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ORTHO > SHOULDER CLAVICLE BRACHIAL DISORDERS > Flashcards

SHOULDER CLAVICLE BRACHIAL DISORDERS Flashcards

1
Q

rotator cuff muscles

A

Subscapularis (anterior)
Supraspinatus (posterior)
Infraspinatus (posterior)
Teres minor (posterior)

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2
Q

shoulder muscles

A 
Rotator Cuff Muscles = Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
Pec Major
Biceps
Deltoid
Trapezius
Serratus Anterior
Rhomboid
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3
Q

shoulder conditions

A 
Trauma
Over-use
Instability
Fractures
Age-related processes
Nerve injuries
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4
Q

AC SEPARATION / AC JOINT DISLOCATION / SHOULDER SEPARATION

A
  • Typically as a result of falling directly on the tip of the shoulder; direct blow to adducted shoulder
  • Acromioclavicular joint separation (possibly along with coracoclavicular joint); due to sprain or actual rupture
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5
Q

grades I-III of AC separation

A

Grade I = AC ligament sprain; have a normal CXR

Grade II = AC ligament rupture & CC ligament sprain (Coracoclavicular ligament); have slight widening on CXR

Grade III = AC & CC ligament rupture; have significant widening on CXR

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6
Q

AC ligament rupture & CC ligament sprain (Coracoclavicular ligament); have slight widening on CXR

A

grade II AC separation

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7
Q

AC & CC ligament rupture; have significant widening on CXR

A

grade III AC separation

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8
Q

AC ligament sprain; have a normal CXR

A

grade I AC separation

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9
Q

CLINICAL PRESENTATION OF AC JOINT SEPARATION

A
  • pain with lifting arm & unable to lift arm @ shoulder
  • tenderness at the AC joint
  • may or may not have a deformity at the AC joint
  • pain with ADDUCTION of the shoulder (putting arm back down)
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10
Q

what tests are positive with AC separation

A

+ cross arm test

+ Paxinos test

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11
Q

cross arm test = tests

A

AC joint disorder

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12
Q

AC Separation treatment

A
  • brief sling immobilization (x 1-2 weeks)
  • Rest, Ice, NSAIDS
  • The return to play / activity is determined by the patient’s comfort level
  • Weaver-Dunn procedure = if pain persists despite conservative management = take coracoacromial ligament to reconstruct the CC ligament
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13
Q

what is the Weaver-Dunn procedure and when is it performed

A

if pain persists despite conservative management for shoulder joint separation = take coracoacromial ligament to reconstruct the CC ligament

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14
Q

most common location for clavicular fracture

A

mid-shaft

medial clavicular fracture = uncommon

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15
Q

CLAVICLE FRACTURE MOA

A
  • Similar mechanism of injury as AC joint separation, except the energy passes through bone instead of a ligament, causing a fracture
  • mid / high energy impact to the area
  • MC in males
  • in children < 2 = suspect child abuse
  • Also rarely treated with surgery, just like AC joint separation
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16
Q

**MC fractured bone in children, adolescents, and newborns (during birth)

A

CLAVICLE

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17
Q

clinical findings of clavicular fracture

A

⦁ tenderness to palpation over clavicle fracture site

⦁ pain with adduction of the shoulder (just like with AC joint separation)

⦁ patient will be sitting with shoulders rolled forward

⦁ deformity at fracture site - possible “TENTING” of the skin

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18
Q

figure of 8 sling

A

for clavicle fracture

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19
Q

clavicle fracture treatment

A
  • Rest, Ice, NSAIDS
  • sling for comfort - figure-of-8 sling in children
  • return to activity in about 8 weeks
  • rarely treated with surgery; may be needed if significant displacement
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20
Q

what is rotator cuff tendonitis

A
  • overuse injury
  • most common in adults in 4th-5th decades of life; also seen in throwing athletes (pitchers)
  • often the result of inability to train appropriately during off season for athletes

MOA = inflammation of the cuff tendon

rotator cuff tendonitis = rotator cuff tendinopathy = rotator cuff bursitis

  • RC tendonitis = inflammation usually associated with sub-acromial bursitis

***MC rotator cuff tendon injury = Supraspinatus

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21
Q

most common tendon injured/torn in rotator cuff

A

supraspinatus

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22
Q

clinical presentation of rotator cuff tendonitis

A

⦁ development of pain after an aggravating activity, such as painting the house
⦁ pain can be insidious without specific injury
⦁ localized to the anterior lateral aspect of the shoulder
⦁ pain = worse with reaching overhead or behind the body
⦁ pain at night - difficulty sleeping
⦁ patients grab deltoid, but this is not an issue with the deltoid muscle, but that the pain is radiating down from the rotator cuff to the deltoid

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23
Q

BOARD QUESTION = shoulder pain + can’t sleep

A

rotator cuff injury!!!!!

