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Musculoskeletal System > Shoulder > Flashcards

Shoulder Flashcards

Present a review of orthopedic problems in the shoulder and their tx. Etiology, signs, Sx, and management

1
Q

What is the common symptom orthopedic problems?

A

Pain

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2
Q

What are associated orthopedic problems?

A 
numbness- swelling can be associated
deformity 
loss of function 
lacerations 
psychological problems - whether or not they have pain is difficult to tell
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3
Q

Pathways of clinical discussion

A 
CC- why are they here 
Hx of CC
physical findings 
suspected differentiated diagnosis 
objective testing 
specific diagnosis 
tx
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4
Q

severity of pain

A 
burn?
aching pain?
numbness?
swelling ?
redness?
what makes it better or worse?
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5
Q

Hx of CC

A 
initiating circumstances 
time factors 
past hx of similar conditions
past hx of tx
previous illness that may be related
family hx of similar problem
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6
Q

Notes of Hx of CC

A 
How was it treated before? Aspirin
Any recent injuries?
Family history with similar condition or pain?
 How did it start ? 
Is it short term or long term ? 
Has it hurt like this before ?
Numbness before?
Tx in the past ? 
Any illnesses? 
Cough or cold urinary problems 
Arthritis or gout in the family?
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7
Q

which joint usually sublux (dislocate) anteriorly?

A

glenohumeral joint

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8
Q

Apprehension test

A

subluxation upon test show shoulder instability (COMMON)
90 degrees abduction to see it if sub luxes
Subluxation of a joint means a condition where a joint is dislocated

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9
Q

What is a normal degree of full abduction

A

180

look for loss of abduction

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10
Q

Physical findings of shoulder

A

inspection (general appearance, symmetry, atrophy, color)
Symmetry between mirrored anatomical structure make for a direct non pathological comparison

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11
Q

Degrees of shoulder ROM

A 
Flexion - 160
Extension - 45 
abduction - 180
adduction - 45
internal rotation - 90
external rotation - 100
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12
Q

Objective testing

A

Radiograph -
Electrodiagnostic
Vascular
Provocative

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13
Q

CAT Scan

A

bony details - fx of intraarticular

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14
Q

MRI

A

if you don’t know if it is a fx or not and there may be infection

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15
Q

Arthrograms

A

if you can’t do an MRI (patient has pacemaker) - inject to see soft tissue (CONTRAST)

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16
Q

ultrasound

A

rotator cuff tears

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17
Q

Pain in shoulder - nerve

A

can be radicular pain (nerve root)

or may be coming from the neck

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18
Q

EMG

A

see how the nerve functions by EMG
whether or not nerve is functioning or is irritated
DO IT for Axillary n.

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19
Q

Nerve conduction velocities

A

speed of the nerve signal

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20
Q

What kind of electrodiagnostic testing is used for carpal tunnel syndrome?

A

EMG/NVC

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21
Q

What is the non-invasive vascular testing?

A

sonogram

=sound

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22
Q

When do you do an objective PROVACATIVE testing?

A

Not sure what is wrong e.g. rotator cuff tear vs neck problem
inject needle under SUBACROMIAL AREA = if pain relieved from site anesthesia, then rule out origin of pain from the neck because it is localized and directly from the shoulder

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23
Q

Can nerve root and localized nerve functioning both contribute to pain?

A

Yes

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24
Q

AC joint

A

acromion process and clavicle

Acromioclavicular joint/ superior acromioclavicular ligament

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25
Q

SC joint

A

Sternoclavicular joint / / anterior sternoclavicular ligament

clavicle and manubrium (not sternum)

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26
Q

Glenohumeral joint

A

glenoid cavity and head of the humerus

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27
Q

Scapulothoracic joint

A

suscapular fossa and medial border of the scapula to the thorax (ribs)

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28
Q

Coracovicular joint

A

corocoid process of the scapular to the clavicle

oracoclavicular ligaments – trapazoid and coracoid ligaments

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29
Q

G-H joint problems

A 
Instability 
Impingement 
rotator cuff
bicipital tendon 
degenerative joint disease 
adhesive capsulitis (arthritis)
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30
Q

Diagnosis of G-H instability

A

subluxation - usually anteriorly
head of the humerus can move from the glenoid fossa
hyaline cartilage not seen in the joint space when collapsed

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31
Q

G-H joint subluxation

A

superiorly

inferiorly (acute dislocation)

