* 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
30
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
31
What is the most freq cause of shoulder pain??
Subacromial Impingement Syndrome (SAIS)
32
**SAIS**
* What is root of problem?
* What are the 2 types?
* Decreased subacromial space
* Primary / Secondary
33
**Which type of SAIS?**
* Driven by degenerative changes
* \> 35 y/o
* Bone spurs &/or calcific deposits
* “true” or “classic” impingement
Primary
34
**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
35
Degenerative Calcification is seen with what?
Primary Impingement (SAIS)
36
**Which type of SAIS?**
* Due to repetitive overhead movement (ABDuction and ER)
* \<35 y/o
* Overhead athlete (volleyball)
* Faulty scapular posture
Secondary Impingement
37
* 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
38
**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
39
**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)
40
3 strength tests for SAIS?
* External rotation/Infraspinatus Strength Test
* Empty can Supraspinatus Test
* Lift-off Subscapularis Test
41
3 components of conservative care for SAIS?
* **NSAIDS**
* **Avoid offending activities / Sleep position modified**
* **Therapy** program for postural correction (PT or home therapy)
42
**SAIS**
* If no improvement in _how many weeks_ of conservative care can you progress to corticosteroid injection in combo w/ conservative?
6 weeks
43
Under what circumstances with SAIS would you do surgery (subacromial decompression)?
* Failure with conservative care
* Evidence of calcifications &/or bone spur
44
**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
45
**Clinical Px of which injury?**
## Footnote
* 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
46
**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
47
4 muscles of the rotator cuff
* Supraspinatus
* Infraspinatus
* Teres minor
* Subscapularis
48
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
49
**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
50
**Surgery for Chronic Injury of RC tear**
* Significant sxs and failed ____ for \> how many months?
* rehab
* \> 3-6 months
51
**Surgery for Acute Traumatic RC tear**
* Best done acutely or no later than within ___ weeks of injury
6 weeks
52
**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
53
**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)**
1. External rotation (most pronounced)
2. Abduction
3. Flexion
54
_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)
55
An MRI in a pt w/ Adhesive Capsulitis will reveal what 2 things?
* Contracted capsule
* Loss of inferior pouch
56
**Which phase of adhesive capsulitis?**
* Pain and progressive loss of motion
"Freezing" phase
57
**Which phase of adhesive capsulitis?**
* Decreasing discomfort associated w/ slow but steady improvement in ROM
"Thawing" phase
58
* 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
59
**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
