Shoulder and Upper arm

Question 1

Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting

Crush

Answer 1

Crush injuries are likely to result in comminuted fractures

Question 2

Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting

Direct trauma

Answer 2

Direct trauma will likely result in comminuted fractures

Question 3

Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting

Fall on outstretched hand

Answer 3

Common indirect cause of multiple fractures in the upper limb

Question 4

Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting

Axial loading or jamming

Answer 4

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Question 5

Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting

Position of arm

Answer 5

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Question 6

Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting

Compressin/distraction, varus/valgus forces

Answer 6

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Question 7

Discuss the relevance of the following areas to mechanism of injury of the shoulder in the context of the ED setting

Direction of force including position of distal joints

Answer 7

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Question 8

What key information is required to assess for red flags?

Answer 8

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Question 9

What key information is required in the setting of chronic shoulder and upper arm problems?

Answer 9

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Question 10

What key information would you ask to differentiate atraumatic shoulder/upper arm pain from non musculoskeletal causes?

Answer 10

Screening questions

1. Have you had a direct blow to your shoulder or a shoulder dislocation?
2. Have you recently used your shoulder excessively?
3. Have you had a traction injury to your arm?
4. Have you had a direct blow to the lateral chest wall?
5. Have you recently fallen on to outstretched arm?
6. Have you noticed difficulty lifting your arm or any other muscle weakness?
7. Have you been experiencing pins and needles anywhere in your body?
8. Do you experience pain that does not improve with rest?
9. If you do have pain, where is your pain?
10. Does your pain radiate into the arm?
11. Do you currently smoke or have smoked in the past?

Question 11

What key information in a patient’s past medical history is important in shoulder and upper arm problems/injuries?

Answer 11

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Question 12

What are important risk factors should be identified in a patient’s history that may indicate non musculoskeletal causes of shoulder and arm pain?

Answer 12

History of smoking. Pancoast’s tumor has the highest occurrence in men older than 50 years with a history of smoking

Question 13

What key information in a patient’s medication history is important in shoulder and upper arm problems/injuries?

Answer 13

Up to date list of medication used.
Previous adverse drug reactions
Aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs are associated with an increased risk of perioperative bleeding

Question 14

What is the relevance of determining any intervention or treatment to date?

Answer 14

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Question 15

What is the relevance of determining the compensable status or health insurance status of the patient?

Answer 15

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Question 16

What is the relevance of determining the first aid/pre hospital treatment?

Answer 16

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Question 17

What is the relevance of determining the last intake of food or fluids?

Answer 17

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Question 18

Name the vascular supply of the upper limb

Answer 18

The arterial supply to the upper limb begins as the subclavian artery. The subclavian artery travels laterally towards the axilla. At the lateral border of the first rib, the subclavian artery enters the axilla and becomes the axillary artery. The axillary artery lies deep to the pectoralis minor and is enclosed in the axillary sheath. At the lower border of the teres major muscle, the axillary artery is renamed brachial artery.
The brachial artery is the main supply of blood for the upper arm. Immediately distal to the teres major, the brachial artery gives rise to the profunda brachii, which travels with the radial nerve in the radial groove of the humerus and supplies structures in the posterior aspect of the upper arm. The brachial artery descends down the arm, passes through the cubital fossa, underneath the bicipital aponeurosis and terminates by bifurcating into the radial and ulnar arteries. Radial artery supplies the posterolateral aspect of the forearm. Ulnar artery supplies the anteromedial aspect of the forearm. It also gives rise to the anterior and posterior interosseous arteries, which supplies deeper structures in the forearm.

Question 19

How would you assess the neurovascular status of the upper limb?

