Shoulder Flashcards
Present a review of orthopedic problems in the shoulder and their tx. Etiology, signs, Sx, and management
What is the common symptom orthopedic problems?
Pain
What are associated orthopedic problems?
numbness- swelling can be associated deformity loss of function lacerations psychological problems - whether or not they have pain is difficult to tell
Pathways of clinical discussion
CC- why are they here Hx of CC physical findings suspected differentiated diagnosis objective testing specific diagnosis tx
severity of pain
burn? aching pain? numbness? swelling ? redness? what makes it better or worse?
Hx of CC
initiating circumstances time factors past hx of similar conditions past hx of tx previous illness that may be related family hx of similar problem
Notes of Hx of CC
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?
which joint usually sublux (dislocate) anteriorly?
glenohumeral joint
Apprehension test
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
What is a normal degree of full abduction
180
look for loss of abduction
Physical findings of shoulder
inspection (general appearance, symmetry, atrophy, color)
Symmetry between mirrored anatomical structure make for a direct non pathological comparison
Degrees of shoulder ROM
Flexion - 160 Extension - 45 abduction - 180 adduction - 45 internal rotation - 90 external rotation - 100
Objective testing
Radiograph -
Electrodiagnostic
Vascular
Provocative
CAT Scan
bony details - fx of intraarticular
MRI
if you don’t know if it is a fx or not and there may be infection
Arthrograms
if you can’t do an MRI (patient has pacemaker) - inject to see soft tissue (CONTRAST)
ultrasound
rotator cuff tears
Pain in shoulder - nerve
can be radicular pain (nerve root)
or may be coming from the neck
EMG
see how the nerve functions by EMG
whether or not nerve is functioning or is irritated
DO IT for Axillary n.
Nerve conduction velocities
speed of the nerve signal
What kind of electrodiagnostic testing is used for carpal tunnel syndrome?
EMG/NVC
What is the non-invasive vascular testing?
sonogram
=sound
When do you do an objective PROVACATIVE testing?
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
Can nerve root and localized nerve functioning both contribute to pain?
Yes
AC joint
acromion process and clavicle
Acromioclavicular joint/ superior acromioclavicular ligament
SC joint
Sternoclavicular joint / / anterior sternoclavicular ligament
clavicle and manubrium (not sternum)
Glenohumeral joint
glenoid cavity and head of the humerus
Scapulothoracic joint
suscapular fossa and medial border of the scapula to the thorax (ribs)
Coracovicular joint
corocoid process of the scapular to the clavicle
oracoclavicular ligaments – trapazoid and coracoid ligaments
G-H joint problems
Instability Impingement rotator cuff bicipital tendon degenerative joint disease adhesive capsulitis (arthritis)
Diagnosis of G-H instability
subluxation - usually anteriorly
head of the humerus can move from the glenoid fossa
hyaline cartilage not seen in the joint space when collapsed
G-H joint subluxation
superiorly
inferiorly (acute dislocation)
How to view inferior G-H joint subluxation
lateral and Y view x-ray
not just AP
CC of G-H instability
Pain Painful ROM Weakness in abduction apprehension of instability guarding spontaneous dislocation
Pain ROM in G-H instability
deformity
Weakness of abduction in G-H instability
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
apprehension of instability (apprehension test)
stress test to stretch the joint and they will feel pain and think the shoulder will dislocate
Guarding
CLINICAL SIGN OF G-H INSTABILITY
-Patient won’t abduct
think they will dislocate the arm
Spontaneous dislocation
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
Hx or cause of G-H instability
TRAUMA
CONGENITAL
INFECTION
Trauma
acute - fall on arm; FOOSH
chronic overuse - that wears out the supporting structure of the shoulder (shoulder tend to sublux)
Congenital (born with it)
Chronic laxity - lax shoulder
deformity of joint
Congenital deformities of the G-H joint
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
Infection
destroy articular spaces and destroy joint
better tx infections quickly
eliminate the possibility of this joint becoming post-infection
Physical findings of G-H instability
asymmetry weakness decreased functional ROM palpatory hypermobility TESTS!!!!!!
What are tests for G-H instability
APPREHENSION TEST
RELOCATION TEST- pop it back in
ANTERIOR DRAW TEST
Weakness of G-H joint
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
Decreased functional ROM at G-H joint
won’t have the ability to move the arm - feels like you would dislocate that arm
Objective testing for G-H instability
- X-rays - AP, exillary Y -view r lateral view)
orthogonal XR should be initial objective testing - CT scan - Hill Sachs lesions
- MRI - labral tear, bankart lesion
- Arthrogram - when you can’t do a MRI
Hill Sachs lesions
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
How do you see a Hill Sachs lesion?
CT
How do you see a bankart lesion?
MRI or arthrogram if can’t do MRI on a patient with pacemaker or other devices
Bankart lesion
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
How to Tx G-H instability?