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32
Q

How to view inferior G-H joint subluxation

A

lateral and Y view x-ray

not just AP

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33
Q

CC of G-H instability

A 
Pain 
Painful ROM
Weakness in abduction 
apprehension of instability 
guarding 
spontaneous dislocation
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34
Q

Pain ROM in G-H instability

A

deformity

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35
Q

Weakness of abduction in G-H instability

A

won’t be able to move the arm if complete dislocation

can indicate nerve injury to the axillary n. which supplied the deltoid (abduction function) = decreased abduction of the arm if ax. n. traumatized

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36
Q

apprehension of instability (apprehension test)

A

stress test to stretch the joint and they will feel pain and think the shoulder will dislocate

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37
Q

Guarding

A

CLINICAL SIGN OF G-H INSTABILITY
-Patient won’t abduct
think they will dislocate the arm

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38
Q

Spontaneous dislocation

A

Instability of the joint will cause spontaneous dislocations
shoulder will pop out of the place ; pt has to be sedated to have it put back into place
FOOSH injury

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39
Q

Hx or cause of G-H instability

A

TRAUMA
CONGENITAL
INFECTION

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40
Q

Trauma

A

acute - fall on arm; FOOSH

chronic overuse - that wears out the supporting structure of the shoulder (shoulder tend to sublux)

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41
Q

Congenital (born with it)

A

Chronic laxity - lax shoulder

deformity of joint

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42
Q

Congenital deformities of the G-H joint

A

Ehler’s Danlos syndrome – how the collagen fibers are laid down in the capsular structures
-weakened capsular structures
-lax everything: elbow hyperextended, thumb hyperextended, and knee caps dislocated

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43
Q

Infection

A

destroy articular spaces and destroy joint
better tx infections quickly
eliminate the possibility of this joint becoming post-infection

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44
Q

Physical findings of G-H instability

A 
asymmetry 
weakness 
decreased functional ROM
palpatory hypermobility
TESTS!!!!!!
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45
Q

What are tests for G-H instability

A

APPREHENSION TEST
RELOCATION TEST- pop it back in
ANTERIOR DRAW TEST

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46
Q

Weakness of G-H joint

A

cause instability
joint sublux where the head of the humerus used to be
SULCUS SIGN - DEPRESSION AT AREA where humeral joint would normally be
-weakness particularly if shoulder is CHRONICALLY INSTABLE

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47
Q

Decreased functional ROM at G-H joint

A

won’t have the ability to move the arm - feels like you would dislocate that arm

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48
Q

Objective testing for G-H instability

A
  1. X-rays - AP, exillary Y -view r lateral view)
    orthogonal XR should be initial objective testing
  2. CT scan - Hill Sachs lesions
  3. MRI - labral tear, bankart lesion
  4. Arthrogram - when you can’t do a MRI
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49
Q

Hill Sachs lesions

A

seen in CT
occur @ G-H joint
head of the humerus gets pushed on and dislocates by the head of the glenoid rim
creates a defect in the head where the head is being pushed

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50
Q

How do you see a Hill Sachs lesion?

A

CT

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51
Q

How do you see a bankart lesion?

A

MRI or arthrogram if can’t do MRI on a patient with pacemaker or other devices

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52
Q

Bankart lesion

A 
torn labrum which is cartilaginous 
it creates a lesion 
labrum is torn off 
usually can do it with MRI 
located in the BACK of the joint
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53
Q

How to Tx G-H instability?

A

Dont do SURGERY if Ehler’s Danlos (upper brachial plexus injury) or collagen type II defect

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54
Q

Tx acute G-H dislocations

A

Need to be put back in place !!!!

use safe technique - stimson’s technique

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55
Q

Surgery for G-H instability

A

Trauma - ACUTE
bankart lesion (fix the labrum)
CHRONIC RECURRENT DISLOCATIONS
instable shoulder (subluxed) - not yet dislocated ; tighten up the capsule and repair the glens

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56
Q

What are chronic recurrent dislocations of G-H?

A

patient will continue to dislocate unless something is done surgically
CHRONIC DISLOCATIONS DO REQUIRE SURGERY

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57
Q

What is the safest way to put G-H joint back in place?

A

Stimson’s technique

joint dislocation

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58
Q

Stimson’s technique

A

weight on the arm
the muscles will relax and the weight will put the bone and put into the place
give med for the pain
FIRST LINE TX

59
Q

What is the tract-countertraction method for putting back G-H joint back into place?