Answer 19

Assessment for the signs and symptoms of neurovascular deficitis should take into consideration the classic ‘five Ps’: pain, paraesthesia, paralysis, pallor, pulses

1. Assess the patient’s level of pain using an appropriate pain scale
2. Palpate the peripheral pulses distal to the injury. Note the presence of the pulse and any inconsistencies between sides in rate and quality of the pulse
3. If the pulse is inaccessible or cannot be felt, perform a capillary refill test and the note the speed of return in seconds on the chart
4. An assessment of sensation should be made by first asking the patient if they feel any altered sensation on the affected limb. Using touch, assess sensation in each of the areas of the foot or hand ensuring all nerve distribution areas are covered. Note any altered sensation on the chart.
5. Ask the patient actively move each toe and/or finger and the ankle and/or wrist. If the patient is unable to move actively, perform a passive movement.
6. Observe the colour of the limb in comparison with the affected side noting any pale, cyanotic or mottled appearance.
7. Feel the warmth of the limb above and below the site of injury using the back of the hand and compare with the other side.
8. Inspect the limb for swelling and compare with the unaffected side.

Question 20

How do you assess the integrity of the glenohumeral joint?

Answer 20

Assess the presence of instability in the GH jt

1. Sulcus signs
2. Anterior drawer test
3. Apprehension test

Question 21

What is the relevance of any local skin changes/open wounds to the upper limb?

Answer 21

Open wounds increases the risk of infection.

Question 22

How would you differentiate shoulder/arm pain originating from the cervical spine?

Answer 22

Screening of cervical spine.

Question 23

How you would differentiate musculoskeletal shoulder pain from non musculoskeletal shoulder pain?

Answer 23

Presence of mechanical sign - clear agg/easing factors.

Presence of systemic symptoms (weight loss, fever, malaise, night sweats)

Question 24

What are the most common non musculoskeletal presentations of shoulder pain

Answer 24

Referred pain from cervical spine
TOS
Pancoast tumor

Question 25

When would you consider obtaining an X-ray for a patient with a shoulder and upper arm problem/injury?

Answer 25

Suspected fracture (visible deformity, trauma)
Following reduction of fracture/dislocation and to ensure proper positioning
Gross restriction of ROM

Question 26

When would a CT scan be indicated for a patient with a shoulder and upper arm problem/injury?

Answer 26

CT of the shoulder is usually reserved for evaluation of fracture/fracture-dislocation or for a prosthetic joint. CT can demonstrate fracture complexity, displacement and angulation. The ability to visualise images in the axial, sagittal and coronal planes and in 3D format can help in interpretation and preoperative planning. Intravenous contrast is reserved for evaluation of soft tissue masses for suspected bone tumour or accesses

Question 27

When would an MRI scan be indicated for a patient with a shoulder and upper arm problem/injury?

Answer 27

MRI is the main modality used for evaluation of the soft tissues of the shoulder, such as the rotator cuff, biceps muscles and tendons, and of the subacromial/subdeltoid bursa. Intravenous contrast is reserved for evaluation of soft tissue masses for suspected bone tumor or abcesses. MRI is also a sensitive modality for detecting subtle fractures, erosive changes of the distal clavicle, AC joint changes, morphology of the acromion, early avascular necrosis, bone marrow edema, and muscle atrophy.

MR athrography involves the intraarticular injection of a gadolinium-based contrast agent followed by MRI. MR-A is the gold standard for evaluation of shoulder instability or labral tear.

Question 28

When would blood investigations be indicated for a patient with a shoulder and upper arm problem/injury?

Answer 28

When suspecting infection, RA,

Question 29

What are other investigations that may be indicated in a patient with shoulder and upper arm pain?

Answer 29

US of the shoulder is useful in the evaulatin of the rotator cuff, biceps tendon and calcific deposits; in the measurement of subacromial space; and in detection of muscle atrophy. US is valuable in the dynamic evaluation of shoulder impingement. US can also be used to guide therapeutic injections.

