Shoulder and Elbow

Question 1

Identify the anatomical structures of the shoulder and elbow

Answer 1

ok

Question 2

Rotator Cuff Tendonitis

Answer 2

Supraspinatus tendon is most often initially involved. Impingement syndrome, characterized by overhead activity

Question 3

Physical Exam for Rotator Cuff Tendonitis

Answer 3

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.

Question 4

Rotator Cuff Tears

Answer 4

Most common at the humeral insertion site of the supraspinatus tendon

Question 5

Cause of Rotator Cuff Tears

Answer 5

Degenerative changes, microtrauma, intrinsic or extrinsic compression; acute trauma. Partial tears or full thickness tears.

Question 6

Patient Presentation with a Rotator Cuff Tear

Answer 6

Pain and weakness (overhead), deltoid insertion (referred). Insidious, more common in older population. Consistent Night pain

Question 7

Physical Exam for Rotator Cuff Tears

Answer 7

Rotator cuff weakness with external rotation, abduction and internal rotation. Tender to palpation on the rotator cuff. Positive impingement signs.

Question 8

X-rays for Rotator Cuff Tears

Answer 8

Acromial hook, Acromioclavicular joint, DJD. Superior migration of humeral head (massive tear).

Can also get: US/Arthrogram or MRI +/- contrast- very sensitive (too sensitive?)

Question 9

Treatment for Rotator Cuff Tears

Answer 9

PT, NSAIDs, Injection, Surgery (open vs. arthroscopic)

Question 10

Treatment for Bursitis

Answer 10

Activity modificiation, PT, oral antiinflammatory meds; surgery after failure of tx

Question 11

Bursitis

Answer 11

Inflammation of the subacromial bursa

Question 12

Bursitis

Answer 12

Neer impingement sign positive (impingement of the supraspinatus tendon) and improves with lidocaine

Question 13

SLAP Lesion

Answer 13

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

Question 14

Diagnosis and Treatment for a SLAP Lesion

Answer 14

Diagnostic arthroscopy remains the best means to dx SLAP definitively. Active compression test may be the most useful maneuver

Question 15

Shoulder Impingement Syndrome

Answer 15

Abnormal calcification of the CA ligament, Abnormal acromial morphology. Dynamic factors- rotator cuff dysfunction.

Question 16

Patient Presentation with Shoulder Impingement Syndrome

Answer 16

Insidious onset, pain (anterolateral shoulder, overhead, reaching behind, night, insidious)

Question 17

Physical Exam for Shoulder Impingement Syndrome

Answer 17

Tenderness over rotator cuff/greater tuberosity. Sometimes limited motion 2 degree pain. Positive for impingement signs. Strength sometimes dimished due to 2 degree pain.

Question 18

X-rays for Shoulder Impingement Syndrome

Answer 18

Acromial hook

Question 19

Treatment for Shoulder Impingement Syndrome

Answer 19

Physical therapy: rotator cuff strengthening, NSAIDs, Injection (diag + ther); Surgery- arthroscopic subacromial decompression.

Question 20

Shoulder Instability (uni- and multi directional)

Answer 20

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.

Question 21

Tests for Shoulder Instability (uni- and multi directional)

Answer 21

Anterior = apprehension test or relocation test. 
Posterior = circumduction test or Jahnke test. 
Inferior = sulcus sign

Question 22

TUBS: Shoulder Instability (uni- and multi directional)

Answer 22

caused by Traumatic event, Unidirectional, Bankart lesion associated; often requires Surgical treatment

Question 23

AMBRI: Shoulder Instability (uni- and multi directional)

Answer 23

Atraumatic, Multidirectional instability that may be Bilateral and best treated by Rehabilitation

Question 24

Adhesive Capsulitis aka:

Answer 24

Frozen Shoulder

Question 25

Cause of Adhesive Capsulitis

Answer 25

Idiopathic: endocrine (DM, hypothyroidism)

Question 26

Who is more prone to Adhesive Capsulitis

Answer 26

Diabetics and Females >40yo.

Question 27

Presentation and Exam of a patient with Adhesive Capsulitis

Answer 27

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.

Question 28

Imaging for Adhesive Capsulitis

Answer 28

Not typically helpful

Question 29

Treatment for Adhesive Capsulitis

Answer 29

THERAPY!!!! (Do specific exercises), athroscopic release, closed manipulation.

Question 30

Lateral Epicondylitis

Answer 30

Most common problem of the elbow, 80% will have symptom improvement at 1 year; “tennis elbow”. 4th and 5th decade,

Question 31

Etiology of Lateral Epicondylitis

Answer 31

chronic degenerative problem of the ECRB tendon. Common tendon to extensor muscles of hand and wrist.

Question 32

Most common site of Lateral Epicondylitis

Answer 32

Extensor carpi radialis brevis is most common site

Question 33

Patient Presentation with Lateral Epicondylitis

Answer 33

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

Question 34

Treatment of Lateral Epicondylitis

Answer 34

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.

Question 35

Medial Epicondylitis

Answer 35

3rd to 5th decade, less common than lateral epicondylitis; “golfer’s elbow”. Ulnar neuropathy present in 50%

Question 36

Etiology of Medial Epicondylitis

Answer 36

Not entirely an inflammatory disorder, more an overuse injury

Question 37

Patient Presentation with Medial Epicondylitis

Answer 37

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.

Question 38

Medial Epicondylitis

Answer 38

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

Question 39

Olecranon Bursitis

Answer 39

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.