A

pull it back into place
sheet through the axillary complex
place heat
PROBLEM CAN OCCUR : AXILLARY N CAN BE DMAGED IN THE PROCESS OF PULLING
the method may not be effective in putting it back into place - usually doesn’t go bakcin to place

60
Q

What is an acceptable method of putting back G-H joint ?

A

series of movements: externally rotate and internally rotate to pop it back into place
RELOCATE THE JOINT

61
Q

WHEN TO NOT PERFORM KOCHER’S METHOD?

A

an elderly woman who is osteoporotic because you can fx the humerus

62
Q

What to do after you relocate the G-H back into place?

A

immobilize the joint

if first time dislocation, there is a 100% chance that redislocation is common

63
Q

Redislocation of G-H joint

A

Older you are age 40 and up the more common it is
Young people who has anterior dislocation frequently - redislocation can occur again = requires a swathe (sling) to further immobilize the joint

64
Q

Why use sling and swathe for G-H joint?

A

prevent redislocation
immobilize the joint after putting it back into place
strap keeps the patient from EXTERNALLY rotate the arm
if it is a rotator cuff injury, USE ABDUCTION PILLOW !!!!!!!!!!

65
Q

What is an associated pathology of the G-H joint instability?

A

traumatic anteroinferior glenohumeral dislocation most commonly injures the anterioinferior labrum and anteriorinferior glenohumeral ligament
TORN LABRUM
BANKART LESION

66
Q

what is the redislocation rate for anterior dislocation?

A

100 % in adolescents with open growth plate

55-95% in 18-30 in air force academy study

67
Q

Adolescents

A

redislocate after an anterior dislocation 100% of the time

68
Q

Tendon tear

A

surgery is required

labrum is anchored by a screw

69
Q

Complications of G-H dislocations!!!!

A

Redislocation
Torn glenoid labrum
Hill sachs lesion
anxillary n damage

70
Q

How to surgically tx hills sachs lesion?

A

UNIQUE
cover the lesion wi with tissue
metal screws will be placed in
the lesion occur at the articular surface of the humerus

71
Q

Which muscle is usually injured with shoulder dislocation?

A

Deltoid m.

72
Q

Subacromial impingement (G-H)

A

impinge rotator cuff tendons between undersurface of acromion and greater tuberosity of the humerus = INFLAMMATION
of the bursa and the tendons
MORE COMON THAN DISLOCATED SHOULDER

73
Q

common CC impingement

A

Painful lifting or working overhead

74
Q

Other complaints due to impingement

A
  1. painful abduction of the shoulder - raying arm up
  2. difficulty throwing
  3. crepitance or catching
75
Q

What is crepitance?

A

means grinding e.g. patient who ACHONDROMALACIA will show crepitance on rotator cuff

76
Q

A patient who is a car mechanic or an electrician are likely to have painful abduction because of this…

A

impingement

77
Q

What is a physical finding for impingement?

A

palpating the edge of the rotator cuff and resting ROM = pain !

78
Q

Why are swimmer unique when they present with impingement?

A

they don’t have bone impingement
They have a hypertrophy of the subscapularis m.
They will come in with pain in the muscle
They have impingement in the BURSAL contents

79
Q

What is the abnormal contact between acromion and greater tuberosity in mid-abduction?

A
  1. bursa can hyperthrophy
  2. Trauma of AC joint can create bone spurs
    compromises the subacromial space and movement of the joint
    Compromises the amount of space the rotator cuff can move through
80
Q

Hx of impingement

A 
Over head work 
Muscle hypertrophy 
Trama to AC joint 
Congenital deformity !!
Degenerative joint disease !!!! - impingement 
CAUSE COMPRESSION
81
Q

Physical findings of impingement

A
  1. Difficulty lifting arm above head
  2. Crepitance with abduction - grinding underneath acromial process
  3. impingement sign
  4. provacative test- whether or not it’s a nerve root injury or from the shoulder itself
82
Q

What is the impingement sign (physical finding)?

A

Passive forward flexion over 90 degree causes pain (physician flexes arm forward)

83
Q

What is the hawkin’s test?

A

it is used in subacromial impingement

it is when you feel a grinding or crepitance when raising the arm forward

84
Q

Objective testing for impingement

A

XR
Arthrogram
MRI

85
Q

What is XR used for in impingement

A

Degenerative joint disease of the AC joint

Calcifications of tendon of the rotator cuff (WHITE TENDON) = CHRONIC !!!!

86
Q

What is arthrogram used for in impingement?