Question 30

Analgesic agents

What is appropriate for pain control

Answer 30

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Question 31

Anti-inflammatory agents

Answer 31

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Question 32

Antibiotics

Answer 32

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Question 33

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the clavicle

Answer 33

Patients present with swelling and tenderness over the fracture site. Middle third fractures (most common) usually result in downward and inward slump of the involved shoulder due to loss of support. Patients will often present with the arm adducted against the chest wall and will resist motion of the extremity. If severe displacement is present that is associated with the tearing of the soft tissues, ecchymosis may be present. All clavicle fracture requires examination and documentation of the neurovascular function distal to the injury.

Childhood clavicle fractures generally require little treatment as rapid healing with remodelling and full return of function is the usual outcome. Adult clavicle fractures are associated with more serious complications and therefore require a more accurate and closer follow up to ensure a full return of function.

Management of middle third fracture: Nondisplaced fractures have intact periosteum and a sling support and ice is all that is necessary. Repeat xray is done at 1 week to ensure proper positioning. Children generally require 3-5 weeks of immobilisation whereas adults usually require 6 weeks or more. With displaced clavicle fractures, attempts at a closed reduction in the ED will not improve fracture healing or alter the alignment. Immobilisation with a sling and orthopaedic referral is recommended. The incidence of non-union (15-20%) and symptomatic mal-union (20-25%) is high. Other factors that are associated with poor outcome include comminution and shortening. Surgical fixation with either a plate or intramedullary nails improve the functional outcome in young active patients with completly displaced midshaft fractures.

Question 34

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the body of the scapula

Answer 34

Scapular fractures are relatively uncommon injuries that generally occur in patients between 40-60 years of age. The mechanisms involved is usually a direct blow over the involved area. A great deal of force is required to fracture the body of the scapula and associated injuries may complicate and mask these fractures. Associated injuries can be life threatening and include thoracic aortic injury, rib #, vertebral compression #, axillary nerve, artery, brachial plexus injury, pneumothorax

The patient will present with pain, swelling and ecchymosis over the involved area. The involved extremity will be held in adduction and the patient will resist abduction.

The ED management include sling or sling with swathe immobilisation with ice, analgesics. After approximately 2 weeks, limited activity as tolerated is advised. Significantly displaced fractures with functional impairments should be referred emergently for consideration of ORIF.

Question 35

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the neck of the scapula

Answer 35

Glenoid neck fractures: these are uncommon injuries that are often associated with humerus fractures. An anterior or posterior force directed against the shoulder is the usual MOI. Proximal humerus fractures or shoulder dislocations are often noted in conjunction with these fractures. Also an associated fracture of the ipsilateral clavicle may occur. The patient will present with the arm adducted and will resist all movement of the shoulder. Medial pressure over the lateral humerus will exacerbate patient’s pain. The ED management of non-displaced glenoid neck fracture includes sling immobilisation, ice and analgesics. Passive exercises should be started at 48 hours. With displaced glenoid neck fractures, emergent orthopaedic consultation is advised. Glenoid neck with greater than 40 degrees of angulation or 1-2cm of displacement require operative fixation. If the clavicle is also fractured, internal fixation of the clavicle should be performed as soon as possible.

Question 36

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the acromion process

Answer 36

Acromion fractures are usually the result of a direct downward blow to the shoulder. The force required is generally large and associated injuries (brachial plexus, AC joint or lateral clavicle fracutre) often complicate the management of these fractures. Superior dislocation of the shoulder may result in a superiorly displaced fracture of the acromion. Patients will present with maximal tenderness and swelling over the acromion process. Non-displaced acromion fractures can be treated with sling immobilisation. ROM exercises should be started early in the management of these fractures. Displaced fractures often require internal fixation to avoid compromise of the subacromial space. Internal fixation is necessary if both clavicle and scapula are injured together.

Question 37

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the coracoid process

Answer 37

the muscles that insert onto the coracoid process include the coracobrahialis, SHB, pec minor. The ligaments inserting on the coracoid process are the coracoacromial, coracoclavicular and coracohumeral. A direct blow to the superior point of the shoulder or violent contraction of one of the inserting muscles may result in fracture. Brachial plexus injuries, AC separation or clavicular fractures are often associated with coracoid fractures. In addition there will be pain with forced adduction and flexion at the elbow. Coracoid process fractures are treated symptomatically. The patient should be given a sling, ice, analgesics and instructions to start early motion as tolerated. Associated injuries must be excluded before DC from ED.

