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Clin Med II - Ortho > Shoulder > Flashcards

Shoulder Flashcards

1
Q

Joints of Shoulder

A

Glenohumeral Joint
Acromioclavicular joint
Scapulothoracic Joint
Sternoclavicular joint

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2
Q

Glenohumeral joint

A

Stability is sacrificed for mobility
Glenoid fossa (socket) is 1/4 size of the humeral head (ball)
Glenoid fossa is deepened by the labrum

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3
Q

Rotator cuff muscles and direction

A

Supraspinatus - abduction
Infraspinatus - external rotation
Teres minor - external rotation
Subscapularis - internal rotation

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4
Q

Sternoclavicular joint

A

Forms the only synovial articulation between the upper limb and the axial skeleton

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5
Q

Shoulder exam

A 
Good hx - MOI is valuable
Palpation - where is it tender
ROM - compare bil
Motor strength - compare bil
Neuro
- reflexes: biceps(C5), brachioradialis (C6), triceps (C7)
- sensation - dermatomes  
Vascular
Special tests / CSP exam - extreme diversity in the performance and interpretation of test which hinders synthesis of evidence / data
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6
Q

Anterior Shoulder Dislocation - in general

A

Most common type - 95%

Anterior capsule is stretched or torn

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7
Q

Anterior Shoulder Dislocation - cause

A

Forced abducted, externally rotated & extended arm
Forced horizontal abduction
Less frequently - a blow from the posterior aspect

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8
Q

Anterior Shoulder Dislocation - exam

A

Causes the arm to be slightly abducted and externally rotated
The acromion appears prominent
Loss of normal rounded appearance
May feel the humeral head in the anterior axilla
Perform a NV examination, paying particular attention to distal pulses and the function of the axillary N.

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9
Q

NV exam of Anterior Shoulder Dislocation

A

Loss of sensation in a “shoulder badge” distribution
Deltoid muscle weakness may also be present, but is impractical to assess during the acute injury
Some degree of axillary N. dysfunction is present in 42% of pts with an Anterior Shoulder Dislocation, but most pts recover completely w/o intervention
In many cases, dysfunction resolves with reduction

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10
Q

Anterior Shoulder Dislocation - Reduction

A

Relatively CI with fx or in elderly
Several methods - depends on clinician preference and pt’s condition
External rotation technique is most common approach
Get pre- & post-reduction radiographs!

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11
Q

Anterior Shoulder Dislocation - external rotation reduction

A

With pt’s arm adducted and the elbow flexed, the forearm is slowly and gently externally rotated
If pain or spasm is felt, the provider stops and allows the pt to relax
No longitudinal traction is necessary

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12
Q

Anterior Shoulder Dislocation - keys to successful reduction

A

Adequate pain control and muscle relaxation, in conjunction with smooth atraumatic technique
Heralded by a “clunk” as the humeral head relocates and there is a return of normal contour

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13
Q

Anterior Shoulder Dislocation - unsuccessful reduction

A

Use another technique

5-10% of cases are not reducible

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14
Q

Anterior Shoulder Dislocation - complications

A

Axillary N. Palsy - higher risk if traction technique is use
Rotator cuff tear - occurs in about 50% of pts >40yo
Hill-Sachs lesion - 35-40%
Bankart lesion - 90% in <30yo
Greater tuberosity fx - 10%

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15
Q

Hill-Sachs Lesion

A

Cortical depression of humeral head

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16
Q

Bankart Lesion

A

Labrum tear

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17
Q

Anterior Shoulder Dislocation - post reduction care

A

Immobilize
Refer to ortho
1-3 week immobilization with slow progression of ROM
Sx is indicated fro irreducible dislocations, displaced greater tuberosity fx and Bankarts that create glenohumeral instability

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18
Q

Chronic Anterior Shoulder Dislocation

A

Focus on strengthen the RC, global musculature of the shoulder and posture
If pt fails conservative methods, may require sx to tighten the capsule +/- repair the labrum
Pt may have positive apprehension sign/crank test or anterior instability with humeral head glides
Multiple ER visits - consider drug seeking

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19
Q

Capsulorraphy

A

Sx tightening of the shoulder capsule

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20
Q

Posterior Shoulder Dislocation - in general

A

Not common - 2-4% of shoulder dislocations
MOI is falling on a flexed arm or blow to anterior shoulder - often seizures
Less obvious to inspection b/c of contour of shoulder and musculature
Presents with shoulder in internal rotation and an inability to externally rotate it
Fx often accompany