Question 40

Diagnosis of Olecranon Bursitis

Answer 40

**Most important test is analysis of bursal fluid (22 gauge needle, take 10ml)

Question 41

Presentation and Physical Exam for Olecranon Bursitis

Answer 41

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

Question 42

Treatment of Olecranon Bursitis

Answer 42

Aseptic: Aspirate and inject cortisone if fluid is clear Septic: Antibiotics (dicloxacillin or ciprofloxacin), may repeat aspiration if needed

Question 43

Mechanism of Anterior Glenohumeral Joint Dislocation

Answer 43

> 90% of all shoulder dislocations. Determine traumatic vs atraumatic. Mechanism: abduction, forced external rotation à humeral head levers against anterior capsule

Question 44

Patient Presentation with Anterior Glenohumeral Joint Dislocation

Answer 44

Arm held at side and external rotation, humeral head prominent, check axiallary nerve, before and after CR

Question 45

Imaging for Anterior Glenohumeral Joint Dislocation

Answer 45

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

Question 46

Treatment for Anterior Glenohumeral Joint Dislocation

Answer 46

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.

Question 47

Posterior Glenohumeral Joint Dislocation

Answer 47

2-4% of dislocation, missed 60-80% of the time

Question 48

Mechanism of Posterior Glenohumeral Joint Dislocation

Answer 48

Posterior direted force in adducted, IR humerus. Also common from violent muscle contractions: seizures, electrocution injuries.

Question 49

Patient Presentation with Posterior Glenohumeral Joint Dislocation

Answer 49

Shoulder internally rotated, unable to abduct or ER

Question 50

Imaging for Posterior Glenohumeral Joint Dislocation

Answer 50

Xrays: light bulb sign (IR), empty glenoid, RIM sign (distance bt glenoid and articular surface of humerus > 6 mm), reverse Hill-Sachs

Question 51

Treatment for Posterior Glenohumeral Joint Dislocation

Answer 51

Reduction maneuer- immobilization for 4-6 weeks in extensionand external rotation

Question 52

What is the most common type of Clavicular Fracture?

Answer 52

85% midclavicular fx, distal fx (15%), proximal fx (5%).

Question 53

Cause of Clavicular Fractures

Answer 53

Falls, MVA

Question 54

Treatment for Clavicular Fractures

Answer 54

Sling vs Figure 8 brace. Neuro exam is extremely important: pulses, strength, and sensation too.

Question 55

Operative Indications for Clavicular Fractures

Answer 55

Open, skin tenting with severe displacement, certain medial and lateral fracture patterns

Question 56

Surgical Treatment for Clavicular Fractures

Answer 56

Union: 2-4 mo. (longer for smokers); X-ray every 4 weeks.

Question 57

Prevalence of Humeral Fractures

Answer 57

Proximal are 4-5% of all fractures

Question 58

Cause of Humeral Fractures

Answer 58

Bimodal distribution- high energy in younger pts; low energy falls in osteoporotic bone. Outcomes based on fracture patterns/severity: AVN, nonunion/malunions

Question 59

Most common nerve injured with Humeral Fractures

Answer 59

Axillary nerve is most common injured nerve; test light touch and pinprick

Question 60

Imaging for Humeral Fractures

Answer 60

Need AP and lateral views as well as axillary view

Question 61

Treatment of Humeral Fractures

Answer 61

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

Question 62

Treatment of Radial Head and Neck Fractures

Answer 62

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.

Question 63

Etiology of Radial Head and Neck Fractures

Answer 63

Fx most commonly involves distal metaphysis of radius (14% of all fractures). Usually from FOOSH or dislocation of elbow

Question 64

Imaging for Radial Head and Neck Fractures

Answer 64

CT for pre-op planning/MRI to r/o injuries to ligaments/cartilage

Question 65

Treatment for Radial Head and Neck Fractures

Answer 65

Influenced by pattern and bone quality. Consider age/functionality. Surgery vs cast application

Question 66

Radial Shaft Fractures

Answer 66

Nondisplaced or minimally displaced fx of the ulnar shaft are common, usually from a direct blow (nightstick fracture)

Question 67

Galeazzi Fracture

Answer 67

Distal 1/3 radius fracture PLUS distal radial joint (DRUJ) injury/dislocation

Question 68

Treatment for a Galeazzi Fracture

Answer 68

Open reduction and internal fixation of radius +/- DRUJ stabilization

Question 69

Monteggia Fracture

Answer 69

Proximal ulnar fracture with radial head dislocation/fracture

Question 70

Treatment for Monteggia Fracture

Answer 70

ORIF ulna plus closed reduction radial head or ORIF

Question 71

Cause of Radial Head Subluxation (Nursemaid's Elbow)

Answer 71

Forceful pull on childs extended/pronated arm. Annular ligament tears.

Question 72

Presentation of a patient with Radial Head Subluxation (Nursemaid's Elbow)

Answer 72

Initial pain, then resumes play but does not use affected arm. Holds at side in flexor and pronation.

Question 73

Physical Exam for Radial Head Subluxation (Nursemaid's Elbow)

Answer 73

Radial Head tenderness

Question 74

X-Rays for Radial Head Subluxation (Nursemaid's Elbow)

Answer 74

Needed but not helpful

Question 75

Treatment for Radial Head Subluxation (Nursemaid's Elbow)

Answer 75

Closed manipulation= constant slow supination, then elbow flexion. You will hear a "pop". Initial pain and then use of arm. No immobilization. Parent education.