Question 38

Discuss the signs, symptoms and management in the ED setting of:

Dislocation of the sterno-clavicular joint

Answer 38

The SC joint is stabilised by the sternoclavicular ligament and costoclavicular ligament. Maximum motion of this joint occurs during normal internal rotation with the arm elevated just above 110 degrees. A mild sprain of the SC joint involves microscopic, incomplete ligamentous tears of the SC and the CC ligaments. A moderate sprain involves subluxation of the clavicle from its manubrial attachment and signifies complete rupture of the SC ligament and partial tear of CC ligament. A dislocation of the SC joint involves complete rupture of the SC and CC ligaments, permitting the clavicle to be removed from its manubrial attachment. This injury is rare.
The most common MOI is a force that thrusts the shoulder forward. It usually involves a tremendous force and most commonly follows a MVA or falls.

Subluxations should be treated in a broad arm sling for 2-3 weeks

Question 39

Discuss the signs, symptoms and management in the ED setting of:

Subluxation and dislocation of the acromio-clavicular joint

Answer 39

Rockwood classification system for AC dislocations:
Type 1: Partial tear of AC lig, CC lig intact. Tenderness over the AC joint, no deformity.
Type 2: Complete tear of AC lig and partial tear of CC lig. Radiograph shows partial elevation of the distal clavicle.
Type 3: Complete tear of AC and CC lig. Radiographs shows substantial elevation of distal clavicle and increased CC distance.

Type 4 injuries exist when the clavicle displaced posteriorly
Type 5 injury involve disruption of all ligaments and clavicle is displaced far superiorly
Type 6 injury, the clavicle is displaced inferiorly.

MOI: direct fall onto the point of the shoulder, FOOSH and direct blow.

Treatment for 1st & 2nd degree injuries is rest, ice and sling with early ROM.

Question 40

Discuss the signs, symptoms and management in the ED setting of:

Subluxation/dislocation of the shoulder and associated injuries

Answer 40

Anterior shoulder dislocation
MOI: usually abduction + ER of the arm which disrupts the anterior capsule and the GH ligaments.

Concomitant fractures occur in approximately 25% of cases. Factors associated with fractures include age over 40, 1st time dislocation and traumatic mechanism. When none of these features are present the clinician is comfortable with their diagnosis and prereduction radiographs can be omitted.
In evaluating the radiographs in patients with suspected anterior dislocations of the shoulder, one should look for a defect in the posterior lateral portion of the humeral head (Hill-Sacks) which is present in up to 40% of cases of anterior shoulder dislocation.

Associated injuries:
Greater tuberosity # (15%)
Glenoid rim # (5%)
Bankart lesion (90%)
RC tear (50-80%)
Brachial plexus or axillary N injury (5-15%)

Rehabilitation:
In younger patients, 3 weeks of immobilisation followed by ROM exercises (ER and AB avoided for further 3 weeks)
In older patients, 7-10 days of immobilisation followed by ROM exercises.

Question 41

Discuss the signs, symptoms and management in the ED setting of:

Rupture of the rotator cuff

Answer 41

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Question 42

Discuss the signs, symptoms and management in the ED setting of:

Chronic labral tear

Answer 42

Bankart lesion: Detachment of the anteroinferior glenoid labrum is thought to occur in upto 90% of cases of traumatic anterior instability. Despite its near-universal presence in cases of traumatic instability, soft-tissue Bankart lesions alone are not a frequent cause of recurrent instability. Rather the underlying cause is most often multifactorial with particular focus on redundancy and plastic deformation of the IGHL complex.

