Shoulder and Elbow Flashcards
Identify the anatomical structures of the shoulder and elbow
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Rotator Cuff Tendonitis
Supraspinatus tendon is most often initially involved. Impingement syndrome, characterized by overhead activity
Physical Exam for Rotator Cuff Tendonitis
Pt may occasionally be awakened by pain at night. Active ROM is limited by pain; no atrophy present; passive ROM shows mild weakness. Neer impingement sign positive and improves with lidocaine.
Rotator Cuff Tears
Most common at the humeral insertion site of the supraspinatus tendon
Cause of Rotator Cuff Tears
Degenerative changes, microtrauma, intrinsic or extrinsic compression; acute trauma. Partial tears or full thickness tears.
Patient Presentation with a Rotator Cuff Tear
Pain and weakness (overhead), deltoid insertion (referred). Insidious, more common in older population. Consistent Night pain
Physical Exam for Rotator Cuff Tears
Rotator cuff weakness with external rotation, abduction and internal rotation. Tender to palpation on the rotator cuff. Positive impingement signs.
X-rays for Rotator Cuff Tears
Acromial hook, Acromioclavicular joint, DJD. Superior migration of humeral head (massive tear).
Can also get: US/Arthrogram or MRI +/- contrast- very sensitive (too sensitive?)
Treatment for Rotator Cuff Tears
PT, NSAIDs, Injection, Surgery (open vs. arthroscopic)
Treatment for Bursitis
Activity modificiation, PT, oral antiinflammatory meds; surgery after failure of tx
Bursitis
Inflammation of the subacromial bursa
Bursitis
Neer impingement sign positive (impingement of the supraspinatus tendon) and improves with lidocaine
SLAP Lesion
5-7% of first time dislocators, O’Brien test: + test if pain is worse when thumb is down. Superior labrum anterior posterior lesions = origin of long head of biceps brachii and superior capsulolabral structures. Type II most common
Diagnosis and Treatment for a SLAP Lesion
Diagnostic arthroscopy remains the best means to dx SLAP definitively. Active compression test may be the most useful maneuver
Shoulder Impingement Syndrome
Abnormal calcification of the CA ligament, Abnormal acromial morphology. Dynamic factors- rotator cuff dysfunction.
Patient Presentation with Shoulder Impingement Syndrome
Insidious onset, pain (anterolateral shoulder, overhead, reaching behind, night, insidious)
Physical Exam for Shoulder Impingement Syndrome
Tenderness over rotator cuff/greater tuberosity. Sometimes limited motion 2 degree pain. Positive for impingement signs. Strength sometimes dimished due to 2 degree pain.
X-rays for Shoulder Impingement Syndrome
Acromial hook
Treatment for Shoulder Impingement Syndrome
Physical therapy: rotator cuff strengthening, NSAIDs, Injection (diag + ther); Surgery- arthroscopic subacromial decompression.
Shoulder Instability (uni- and multi directional)
Test anterior, posterior and inferior instability. Multidirectional = positive sulcus sign. Classification based on direction of instability that elicits symptoms and presence or absence of hyperlaxity.
Tests for Shoulder Instability (uni- and multi directional)
Anterior = apprehension test or relocation test. Posterior = circumduction test or Jahnke test. Inferior = sulcus sign
TUBS: Shoulder Instability (uni- and multi directional)
caused by Traumatic event, Unidirectional, Bankart lesion associated; often requires Surgical treatment
AMBRI: Shoulder Instability (uni- and multi directional)
Atraumatic, Multidirectional instability that may be Bilateral and best treated by Rehabilitation
Adhesive Capsulitis aka:
Frozen Shoulder
Cause of Adhesive Capsulitis
Idiopathic: endocrine (DM, hypothyroidism)
Who is more prone to Adhesive Capsulitis
Diabetics and Females >40yo.
Presentation and Exam of a patient with Adhesive Capsulitis
Global, mostly anterior pain. Pain with any motion, especially sudden movements.
Active = passive ROM. Shoulder stiffness, painful, significant restriction in both active and passive ROM
Articular surfaces are normal and joint is stable, yet there is restricted ROM. Painful External Rotation.