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21
Q

Posterior Shoulder Dislocation - imaging

A

X-rays are more discrete - up to 50% are missed

An axillary view is a preferred view for dx

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22
Q

Inferior Shoulder Dislocation

A

Least common - 0.5%
MOI axial loading with arm overhead
Highest incidence of axillary nerve injury

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23
Q

Impingement syndrome - in general

A

Most common cause of shoulder pain in FP
Compromise of the subacromial space that causes microtrauma to the underlying bursa and supraspinatus tendon
This leads to local inflammation, edema, softening of the cuff, pain and decreased function
Spectrum of clinical findings, not injury to a specific structure

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24
Q

Impingement syndrome - MOI

A

Any prolonged repetitive overhead activity, muscle imbalance patterns or can be secondary to trauma

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25
Q

Acromion Morphology

A

Impingement may also be caused or exacerbated by acromion morphology and presence of spurs

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26
Q

Types of acromion morphology

A

Type I - Flat
Type II - Curved
Type III - Hooked

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27
Q

Impingement syndrome - Presentation

A

Pain to palpation of subacromial space
Pain with rotational activities, mild nocturnal aches
Positive Neer or Hawkins-Kennedy impingement tests
Painful arc of ROM from 60-120° of abduction

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28
Q

Neer’s sign

A

The pt’s arm is foricbly elevated through flexion by the examiner, causing a “jamming” of the greater tuberosity against the inferior border of the acrominon
Arm is internally rotated

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29
Q

Hawkins-Kennedy Test

A

The pt’s should should be in 90° flexion and then passively internally rotated

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30
Q

Impingement syndrome - conservative tx

A

NSAID
PT / Postural improvement
Rest from precipitating activity
Subacromial injection

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31
Q

Subacromial shoulder injection

A

1 ml Depo (or Kenalog)
2 ml lidocaine
2 ml marcaine

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32
Q

Rotator cuff tendinopathy - in general

A

A clinical syndrom characterized by tendon thickening and chronic, localized tendon pain
More commonly from overuse
Also from traumatic injuries

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33
Q

Tendinosis

A

Collagen fibers are thinner and more loosely organized
Higher amount of type III collagen
Increase in proteoglycans leading to increased water content (swelling) within the tissue
Increase in blood vessels
Cross linking of collagen (increases elasticity) leads to cell metaplasia and death

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34
Q

Rotator cuff tendinosis - RF

A 
Increased age
Increased BMI
Biomechanical abnormalities
Prior tendon lesions
Fluroquinolone use
Training errors
Poor ergonomics
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35
Q

Rotator cuff tendinosis - Presentation

A

Complain of pain with overhead activity or rotational activities - putting on a shirt, brushing hair, reaching for seat belt
May localize the pain to the lateral deltoid
Often describe pain at night, esp. when lying on the affected shoulder
Similar presentation to impingement

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36
Q

Rotator cuff tendinosis - exam

A

Chronic - may note atrophy of supraspinatus and infraspinatus muscles, a sunken appearance in the scapular fossa
May have mild strength deficits secondary to pain
Painful arc of motion

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37
Q

Rotator cuff tendinosis - imaging

A

Radiographs - when not responsive to conservative therapy
US - may be helpful to r/o tear by a skilled user
MRI - when not responsive to conservative therapy or suspicion of a RC tear

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38
Q

Rotator cuff tear - chronic

A

From impingement / tendonosis which leads to poor vascularity and degeneration of the tissue

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39
Q

Rotator cuff tear - traumatic

A

From violent pull to the arm (traction), abnormal hyper-rotation, or fall to the outstretched arm

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40
Q

Rotator cuff tear - most common site

A

Humeral insertion site of the supraspinatus tendon

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41
Q

Rotator cuff tear - presentation

A

May be full thickness or partial thickness
Classic s/s of tendonosis with considerable weakness, positive drop arm test, increased nocturnal ache, and/or referred pain to the lateral biceps region

