Shoulder Flashcards
What are the stabilizing structures of the shoulder?
Glenohumeral ligaments, labrum, biceps tendon
What are the rotator cuff muscles>
Supraspinatus, subscapularis, teres minor, infraspinatus
What creates the FORCE COUPLE?
deltoid (up) and rotator cuff (in)
Spinoglenoid notch cyst
selective infraspinatus atrophy
Shoulder ___ rotators are stronger than ___ rotators. Noteable for shoulder dislocation.
internal, external
Winging of scapula
spinal accessory nerve (XI) to trapezius (lateral scapular translation due to unopposed pull of serratus anterior)
Medial wing= long thoracic nerve
5 sites of shoulder pain
rotator cuff, C-spine, biceps, labrum, AC Joint
Inspection
scapular motion, rotator cuff strength, hawkins, speeds, obriens, yergasons, ant/post glide, apprehension test
Imaging
True AP in ER, axillary or lateral
Instability view (west point, apical obl)
Clavicalular view: Zanca, AP stress
Sternoclavicular- serendipity
MRI instead of diagnostic arthroscopy
Age of patient and relative disease 20s 30s 40s older
atraumatic instability
traumatic instability
Partial cuff tear, avascular necrosis, capsulorrhaphy arthropathy
RA, frozen shoulder, rotator cuff tear, arthritis
Glenohumeral instability
disassociation of humeral head from glenoid (anterior 97%)
Abducted externally rotated
XRAYS
Reduction, immobilize, surgery?
Degree, direction, etiology, frequency
Traumatic Ant Instability
abducted externally rotated
arm tackling
Traumatic Post Instability
fall on outstretched arm
pass blocking
seizure or electrocution
Dislocation treatment
Closed Reduction- traction/countertraction with sedation and complete muscle relaxation
immobilize for 4-6 weeks
PT
Arthroscopic repair of bankart lesion
EBM for Shoulder Dislocation
Natural history- 50-90% recurrence
1st time dislocation, surgery results in less recurrence
Quality of life better with surgery
Immobilization in external rotation may prevent dislocation
SLAP tears
Superior labrum anterior to posterior
fall or jerking motion
Exam*, MRI**, arthroscopy Dx
degenerative tears: arthroscopic debridement or untreated
acute tears: arthoscopic fixation
Hill-Sachs Deformity
compression fracture of humeral head
associated with dislocation
Adhesive Capsulitis
insidious onset pain with restricted ROM
50th decade of life
may develop after injury etc but often idiopathic
generalized tenderness
marked decrease of both passive and active motion
Treatment of Adhesive capsulitis
18 month course, usually regain full ROM
prevention of trauma XRAY relief of pain (rest, moist heat, analgesia corticosteroid injection systemic steroids PT Manipulation under anesthesia
Arthritis
Types: primary, post-traumatic, rheumatoid arthritis, rotator cuff arthropathy, capsulorraphy arthropathy, avascular necrosis
Treatments
Arthritis
- Non-operative
* Operative: resectional arthroplasty, arthrodesis, total shoulder arthroplasty, reverse total shoulder arthroplasty
Rotator Cuff Pathology
Impingement, Bursitis, Partial and Complete Tear
Intrinsic and Extrinsic factors lead to rotator cuff degeneration
• Age related weakening of tendon
• Subacromial impingement
• Other environmental conditions
Subacromial Impingement
- Rest or activity modification
- NSAID
- Physical Therapy
- Injection
- Surgery
Injection for Painful Shoulder
favored over placebo, NSAIDs, PT
In young overhead athletes, rotator cuff problems and
impingement are usually the result of subtle _____ ____.
glenohumeral instability
Rotator Cuff Tear
Present in 54% of patients >60 years
- 51% become symptomatic by 3 years
- Partial tears: 20% heal, 80% progress
- Full thickness tears: do not heal spontaneously
- Can lead to irreparable tear
No sig difference in MRI, US, MRA in partial vs full thickness tear
Rotator Cuff Arthropathy
Characteristics
- Rotator cuff insufficiency
- Glenohumeral cartilage destruction
- Superior migration of humeral head
• Subchondral osteoporosis, humeral head
collapse
Treatment: injection, PT, surg debridement, reverse total shoulder
AC Joint Injury
separation of AC, direct blow, tenderness DEFORMITY
- Incomplete injuries (type I and II)
- Brief period of immobilization, ice, NSAIDS
- Return to activity in 2-3 weeks
- Dislocations (types IV, V, VI)
- Surgical treatment
- Type III Injuries
- Controversial
Type III AC Tx
higher complications in surgical tx (vs non-op)
No diff in pain and ROM
Surgery not recommended
Clavicular Fracture
ORIF Neurovasc injury Tenting of skin/open fracture Multiple trauma 20 mm shortening
Scapula Fracture
mostly non-op tx
Proximal Humerus
- Greater tuberosity: 3-5 mm displacement acceptable
- Surgical neck: malunion well tolerated
• 3 or 4 part
• “part” = 1 cm displacement or 45° angulation
• ORIF for younger patients
• Hemiarthroplasty or reverse total shoulder arthroplasty
for older patients
Cervical Spine Pathology
Dysfunction of nerve root at the cervical spine.
• Most commonly affect C7 (60%) and C6 (25%).
• Younger patients: disc
herniation affecting the exiting nerve root
• Older patients: foraminal
narrowing
Treatment: conservative
- Rest, NSAIDS, Physical Therapy, Injection
- Cervical traction
- Surgery if fails to improve after 6-8 weeks.
Treatment in older patients is more ____ while in younger patients _____.
conservative, they choose surgery earlier
