Shoulder 2 Flashcards
In younger patients, high energy trauma results in
Humerus fractures!
While in elderly, MCC is a simple fall
How do humerus fractures present
Severe pain
Limited ROM
Swelling
Ecchymosis
How do you classify a humerus fracture
Neers classification for the proximal humerus; based on location, fracture parts, and displacement
What are the types of humerus fractures
Two, Three, or Four part
Transverse
Oblique
Spiral (like a candy cane)
A posterior fracture preserves
Extension! B/c it does not affect the radial nerve?
What is Subacromial Impingement Syndrome
most frequent cause of shoulder pain!
Decreased subacromial space
What is the MOI of a subacromial impingement
Repetitive microtrauma to supraspinatus tendon, subacromial bursa, and long head of biceps
What can cause increased compression in SAIS
increased inflammation affecting volume in subacromial space
Tendon degeneration can be caused by
Inflammation
Repetitive microtrauma
Reduction in stress intolerance
What are the types of acromion morphology
I: Flat
II: Curved
III: Hooked
Hooked acromion results in
Increased subacromial pressure and decreased space
More contact with rotator cuff tendons
Increased risk of SAIS= increased risk of rotator cuff tear
What is a primary impingement
Driven by degenerative changes
MC in 35+ y/o
Associates osteophytes and calcified deposits
This is true or classic impingement
What is secondary impingement
Due to repetitive overhead movement (Abduct and ER)
MC <35 y/o, overhead athlete
Faulty scapular posture (hunched forward)
What contributes to faulty scapular posture
Forward head, Increased thoracic kyphosis
Faulty scapular posture leads to
adaptive muscle imbalance
tight pec minor= anterior tilting and protraction= decreased subacromial space= impingement= inflammation and degeneration of subacromial structures
SAIS presents with
Gradual onset antero/lateral shoulder pain, worse w/ overhead activity
Night pain and difficulty sleeping on affected side
TTP over greater tuberosity, subacromial bursa, and long head of biceps tendon
Impingement tests are
Neers (No pain from 45-60 and >170)
Modified Hawkins-Kennedy
Strength testing for SAIS includes
Empty can test (supraspinatus)
ER against resistance (infraspinatus)
Lift off (subscap)- internally rotate behind back and push against provider’s hand
Muscles of the rotator cuff are
Supreaspinatus: Abduction
Infraspinatus: ER
Teres minor: ER
Subscapularis: IR
What radiographs can you get with SAIS suspicion
X-ray: always if traumatic, to r/o Fx, eval for calcifications, bone spurs, and acromial morphology
How do you treat SAIS
NSAIDs
avoid offending activities
PT and home therapy to correct posture
If there is no improvement in 6 weeks of SAIS w/ initial therapy
Consider subacromial injection and continued therapy
Surgery (subacromial decompression) if failed conservative care, or if you have a calcification or bone spur!
What causes rotator cuff tear
MC: Overuse (age related degeneration, chronic mechanical impingement)
Traumatic
Full thickness is NOT common <40
Rotator cuff tears typically originate
in Supraspinatus tendon, and may progress
How do rotator cuff tears typically present
Recurrent shoulder pain for months, or specific injury triggering Sx
Subacromial pain, Pain localized to deltoid tuberosity
Night pain and difficulty sleeping on affected side
Weakness, catching, grating when lifting arm overhead
On rotator cuff PE you may find
TTP over subacromial space
Decreased ROM (shoulder shrug w/ abduction)
+ drop arm test
Pain/weakness w/ isolation of involved RC muscles
What imaging should you get for rotator cuff injuries
XR: all traumatic injuries to r/o Fx, eval for calcifications and bone spurs
GOLD is MRI*: if chronic or concern for partial tear add arthroscopy. If full thickness, don’t need arthrogram
What is non-surgical Tx of rotator cuff
NSAIDs, PT, avoid overhead activities if <5-% tear
Steroid injection to decrease inflammation of subacromial bursitis, and short term pain relief
Why should pts not get more than 3 subacromial injections per year
can lead to weakened tendon, and accelerate propagation of the tear
When would you preform surgery to fix a rotator cuff
Significant Sx and failed rehab >3-6 months
Acute traumatic cuff tear (surgery w/in 6 weeks of injury!)
What is adhesive capsulitis
Idiopathic loss of active and passive motion
MC affects patients 40-60
Due to inflammation in GH capsule
Adhesive capsulitis is related to these comorbidities
MC* DM type 1
Also, hypothyroid, cervical herniation (what level???????), Parkinsons, and Dupuytren contracture
Adhesive capsulitis leads to
gradual loss of ROM that pt is not aware of
mechanical restriction- ER (MC*), abduction, and flexion
When evaluating adhesive capsulitis, you may find
Reduced ROM (50% or more) in ER (mostly), flexion and abduction Pain dull and achy at rest, sharp at end ROM of GH joint Diffuse shoulder ttp
XR can be used for what in adhesive capsulitis
R/o other pathology
MRI can be used for what in adhesive capsulitis
contracted capsule and loss of inferior pouch on arthrography
What are the phases of adhesive capsulitis
Freezing: pain and progressive loss of motion
Thawing: decreased discomfort associated w/ slow but steady improvement in ROM
-can take 6 months-2 years for resolution aka end of thawing phase
How do you treat adhesive capsulitis
Intra-articular steroid injection
PT (aggressive ROM)
Consider for pain control prior to PT visits
If no improvement in 9-12 months, consider surgery