Imaging for Adhesive Capsulitis
Not typically helpful
Treatment for Adhesive Capsulitis
THERAPY!!!! (Do specific exercises), athroscopic release, closed manipulation.
Lateral Epicondylitis
Most common problem of the elbow, 80% will have symptom improvement at 1 year; “tennis elbow”. 4th and 5th decade,
Etiology of Lateral Epicondylitis
chronic degenerative problem of the ECRB tendon. Common tendon to extensor muscles of hand and wrist.
Most common site of Lateral Epicondylitis
Extensor carpi radialis brevis is most common site
Patient Presentation with Lateral Epicondylitis
Chronic, bothersome pain, tenderness at lateral humeral epicondyle, pain with extension of wrist against resistance. Tender slightly anterior and distal to the lateral epicondyle, pain with resisted wrist extension; resisted 3rd MCP extension = pain
Treatment of Lateral Epicondylitis
Non-op TX: NSAIDs, cortisone injections, orthotics, shockwave/laser/sclerotherapy, PRP, trephinatino, PT
Sx: failure of conservative tx, > 90% good to excellent result
TX: tennis elbow band, exercises, injection of local anesthetic and cortisone.
Medial Epicondylitis
3rd to 5th decade, less common than lateral epicondylitis; “golfer’s elbow”. Ulnar neuropathy present in 50%
Etiology of Medial Epicondylitis
Not entirely an inflammatory disorder, more an overuse injury
Patient Presentation with Medial Epicondylitis
Common flexor origin, possibly with ulnar nerve compression. Medial elbow pain with activity, esp pronation. Tenderness over anterior aspect of the medial epicondyle or just distal in the flexor pronator mass, resisted pronation tenderness, resisted wrist volar flexion, ROM normal.
Medial Epicondylitis
Non-op TX: NSAIDs, cortisone injection, wrist splint, PT after rest and discomfor decreases
SX: failed conservative tx, medial epicondylar debridement, ulnar nerve decompression/transposition, usually good to excellent results
Olecranon Bursitis
Swelling and inflammation of olecranon bursa may result from trauma or may be associated with RA or gouty arthritis. Majority of cases are aseptic (three groups: idiopathic, traumatic and crystal induced). Patients are likely to be in fourth to sixth decades of life. Patients may have jobs involving repetitive elbow motion (mining, gardening and mechanical work). Swelling is superficial to olecranon process.
Diagnosis of Olecranon Bursitis
**Most important test is analysis of bursal fluid (22 gauge needle, take 10ml)
Presentation and Physical Exam for Olecranon Bursitis
Patient usually report direct blow to area or a hx of repetitive trauma. Localized bursal swelling and fluctuance over dorsal aspect of elbow. Fluid levels vary from a few mL to 40mL. Pts usually have painless ROM. Need to r/o fracture, infection and gout. Aspiration is indicated in pts on initial presentation
Treatment of Olecranon Bursitis
Aseptic: Aspirate and inject cortisone if fluid is clear
Septic: Antibiotics (dicloxacillin or ciprofloxacin), may repeat aspiration if needed
Mechanism of Anterior Glenohumeral Joint Dislocation
> 90% of all shoulder dislocations. Determine traumatic vs atraumatic. Mechanism: abduction, forced external rotation à humeral head levers against anterior capsule
Patient Presentation with Anterior Glenohumeral Joint Dislocation
Arm held at side and external rotation, humeral head prominent, check axiallary nerve, before and after CR
Imaging for Anterior Glenohumeral Joint Dislocation
Xray: axiallary lateral most importatnt, esp post reduction. May need MRI to evaluate labrum and cuff after reduction. CT sensitive for glenoid and humeral bone loss
Treatment for Anterior Glenohumeral Joint Dislocation
TX in a sling, return to activity in 10 days. Surgery for first time dislocators in < 20, active. > 90% chance of recurrence.
Reduction maneuvers: conscious sedation, intra-articular lidocaine.