A

to see soft tissue

usually normal

87
Q

What does MRI show in impingement?

A

MUSCLE hypertrophy

congenital downsloping of the acromion

88
Q

What are the congenital acromion downslopping types?

A 
BIGLIANA CLASSIFICATION
Type I - flat acromion 
Type II - curved acromion 
Type III - hooked acromion  (pointed down) ****MOST common
HOW TO SEE IT? CT
89
Q

Tx of impingement

A
  1. Meds
  2. Modification of activity - don’t raise arm over the head
  3. PT
  4. Surgery
90
Q

Tx impingement with meds

A

Oral - ibuprofen
injection - cortisone - prevent inflammation
inotophoresis

91
Q

What is inotophoresis?

A

Take cortisone cream and put it on the skin and use electric current through the subcutaneous tissue
Get rid of the inflammation

92
Q

Surgery options for impingement

A

acromioplasty - acromion is removed
Mumford - clavicle and acromion process
Arthroscopic decompression - take off part of acromion off

93
Q

What is mumford procedure?

A

Take off a part of the clavical to the coracoclavicular ligament (open up the joint) and acromion process
Also take out Subacromial bursa which causes inflammation

94
Q

What is athroscopic decompression?

A

take part of the acromion process off

95
Q

Dx of Rotator Cuff Tear

A

Partial thickness tears = incomplete tear = repetitive microtrauma
Full thickness tears - tear the tendon = either full on trauma

96
Q

How does rotator cuff tears occur?

A

SITS = 4 muscles of the rotator cuff
impingement it enough that it can tear

  1. Can be caused by Wear and tear OR
  2. VASCULAR cause weakening and rupture
97
Q

What is the common demographic for rotator cuff tears?

A

50 years

Usually Occur in the elder man

98
Q

Watershed area of the supraspinatus - vascular injury to ROTCUFF

A

Undernearth the acromion bursa - has very little blood supply

99
Q

The critical area of rotator cuff injury is?

A

the tendons that fuse and attach to the greater tuberosity

100
Q

Early vs late complete tears

A

late tear shows resolved tendons at the ends

101
Q

CC of Rotator cuff tear

A 
weakness  in abduction
painful abduction 
can't lift arm overhead
can't lay on arm 
can't throw
can't work overhead
pain at rest
102
Q

How to test for rotator cuff tear?

A

DROP ARM TEST- can’t abduct arm (weakness and painful)

103
Q

Hx of rotator cuff injury

A

microtrauma - over use
Chronic impingement -> can cause micro trauma (partial tears)
Trauma

104
Q

What are the mechanisms of injury rotator cuff tears?

A

Microtrauma - overhead work, repeated lifting
chronic impingement - acromion downsloping
Trauma - fall, pulling and lifting (stretch tendon)

105
Q

2 cause theories for rotator cuff

A

vascular insufficency in critical zone (supraspinatus)

micro trauma from chronic impingement

106
Q

Physical findings of R-C tear

A 
weakened and painful abduction 
muscle spasms !!!!
DROP arm test 
gerber's lift off 
empty can
107
Q

What is the GERBER’S LIFT OFF?

A

test R-C tear
test subscapularis m.
HAND AT OR BELOW THE SCAPULA = ATTEMPT TO LIFT HAND

108
Q

Empty can tests which important m. in R-C injury?

A

supraspinatus

a common m. injury in R-C tear

109
Q

Objective finding of R-C tear

A

X-ray
MRI
Arthrogram

110
Q

XR will show the following in R-C tear

A

bony spurs (will form from tendon) and DJD
narrowing !
resorption

will show as a subluxed humerus (superiorly) = no tissue to prevent sublux

111
Q

MRI will show an important R-C finding

A 
tears 
bony spurs 
DJD 
narrowing 
resorption
112
Q

Arthrogram - RC tear

A

contrast that spreads outside the bursa to see area

113
Q

Tx of RC tears

A 
Rest 
Abduction sling 
physical therapy 
modification of activity 
meds
surgery
114
Q

Tx of Incomplete RC tear

A

Simple traction

115
Q

In surgery, a massive RC tear will show what

A

no muscles on top of the head of the humerus

116
Q

Surgery method for RC tear impingment

A

Arthroscopic method to remove subacromial bursa and also partial acromionectomy
- can’t also place in screw to put RC tendon back into place on humerus

117
Q

Bracing RC after surgery

A

Shoulder abduction brace

118
Q

Dx of Biceps tendon

A

Proximal
Distal
weakness in SUPINATION

119
Q

CC of BC Tendon Tear

A

Pain - rubber band
Weakness - supination
deformity - pop eye = on the anterior forearm, a bulge will be seen

120
Q

Hx of BCT tear

A

Lifting and supination
impingement
overuse - microtrauma
Iatrogenic- cortisone injection into the tendon (NEVER DO THIS!!!!)