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42
Q

Rotator cuff tear - imaging

A

MRI or XR arthrogram

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43
Q

MRI is CI in pts who

A

Work with metal
Have PM
Aneurysm clips

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44
Q

Rotator cuff tear - tx

A

Depends on pt and activity level
If tear is small or partial thickness, you can try conservative s/s tx of rest, NSAIDs, rehab, but be cautious with injections
If tear is large or full-thickness, it will require arthroscopic or mini-open sx repair to regain function and lessen pain
Rehab is 3-6 months

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45
Q

Rehab of Rotator cuff tear

A

1 month of PROM
1 month of AROM
1 month of strengthening

46
Q

Labrum anatomy

A

Fibrocartilaginous tissue surrounding the glenoid which deepens the socket and adds stability

47
Q

Labral tears - MOI

A

May be result of a traumatic episode of sublux or dislocation

May also result from repeated microtraumas of instability or atraumatic overhead injury

48
Q

SLAP

A

Superior Labrum Anterior to Posterior

49
Q

Posterior labral tear

A

Least common

50
Q

Labral tears - presentation

A 
Younger pts
Throwing athletes
Mechanical s/s
- clicking
- grinding
- catching
51
Q

Labral tears - imaging

A

Best dx with an MRI arthrogram

52
Q

Special Tests for SLAP tear

A

The Crank test

The O’Brien Test

53
Q

The Crank Test

A

Abduct the shoulder 160° while keeping the arm in the plane of the scapula
The elbow is flexed 90°
Apply an axial load to the humerus with one hand while rotating the arm internally and externally
Pain, a clicking sensation during the maneuver, or reproduction of s/s indicates a positive test

54
Q

The O’Brien Test

A

Starting position - flex should 90° with the elbow in full extension
Then pt adducts arm 10°
The pt internally rotates arm until the thumb points downward
The examiner then pushes the arm toward the floor while the pt resists by maintaining their arm in the staring position.
The maneuver is then repeated with the pt’s arm fully supinated
The test is positive if the pain or click is created in supination and reduced or eliminated in pronation

55
Q

Bicipital Tendinopathy - in general

A

May occur from teh same mechanisms as impingement syndrome
Degenerative tendinosis and rupture are usually seen in older adults
Isolated tendonitis present in young and middle ages
May also result from tsublux of the tendon out of its groove in the proximal humerus due to a rupture of the transverse ligament

56
Q

Bicipital Tendinopathy - presentation

A

Pain to the anterior portion of the humerus - may radiate into biceps region
Difficulty / pain with resisted supination

57
Q

Bicipital Tendinopathy - exam

A

Pain with palpation of proximal tendon
Might feel some swelling
May have positive Yergason test or Speed’s test

58
Q

Speed’s test

A

Resist shoulder flexion while pt’s forearm is first supinated then pronated - elbow is completely extended
Positive test is pain at bicipital groove with palpation or sublux of the tendon from the groove

59
Q

Yergason’s test

A

The pt’s elbow should be flexed to 90° pronated and stibilized against the chest
Resist supination and external rotation

60
Q

Bicipital Tendinopathy - imaging

A

X-rays are not too helpful
US is very useful
MRI reserved for more severe pathology

61
Q

Bicipital Tendinopathy - Tx

A

Tx conservatively - rest, ice, NSAIDs, topical analgesics, (skilled) injection
Persistent s/s warrant referral
Sx is biceps tenodesis or tenotomy

62
Q

Biceps tenodesis

A

Debridement of the tendon and reattachment distally and anteriorly directly into the humeral head

63
Q

Proximal Biceps Tendon Rupture

A

MOI may be a forceful flexion of the arm or eccentric loading of the biceps (carrying a couch)
Longstanding tendinosis weakens the tendon and predisposes to rupture as well
Most commonly occurs at the insertion on the glenoid labrum

64
Q

Proximal Biceps Tendon Rupture - presentation

A

Pain at insertion or at belly of muscle

Ecchymosis

65
Q

Proximal Biceps Tendon Rupture - exam

A

Perhaps a weak elbow and shoulder

“Popeye’s sign”

66
Q

Popeye’s sign

A

Bulging mass of the biceps muscle

67
Q

Proximal Biceps Tendon Rupture - imaging

A

Confirm with US or MRI
Refer ASAP for sx repair
Can be tx conservatively in older, lower-demand pts