Dont do SURGERY if Ehler’s Danlos (upper brachial plexus injury) or collagen type II defect
Tx acute G-H dislocations
Need to be put back in place !!!!
use safe technique - stimson’s technique
Surgery for G-H instability
Trauma - ACUTE
bankart lesion (fix the labrum)
CHRONIC RECURRENT DISLOCATIONS
instable shoulder (subluxed) - not yet dislocated ; tighten up the capsule and repair the glens
What are chronic recurrent dislocations of G-H?
patient will continue to dislocate unless something is done surgically
CHRONIC DISLOCATIONS DO REQUIRE SURGERY
What is the safest way to put G-H joint back in place?
Stimson’s technique
joint dislocation
Stimson’s technique
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
What is the tract-countertraction method for putting back G-H joint back into place?
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
What is an acceptable method of putting back G-H joint ?
series of movements: externally rotate and internally rotate to pop it back into place
RELOCATE THE JOINT
WHEN TO NOT PERFORM KOCHER’S METHOD?
an elderly woman who is osteoporotic because you can fx the humerus
What to do after you relocate the G-H back into place?
immobilize the joint
if first time dislocation, there is a 100% chance that redislocation is common
Redislocation of G-H joint
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
Why use sling and swathe for G-H joint?
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 !!!!!!!!!!
What is an associated pathology of the G-H joint instability?
traumatic anteroinferior glenohumeral dislocation most commonly injures the anterioinferior labrum and anteriorinferior glenohumeral ligament
TORN LABRUM
BANKART LESION
what is the redislocation rate for anterior dislocation?
100 % in adolescents with open growth plate
55-95% in 18-30 in air force academy study
Adolescents
redislocate after an anterior dislocation 100% of the time
Tendon tear
surgery is required
labrum is anchored by a screw
Complications of G-H dislocations!!!!
Redislocation
Torn glenoid labrum
Hill sachs lesion
anxillary n damage
How to surgically tx hills sachs lesion?
UNIQUE
cover the lesion wi with tissue
metal screws will be placed in
the lesion occur at the articular surface of the humerus
Which muscle is usually injured with shoulder dislocation?
Deltoid m.
Subacromial impingement (G-H)
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
common CC impingement
Painful lifting or working overhead
Other complaints due to impingement
- painful abduction of the shoulder - raying arm up
- difficulty throwing
- crepitance or catching
What is crepitance?
means grinding e.g. patient who ACHONDROMALACIA will show crepitance on rotator cuff
A patient who is a car mechanic or an electrician are likely to have painful abduction because of this…
impingement
What is a physical finding for impingement?
palpating the edge of the rotator cuff and resting ROM = pain !
Why are swimmer unique when they present with impingement?
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
What is the abnormal contact between acromion and greater tuberosity in mid-abduction?
- bursa can hyperthrophy
- 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
Hx of impingement
Over head work Muscle hypertrophy Trama to AC joint Congenital deformity !! Degenerative joint disease !!!! - impingement CAUSE COMPRESSION
Physical findings of impingement
- Difficulty lifting arm above head
- Crepitance with abduction - grinding underneath acromial process
- impingement sign
- provacative test- whether or not it’s a nerve root injury or from the shoulder itself
What is the impingement sign (physical finding)?
Passive forward flexion over 90 degree causes pain (physician flexes arm forward)
What is the hawkin’s test?
it is used in subacromial impingement
it is when you feel a grinding or crepitance when raising the arm forward
Objective testing for impingement
XR
Arthrogram
MRI
What is XR used for in impingement
Degenerative joint disease of the AC joint
Calcifications of tendon of the rotator cuff (WHITE TENDON) = CHRONIC !!!!
What is arthrogram used for in impingement?
to see soft tissue
usually normal
What does MRI show in impingement?
MUSCLE hypertrophy
congenital downsloping of the acromion
What are the congenital acromion downslopping types?
BIGLIANA CLASSIFICATION Type I - flat acromion Type II - curved acromion Type III - hooked acromion (pointed down) ****MOST common HOW TO SEE IT? CT
Tx of impingement
- Meds
- Modification of activity - don’t raise arm over the head
- PT
- Surgery
Tx impingement with meds
Oral - ibuprofen
injection - cortisone - prevent inflammation
inotophoresis
What is inotophoresis?
Take cortisone cream and put it on the skin and use electric current through the subcutaneous tissue
Get rid of the inflammation
Surgery options for impingement
acromioplasty - acromion is removed
Mumford - clavicle and acromion process
Arthroscopic decompression - take off part of acromion off
What is mumford procedure?
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
What is athroscopic decompression?
take part of the acromion process off
Dx of Rotator Cuff Tear
Partial thickness tears = incomplete tear = repetitive microtrauma
Full thickness tears - tear the tendon = either full on trauma
How does rotator cuff tears occur?