121
Q

How does a doctor cause BCT tear?

A

from cortisone injection to the biceps tendon

RUPTURE THE TENDON

122
Q

Physical finding of BCT tear

A

Tenderness over tehe bicipital groove
popeye muscle
yerguson’s test

123
Q

Yerguson’s test

A

Hold patients hand and feel bicipital groove as you supinate the arm

124
Q

Objective finding of BCT Tear

A

MRI - see the muscle tear

Ultrasound

125
Q

Tx of BCT tear

A

skillful neglect- will heal but the deformity will remain; leave it alone and monitor it
surgery

126
Q

Grades of AC joint separations

A

1 Sprain the AC ligament
2 Tear the cap - AC ligament
3 complete tear of AC, and trapezoid and cuboid? ligament

127
Q

Classifications of AC separations

A

Type I = sprain like grade 1
Type II torn AC lig and acromion moves downward
Type III - torn of all the ligaments and acromion moves inferior
Type IV the clavicle move inferior when ligaments are torn
Type V Clavicle moved superior when ligaments are torn
Type VI clavicle moves inferior to the biceps tendon

128
Q

CC of AC separation

A

Pain at rest and with ROM
Crepitance - grinding
palpable deformity

129
Q

AC joint separation = THINK….

A

HOCKEY!!!!

130
Q

Hx of AC separations

A

Trauma - common - FALL or HOCKEY

Infection - RARE

131
Q

AC separation from trauma can show this

A

Elevated joint
but at grade 3 separation
inflammation will there

132
Q

Physical finding of AC joint separation

A
  1. pain directly over AC joint = after 90 degrees AC joint rotates = ILICIT pain
  2. palpable deformity
  3. warmth
  4. painful ROM
133
Q

AC joint function

A

rotation

plane = gliding joint

134
Q

What is unique about taking a XR of the AC joint?

A

compare load-bearing vs. non-load bearing

when pt. is given weights

135
Q

Objective testing of AC separation

A
  1. XR - common
  2. CT
  3. MRI
136
Q

Tx of AC separation

A
  1. Skillful NEGLECT for grade 2 and below
  2. sling
  3. AC strap
  4. surgery if severe subluxations and dislocations
137
Q

What tx method for AC separation not popular?

A

AC strap

138
Q

Snapping scapula

A

CC - catching THE ARM when raises arm
Hx - congenital
Physical findings - PROMINENCE ON THE RIBS AS YOU ROTATE THE SCAPULA
Objective test - CT, XR
Tx - injections underneath the scapula! AVOID SURGERY
scapulo-thoracic impingment

139
Q

Adhesive capsulitis AKA …. FROZEN SHOULDER SYNDROME

A 
Frozen shoulder syndrome 
Scarring down of the articular capsule 
CC: cant raise arm 
Hx : slow progression of loss of motion
Physical : passive and active ROM is lost 
Testing : MRI to see capsule 
Tx : meds, PT, manipulation
140
Q

Etiology of frozen shoulder syndrome

A

Due to trauma
or Disuse (OLD PEOPLE)
Inflammaton of the shoulder capsule
Complication fx or dislocation of the humerus

141
Q

Adhesive capsulitis AKA …. FROZEN SHOULDER SYNDROME

A 
Frozen shoulder syndrome 
Scarring down of the articular capsule 
CC: cant raise arm 
Hx : slow progression of loss of motion
Physical : passive and active ROM is lost 
Testing : MRI to see capsule 
Tx : meds, PT, manipulation
142
Q

Adhesive capsulitis AKA …. FROZEN SHOULDER SYNDROME

A 
Frozen shoulder syndrome 
Scarring down of the articular capsule 
CC: cant raise arm 
Hx : slow progression of loss of motion
Physical : passive and active ROM is lost 
Testing : MRI to see capsule 
Tx : meds, PT, manipulation
143
Q

Etiology of frozen shoulder syndrome

A

Due to trauma
or Disuse (OLD PEOPLE)
Inflammaton of the shoulder capsule
Complication fx or dislocation of the humerus

Musculoskeletal System (27 decks)

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