SLAP tears: superior labral anterior to posterior tears are common in overhead athletes probably as a result of the peel-back mechanism. The deceleration phase of the throwing motion may also produce extraphysiologic eccentric load on the biceps anchor that can result in tearing or rupture.

HAGL lesions: the humeral avulsion of the GH ligament lesion occurs when the insertion of the IGHL complex avulses or otherwise separates from the humeral neck. Although its incidence is relatively low, this injury most commonly occurs after a first-time anterior shoulder dislocation.

Question 43

Discuss the signs, symptoms and management in the ED setting of:

Degenerative tear of rotator cuff

Answer 43

Tears of the RC are more common in the elderly because of the degenerative changes that occur with advancing age, particularly after the 5th decade of life. In patients older than 60 years, full thickness RC tears occurred with a reported incidence of 28% in asymptomatic individuals. Only 25% of RC tears are symptomatic.

Question 44

Discuss the signs, symptoms and management in the ED setting of:

Rotator cuff - full and partial tear

Answer 44

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Question 45

Discuss the signs, symptoms and management in the ED setting of:

Supraspinatus tendinopathy

Answer 45

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Question 46

Discuss the signs, symptoms and management in the ED setting of:

Acute calcific tendinitis

Answer 46

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Question 47

Discuss the signs, symptoms and management in the ED setting of:

Subacromial bursitis

Answer 47

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Question 48

Discuss the signs, symptoms and management in the ED setting of:

Impingement

Answer 48

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Question 49

Discuss the signs, symptoms and management in the ED setting of:

Winging of the scapula

Answer 49

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Question 50

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the neck of the humerus

Answer 50

Anatomic neck fractures are through the area of the physis and can be divided into adult or childhood injuries. Adult injuries are rare and may be classified as nondisplaced or displaced (>1cm). Childhood injuries are generally limited to 8 to 14 year olds. MOI: FOOSH.
Swelling and tenderness to palpation will be apparent in the shoulder area. Pain will be increased with any shoulder motion. The ED management of these fractures include immobilisation is a sling, ice, analgesics and early referral. Both nondisplaced and displaced fractures will require orthopaedic referral. Emergent referral is indicated for displaced fractures because they will require open reduction in young patients or early prosthetic replacement in older patients. Anatomic neck injuries are often complicated by the development of avascular necrosis.

Surgical neck fractures may alter the angle that the humeral head makes with the shaft. The normal angle between the humeral head and the shaft is 135 degrees. Surgical neck fractures can be divided into 3 classes – one part (nondisplaced and nonangulated), two-part (angulated or displaced) or comminuted fractures.
Two mechanisms result in surgical neck fractures of the proximal humerus. The most common mechanism is indirect and is due to FOOSH. If the arm was abducted during the fall, the humerus shaft will be displaced laterally. If the arm was adducted during the fall, the humeral shaft will be displaced medially in most cases. Direct trauma may result in surgical neck fracture.

Nondisplaced surgical neck fractures may be associated with a contusion or tear of the axillary nerve. Axillary neurovascular injury and brachial plexus injuries are more common after displaced or comminuted fractures of the surgical neck.
The patient will present with tenderness and welling over the upper arm and shoulder. If on presentation, the arm is held in adduction, the incidence of brachial plexus and axillary arterial injury is low. If the patient presents with the arm abducted, the incidence of
neurovascular injury is much significant. Before the radiographic examination, document the presence of distal pulses and sensory function.
A patient with a suspected surgical neck fracture, who presents with the arm abducted, should have the extremity immobilised in the position of presentation before radiographs. These patients may have a severely displaced fracture and the adduction may result in neurovascular damage.