68
Q

Acromioclavicular sprain / separation

A

Strong but vulnerable joint
Majority of cases are men in 20’s
Results in a sprain or rupture of the AC +/- coracoclavicular ligaments

69
Q

AC injury Classification - Type I

A

Minor strain to the AC ligament
Joint remains stable
Mild swelling but no deformity
Mild pain with ROM

70
Q

AC injury Classification - Type II

A

Rupture of the AC ligament
Sprain of the CC
Distal clavicle may be elevated adn can be manipulated
More swelling and pain
X-rays reveal elevation of distal clavicle
Can also get weightbearing or stress

71
Q

AC injury Classification - Type III

A 
Rupture of both AC and CC ligaments
Joint is unstable  - piano key sign
Swelling and ecchymosis
Skin my be tented
Marked tenderness of AC and CC ligaments
72
Q

AC injury - Examination

A

Crossover test

73
Q

AC injury - imaging

A

Radiographs should be performed

May add a weighted view as well

74
Q

AC injury - tx

A 
Sling
Rest
NSAIDs / pain control
Early ROM
Refer Type II / III to ortho for sx eval
75
Q

AC joint arthritis - in general

A

The AC joint typically degenerated more rapidly than most other joints in the body
Radiographic signs of degeneration are often present in asymptomatic individuals in their mid-40s
<5% of the population develops a painful AC joint
May develop more rapidly following trauma or repetitive stress

76
Q

AC joint arthritis - presentation

A

Pain may extend over the AC joint, deltoid or trapezius areas
Often worsens with activities involving overhead or cross body movement of the arm
May experience a painful grinding around the joint

77
Q

AC joint arthritis - exam

A

Palpable enlargement of the joint

Reproduction of pain with provocative maneuvers

78
Q

AC joint arthritis - imaging

A 
Radiographic findings
Joint space narrowing
Subchondral sclerosis
Subchondral cyst formation
Osteophyte formation 
The severity of a pt's s/s may not correlate with the extent of radiographic changes
79
Q

AC joint arthritis - tx

A

Begins with activity modification, rest, ice and OTC analgesics
Exercises to improve scapular retraction may be useful
Injection with corticosteroids
Refer for refractive cases - sx includes distal clavicle excision

80
Q

Glenohumeral joint OA - in general

A

A relatively uncommon cause of shoulder complaints
Trauma precedes the condition in most cases
Primary OA is more common in women >60yo

81
Q

Glenohumeral joint OA - presentation

A

Gradual development of anterior shoulder pain and stiffness
Aggravated with activity
Night pain

82
Q

Glenohumeral joint OA - exam

A

GH line joint pain +/- swelling
Decreased ROM, esp. external rotation
Crepitus

83
Q

Glenohumeral joint OA - imaging

A

Radiographs of shoulder (PA, external rotation, Y-outlet, axillary views)
Catilaginous wear
Osteophytes on the inferior portion of the humeral head
Sclerosis and flattening of the humeral head
Narrowing of inferior portion of GH articular cartilage

84
Q

Glenohumeral joint OA - tx

A

Slow progressive d/o that is usually effectively controlled with PT, NSAIDs and intra-articular injections
Refer - shoulder replacement sx is indicated for pts who have impairment of overall shoulder function that has a significant impact on ADLs or that is associated with intractable pain

85
Q

Adhesive Capsulitis

A

AKA - frozen shoulder
Painful condition characterized by significant restrictive in both active and passive ROM
Internal rotation is usually the first motion to be affected
Prolonged course (2-3y)

86
Q

Adhesive Capsulitis - E/E

A

Stiffness is caused by soft-tissue contractures, bursal and capsular adhesions, and a shortened muscle-tendon unit
Secondary to an injury, idopathic or associated with systemic d/o (DM, hypothyroidism, AI)
Common after periods of immobilization - any procedure of the thorax or shoulder girdle can put a pt at risk for Adhesive Capsulitis
More common in W >50yo

87
Q

Adhesive Capsulitis - presentation

A

Complaints of severe, nagging pain at night

Progressive global stiffness of the shoulder with significant disability restricting ADLs, work and leisure

88
Q

Adhesive Capsulitis - exam

A

Significant reductions in AROM and PROM in 2 or more planes compared with their unaffected shoulder
A firm, painful and premature end to PROM
Record the AROM and PROM
Injection Test

89
Q

Injection test for Adhesive Capsulitis

A

Give subacromial anesthetic injection.