Posterior Glenohumeral Joint Dislocation
2-4% of dislocation, missed 60-80% of the time
Mechanism of Posterior Glenohumeral Joint Dislocation
Posterior direted force in adducted, IR humerus. Also common from violent muscle contractions: seizures, electrocution injuries.
Patient Presentation with Posterior Glenohumeral Joint Dislocation
Shoulder internally rotated, unable to abduct or ER
Imaging for Posterior Glenohumeral Joint Dislocation
Xrays: light bulb sign (IR), empty glenoid, RIM sign (distance bt glenoid and articular surface of humerus > 6 mm), reverse Hill-Sachs
Treatment for Posterior Glenohumeral Joint Dislocation
Reduction maneuer- immobilization for 4-6 weeks in extensionand external rotation
What is the most common type of Clavicular Fracture?
85% midclavicular fx, distal fx (15%), proximal fx (5%).
Cause of Clavicular Fractures
Falls, MVA
Treatment for Clavicular Fractures
Sling vs Figure 8 brace. Neuro exam is extremely important: pulses, strength, and sensation too.
Operative Indications for Clavicular Fractures
Open, skin tenting with severe displacement, certain medial and lateral fracture patterns
Surgical Treatment for Clavicular Fractures
Union: 2-4 mo. (longer for smokers); X-ray every 4 weeks.
Prevalence of Humeral Fractures
Proximal are 4-5% of all fractures
Cause of Humeral Fractures
Bimodal distribution- high energy in younger pts; low energy falls in osteoporotic bone. Outcomes based on fracture patterns/severity: AVN, nonunion/malunions
Most common nerve injured with Humeral Fractures
Axillary nerve is most common injured nerve; test light touch and pinprick
Imaging for Humeral Fractures
Need AP and lateral views as well as axillary view
Treatment of Humeral Fractures
Most treated non-op: sling, PT after short immobilization, will often have residual stiffness, pain until callus formation. ORIF in younger pts; ORIF vs hemiarthroplasty in older pts with comminuted fx.
Long recovery: 6 mo-1 year, all will have residual stiffness. Loss of normal contour of shoulder, tenderness, ecchymosis and crepitus on ROM
Treatment of Radial Head and Neck Fractures
Non-op: minimally displaced fractures, early ROM w/in 1 week. ORIF; younger, intra-articlar step-ff > 2 mm, block to motion. Radial head replacement: older, severe comminution.
Etiology of Radial Head and Neck Fractures
Fx most commonly involves distal metaphysis of radius (14% of all fractures). Usually from FOOSH or dislocation of elbow
Imaging for Radial Head and Neck Fractures
CT for pre-op planning/MRI to r/o injuries to ligaments/cartilage
Treatment for Radial Head and Neck Fractures
Influenced by pattern and bone quality. Consider age/functionality. Surgery vs cast application
Radial Shaft Fractures
Nondisplaced or minimally displaced fx of the ulnar shaft are common, usually from a direct blow (nightstick fracture)
Galeazzi Fracture
Distal 1/3 radius fracture PLUS distal radial joint (DRUJ) injury/dislocation
Treatment for a Galeazzi Fracture
Open reduction and internal fixation of radius +/- DRUJ stabilization
Monteggia Fracture
Proximal ulnar fracture with radial head dislocation/fracture
Treatment for Monteggia Fracture
ORIF ulna plus closed reduction radial head or ORIF
Cause of Radial Head Subluxation (Nursemaid’s Elbow)
Forceful pull on childs extended/pronated arm. Annular ligament tears.
Presentation of a patient with Radial Head Subluxation (Nursemaid’s Elbow)
Initial pain, then resumes play but does not use affected arm. Holds at side in flexor and pronation.
Physical Exam for Radial Head Subluxation (Nursemaid’s Elbow)
Radial Head tenderness
X-Rays for Radial Head Subluxation (Nursemaid’s Elbow)
Needed but not helpful
Treatment for Radial Head Subluxation (Nursemaid’s Elbow)
Closed manipulation= constant slow supination, then elbow flexion. You will hear a “pop”. Initial pain and then use of arm. No immobilization. Parent education.