SITS = 4 muscles of the rotator cuff
impingement it enough that it can tear
- Can be caused by Wear and tear OR
- VASCULAR cause weakening and rupture
What is the common demographic for rotator cuff tears?
50 years
Usually Occur in the elder man
Watershed area of the supraspinatus - vascular injury to ROTCUFF
Undernearth the acromion bursa - has very little blood supply
The critical area of rotator cuff injury is?
the tendons that fuse and attach to the greater tuberosity
Early vs late complete tears
late tear shows resolved tendons at the ends
CC of Rotator cuff tear
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
How to test for rotator cuff tear?
DROP ARM TEST- can’t abduct arm (weakness and painful)
Hx of rotator cuff injury
microtrauma - over use
Chronic impingement -> can cause micro trauma (partial tears)
Trauma
What are the mechanisms of injury rotator cuff tears?
Microtrauma - overhead work, repeated lifting
chronic impingement - acromion downsloping
Trauma - fall, pulling and lifting (stretch tendon)
2 cause theories for rotator cuff
vascular insufficency in critical zone (supraspinatus)
micro trauma from chronic impingement
Physical findings of R-C tear
weakened and painful abduction muscle spasms !!!! DROP arm test gerber's lift off empty can
What is the GERBER’S LIFT OFF?
test R-C tear
test subscapularis m.
HAND AT OR BELOW THE SCAPULA = ATTEMPT TO LIFT HAND
Empty can tests which important m. in R-C injury?
supraspinatus
a common m. injury in R-C tear
Objective finding of R-C tear
X-ray
MRI
Arthrogram
XR will show the following in R-C tear
bony spurs (will form from tendon) and DJD
narrowing !
resorption
will show as a subluxed humerus (superiorly) = no tissue to prevent sublux
MRI will show an important R-C finding
tears bony spurs DJD narrowing resorption
Arthrogram - RC tear
contrast that spreads outside the bursa to see area
Tx of RC tears
Rest Abduction sling physical therapy modification of activity meds surgery
Tx of Incomplete RC tear
Simple traction
In surgery, a massive RC tear will show what
no muscles on top of the head of the humerus
Surgery method for RC tear impingment
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
Bracing RC after surgery
Shoulder abduction brace
Dx of Biceps tendon
Proximal
Distal
weakness in SUPINATION
CC of BC Tendon Tear
Pain - rubber band
Weakness - supination
deformity - pop eye = on the anterior forearm, a bulge will be seen
Hx of BCT tear
Lifting and supination
impingement
overuse - microtrauma
Iatrogenic- cortisone injection into the tendon (NEVER DO THIS!!!!)
How does a doctor cause BCT tear?
from cortisone injection to the biceps tendon
RUPTURE THE TENDON
Physical finding of BCT tear
Tenderness over tehe bicipital groove
popeye muscle
yerguson’s test
Yerguson’s test
Hold patients hand and feel bicipital groove as you supinate the arm
Objective finding of BCT Tear
MRI - see the muscle tear
Ultrasound
Tx of BCT tear
skillful neglect- will heal but the deformity will remain; leave it alone and monitor it
surgery
Grades of AC joint separations
1 Sprain the AC ligament
2 Tear the cap - AC ligament
3 complete tear of AC, and trapezoid and cuboid? ligament
Classifications of AC separations
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
CC of AC separation
Pain at rest and with ROM
Crepitance - grinding
palpable deformity
AC joint separation = THINK….
HOCKEY!!!!
Hx of AC separations
Trauma - common - FALL or HOCKEY
Infection - RARE
AC separation from trauma can show this
Elevated joint
but at grade 3 separation
inflammation will there
Physical finding of AC joint separation
- pain directly over AC joint = after 90 degrees AC joint rotates = ILICIT pain
- palpable deformity
- warmth
- painful ROM
AC joint function
rotation
plane = gliding joint
What is unique about taking a XR of the AC joint?
compare load-bearing vs. non-load bearing
when pt. is given weights
Objective testing of AC separation
- XR - common
- CT
- MRI
Tx of AC separation
- Skillful NEGLECT for grade 2 and below
- sling
- AC strap
- surgery if severe subluxations and dislocations
What tx method for AC separation not popular?
AC strap
Snapping scapula
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
Adhesive capsulitis AKA …. FROZEN SHOULDER SYNDROME
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
Etiology of frozen shoulder syndrome
Due to trauma
or Disuse (OLD PEOPLE)
Inflammaton of the shoulder capsule
Complication fx or dislocation of the humerus
Adhesive capsulitis AKA …. FROZEN SHOULDER SYNDROME
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
Adhesive capsulitis AKA …. FROZEN SHOULDER SYNDROME
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
Etiology of frozen shoulder syndrome
Due to trauma
or Disuse (OLD PEOPLE)
Inflammaton of the shoulder capsule
Complication fx or dislocation of the humerus