Other conditions will improve - frozen shoulder will not

90
Q

Adhesive Capsulitis - imaging

A

A clinical dx
Some cases may have osteopenia between other patho
MRI may help differentiate between other patho - may show thickening of the joint capsule and ligaments

91
Q

Adhesive Capsulitis - Tx

A

Start with conservative - PT and home exercise program for several months
If no improvement - consider steroid injection
Refer to ortho for manipulation under anesthesia or arthroscopic capsular release and debridement

92
Q

Clavicular fx - in general

A 
MOI is falling on shoulder or blow to clavicle
Distribution
- midclavicular-69%
- distal-28%
- proximal-2.8%
93
Q

Clavicular fx - presentation

A

Pain well localized over fx site

May report snapping / cracking at time of injury

94
Q

Clavicular fx - exam

A

Often reveals visible bulge - fx or hematoma
Ecchymosis
Pain with palpation
Pain with should motion, esp. flexion
Perform neuro & lung exam
Look for any break in skin integrity
Despite the proximity of the subclavian artery and brachial plexus, these are rarely associated with neurovascular damage
May be complicated by a AC joint separation

95
Q

Clavicular fx - imaging

A

Radiograph - AP

Cephalic view of clavicle - for more subtle fx

96
Q

Clavicular fx - tx

A

Emergent referral for open fx, NV compromise skin tenting
Referral for displacement, comminution, shortening
Surgeon / pt decision making process
In the past, non-op tx was recommended even if displacement was considerable
Completely displaced fx tx non-operatively produce unsatisfactoryr results in over 30% of pts
Depending on clinical scenario, pt needs & preferences the pt and surgeion may decide that either operative repair or non-operative management is best approach.

97
Q

Proximal Humerus fx - in general

A

3rd most common fx of elderly (behind hip and distal radius)
Highest incidence in 73-87yo
3-4x more common in females

98
Q

Proximal Humerus fx - MOI

A

90% are from a fall form standing height

99
Q

Proximal Humerus fx - exam

A

Shoulder pain
Swelling
Ecchymosis
Deformity
A good NV exam
Axillary N. injury - deltoid muscle weakness and diminished sensation over the mid-deltoid region
Suprascapular N. injury - supraspinaturs and infraspinatus muscle weakness

100
Q

Proximal Humerus fx - imaging

A

GET 3 VIEWS - AP, anillary and a scapular-Y

CT with 3D reconstruction if further info needed for sx planned

101
Q

Proximal Humerus fx - Classification

A

Neer Classification - based on the anatomical relationship of the 4 major segments of the proximal humerus
1-part fx are defined as fx in which no fragments are displaced
2-part fx are defined by 1 displaced fragment
3-part fx are defined by 2 displaced fragments but the humeral head remains in contact with the glenoid
4-part fx are defined by 3 or more displaced fragments and dislocation of the articular surface from the glenoid

102
Q

Humeral Shaft fx - MOI

A 
May be direct blow
fall
MVA
Crush
If low force, think pathological
103
Q

Humeral Shaft fx - presentation

A 
Shortened extremity
Pain
Ecchymosis
Swelling
Crepitus at the Diaphysis of humerus
104
Q

Humeral Shaft fx - exam

A

Always eval the should and elbow as well

105
Q

Humeral Shaft fx - tx

A

Closed tx - reduce then function coadaptation bracing - 70-80%
Open tx - compression plate and screws, intramedullary nail, or external fixation

106
Q

Humeral Shaft fx - complications

A

11-16% incidence fo radial nerve palsy

107
Q

Radial N. palsy

A

Inability to extend wrist and digits

Sensory loss to dorsum of the hand and dorsal web space between the thumb and index finger

108
Q

Scapular fx - in general

A 
Not common
Results from high force trauma
Rarely isolated, look for concomitant injuries
- intrathroacic injuries
- clavicle fx
- rib fx
- spine fx
- spleen and liver
- blunt aortic injury
109
Q

Scapular fx - imaging

A

CT

110
Q

Scapular fx - tx

A

Conservative unless it affects the glenoid

If glenoid is affected, sx will be required if minimally displaced

111
Q

Scapular fx - complications

A

Suprascapular N. damage may be complication

Clin Med II - Ortho (13 decks)

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