Management: A nondisplaced (<1cm) surgical neck fracture with less than 45 degrees is a one-part fracture. A sling is recommended mode of therapy. Ice, elevation and analgesics with hand exercises should be initiated soon after injury. Circumduction exercises should begin as soon as tolerated and be followed by elbow and shoulder passive exercises at 2-3 weeks. Shoulder motion exercises can usually be started within 3-4 weeks.
In elderly pateints with lower physical demands, significant angulation (>45 degrees) can be well tolerated as long as there is some bony contact. However, in young patients, these injuries require reduction. The ED management consists of immobilisation in a sling analgesics and emergent referral for reduction.
The ED management of displaced 2 part surgical neck fractures include sling immobilisation, ice, analgesics and emergent referral. Closed reduction under regional or general anesthesia is preferred followed by immobilisation in a sling. If the reduction is unstable, percutaneous pins and open reduction is performed.
Surgical neck fractures are associated with several significant complications: 1. Joint stiffness with adhesions can be avoided or minimised with early motion exercises 2. Malunion is common after displaced fractures 3. Myositis ossificans

Question 51

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the greater tuberosity

Answer 51

Greater tuberosity fractures are common and are seen in isolation or in approximately 15% of all shoulder dislocations. These fractures can be displaced or nondisplaced. Displacement is common due to the effect of the RC muscles. The superiorly displaced tuberosity will mechanically block abduction of the shoulder. Displaced fractures of the greater tuberosity are associated with tears of the RC.
Two mechanisms can result in grater tuberosity fractures. Compression fractures are usually result of a direct blow to the upper humerus, as during a fall. The elderly are particularly susceptible to these injuries due to atrophy and weakening of the surrounding musculature. Nondisplaced fractures usually result from a FOOSH. Displaced fractures are secondary to FOOSH with RC contraction resulting in displacement.
Neurovascular injuries are rarely associated with these fractures. Greater tuberosity fractures are commonly associated with anterior shoulder dislocations and RC tears. Both of these injuries are more common with displaced fractures.
The patient will complain of pain and swelling over the greater tuberosity. The patient will be unable to abduct the arm and will note increased pain with ER. Aslo ER of the shoulder may be inhibited if a posteriorly displaced tuberosity impinges against the posterior glenoid.
The ED management of nondisplaced fractures of the greater tuberosity consists of ice, analgesics, sling, immobilisation and early referral because of the high incidence of complications.
Displaced fractures: if associated with anterior shoulder dislocation, reduction of the dislocation often corrects the displacement of greater tuberosity and the fracture can then be managed as a nondisplaced fracture.
If displacement remains or a displaced fracture is present without a shoulder dislocation, the management of these injuries is dependent on the age and activity of the patient. Young patients require internal fixation of the fragment with repair of the torn RC. Older patients are usually not candidate for surgical repair and require ice, immobilisation in a sling. Early mobilisation in the elderly patient is essential.
Compression fractures are often complicated by impingement on the LHB resulting in chronic tenosynovitis and eventually tendon rupture. Nonunion. Myositis ossificans.

Question 52

Discuss the signs, symptoms and management in the ED setting of:

Fracture of the shaft of the humerus

Answer 52

The most common MOI is direct force usually resulting from a fall or direct blow. Typically, a direct force results in a transverse fracture. An indirect mechanism involves a fall on the elbow or outstretched arm.

On examination, shortening, obvious deformity or abnormal mobility with crepitation may be detected. It is imperative that a thorough neurovascular examination accompanies the initial assessment of all humeral shaft fractures.

Humeral shaft fractures may be associated with several significant injuries including brachial artery injury, nerve injury or additional fractures to the shoulder or distal humerus.

For nondisplaced/Displaced humerus shaft fractures, coaptation splint is applied by referred early. A collar and cuff suspension should be used to support the forearm. Definitive therapy is nonoperative in most cases.
Humeral shaft factures generally take from 10-12 weeks to heal.

Question 53

Discuss the signs, symptoms and management in the ED setting of:

OA/RA/AVN of the shoulder.

Answer 53

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Question 54

Discuss the signs, symptoms and management in the ED setting of:

Thoracic outlet syndrome

Answer 54

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Question 55

Discuss the signs, symptoms and management in the ED setting of:

Adhesive capulitis

Answer 55

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Question 56

Discuss the signs, symptoms and management in the ED setting of:

Cervical/thoracic referred pain

Answer 56

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Question 57

Discuss the signs, symptoms and management in the ED setting of:

Brachial plexus neuritis

Answer 57

Brachial plexus neuropathies can occur secondary to repetitive overuse, postural syndromes and trauma. Nerves affected by such neuropathies can be of 3 categories: sensory, motor or mixed. The emphasis is on motor nerves but there is no such thing as pure motor nerve. A motor nerve carries efferent commands to the muscles but also returns with information from the muscles, joints and associated ligamentous structures. A nerve that innervates a muscle also augments the sensation from the joint on which the muscle acts. Pain produced by a motor nerve entrapment neuropathy is not well localised, is present at rest, and has a retrograde distribution. The muscles innervated can be tender to palpate, and if the neuropathy has been present for an extended time, muscle atrophy is present, although the patient may be unaware of the weakness. The greatest challenge with entrapment neuropathies is not treatment but diagnosis.
with the evaluation of new patient, the PT should conduct a thorough examination of motor and sensory function and reflexes in the area of interest. The PT should observe the area and compare both sides. The PT should palpate bilaterally along the path of the suspected nerve, looking for bone, joint or soft tissue abnormality. Local tenderness or a positive Tinel’s sign helps identify the site of nerve entrapment. Suspicion can be confirmed by electromyography or nerve conduction or both.

Question 58

Discuss the signs, symptoms and management in the ED setting of:

Supra-scapular nerve entrapment
Long thoracic nerve
Spinal accessory nerve
Axillary nerve

Answer 58

If a patient presents with weakness of shoulder abduction and cannot shrug a shoulder, the PT should suspect a nerve entrapment of the spinal accessory nerve. The patient typically has dull pain, weakness and drooping of the shoulder. The patient has paralysis of the trapezius muscle, and winging of the scapula is usually present. The spinal accessory nerve can be injured by blunt trauma to the posterior triangle of the neck or a traction injury or it can be result of cervical surgery.

Weakness of shoulder abduction and flexion should raise suspicion of a possible axillary nerve entrapment or injury. The axillary nerve arises from the posterior cord of the brachial plexus and has fibres from C5,6 nerve roots. After branching from the brachial plexus, it travels just below the shoulder joint and the nerve curves around the posterior and lateral portion of the proximal humerus to innervate the deltoid and teres minor muscles, while supplying the sensation to the lateral aspect of the upper arm. A typical axillary nerve injury is caused by trauma - either a direct blow to the shoulder or a dislocation that stretch the nerve.

Scapular winging may be due to trapezius involvement or related to serratus anterior paralysis. The serratus anterior is innervated by the long thoracic nerve after it branches from the root of C4-7. The nerve passes down the posterolateral chest wall. The nerve can be damaged by excessive use of the shoulder, prolonged traction to the nerve or trauma to the lateral chest wall. A patient with entrapment or injury of the long thoracic nerve experiences pain in the shoulder girdle, reduction in active shoulder motions caused by a loss of scapula humeral rhythm and scapular winging that becomes especially evident when doing a wall push up.

Poorly localised shoulder pain also be related to rotator cuff tear or to suprascapular nerve entrapment. The suprascapular nerve is a motor nerve and pain resulting from its irritation is deep and poorly localised. The suprascapular nerve derives from the upper trunk of the brachial plexus formed from the roots of C5 and 6

Question 59

Discuss the signs, symptoms and management in the ED setting of:

Biceps rupture

Answer 59

LHB rupture: the patient usually notices an immediate sharp pain in the region of the bicipital groove and the biceps is noted to bulge within the arm. Surgical reattachment to the bicipital groove is recommended in most active patients but repair may not be indicated for elderly patients.

Distal biceps rupture: can occur as a result of sudden eccentric load with the elbow flexed. Usually there is history of tearing sensation accompanied by pain in the region of the antecubital fossa.