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24
Q

supraspinatus strength test

A

empty can test

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25
Q

impingement tests for subscapular nerve / supraspinatus

A

Hawkins & Neers test

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26
Q

rotator cuff tendonitis PE

A
  • tenderness to palpation over the greater tuberosity or bicipital groove
  • full range of motion, but painful arc of motion and elevation
  • pain with resisted supraspinatus testing
  • no weakness on exam

⦁ + Hawkins test - tests impingement of subscapular nerve/supraspinatus (chicken wing)

⦁ + Neers test - tests impingement of subscapular nerve/supraspinatus (arm straight up)
- hold shoulder down on patient to prevent shrugging

⦁ + drop arm test = pain with inability to lift arm above shoulder level, and severe pain when lowering arm after shoulder is abducted

Since most common location = supraspinatus = can do empty can test = supraspinatus strength test

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27
Q

rotator cuff tendonitis treatment

A

⦁ Rest, ice, NSAIDS, maybe stop the offending activity

⦁ PT for rotator cuff strengthening exercises

⦁ can do subacromial steroid injections if not improving or if pain severe at night

  • if still not getting better = may have a rotator cuff tear instead of tendonitis
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28
Q

external rotation of shoulder with elbow bent at 90 = strengthens____________

A

infraspinatus & teres minor

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29
Q

internal rotation of shoulder with elbow bent at 90 = strengthens _______________

A

subscapularis

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30
Q

arm straight out at 30 degrees in front of you & pronated = strengthens _____________

A

supraspinatus (empty can test)

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31
Q

ROTATOR CUFF TEAR

A
  • Most commonly a degenerative process, with tears occurring as a result of breakdown of the tendon and eventual wearing out
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32
Q

MC torn rotator cuff tendon

A

Supraspinatus

then infraspinatus, then subscapularis

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33
Q

Rotator cuff tendon more commonly torn as a result of trauma

A

Subscapularis

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34
Q

rotator cuff tear = very uncommon before age

A

30

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35
Q

RISK FACTORS FOR TORN ROTATOR CUFF

A

⦁ Age
⦁ Smoking
⦁ Fall

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36
Q

main difference between rotator cuff tendonitis vs tear

A

WEAKNESS with tear

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37
Q

clinical presentation of rotator cuff tear

A

similar to rotator cuff tendonitis)

  • pain with reaching overhead
  • NIGHT PAIN
  • WEAKNESS
  • pain over anterior lateral aspect of shoulder
  • pain radiates to the deltoid insertion - so pts often holding on to their deltoid
  • pain can be insidious, or as a result of trauma, such as a fall or after lifting something
  • may have felt a pop or tearing sound at time of injury
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38
Q

CLINICAL EXAM OF ROTATOR CUFF TEAR

A
  • similar exam to tendonitis, with exception of WEAKNESS of affected rotator cuff (tendonitis = just pain, but tear = both pain + weakness)
  • FULL PASSIVE ROM, but limited active ROM (whereas tendonitis = full range of motion)

⦁ Weakness in external rotation = Infraspinatus tear
⦁ Weakness with empty can = Supraspinatus tear
⦁ Weakness with internal rotation = Subscapularis
⦁ + Neers Test
⦁ + Hawkins Test
⦁ Lift off test & Belly Compression test = tests Subscapularis
⦁ Bear Hugger Test = tests subscapularis too

Xray may have subtle findings, but most of the time = negative
- would see disruption of shenton’s line

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39
Q

internal rotation muscles

A

subscapularis + pec major

so internal rotation tests - test subscapularis tendon with rotator cuff injuries

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40
Q

treatment for rotator cuff tear

A
  • Rest, Ice, NSAIDS
  • PT for rotator cuff strengthening
  • Subacromial steroid injection
  • MRI to evaluate size of rotator cuff tear or to rule it in
  • surgical repair of rotator cuff (if severe)
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41
Q

MC tendon with calcific tendonitis

A

supraspinatus

42
Q

calcific tendonitis

A
  • deposition of calcium “hydroxyapatite” in rotator cuff tendon
  • MC tendon of calcium deposition = Supraspinatus
  • different consistency in different phases
    ⦁ During Liquid / tooth paste phase = more painful & inflammatory
    ⦁ During chalk consistency phase = more dormant, no inflammation

VERY PAINFUL - not as much with passive ROM, but extremely painful with active ROM

43
Q

clinical presentation of calcific tendonitis

A
  • can be insidious in onset, or can have sudden development of severe “white knuckle pain”
  • pain with any movement of the shoulder
  • unable to sleep due to pain
44
Q

clinical exam for calcific tendonitis

A
  • tenderness over greater tuberosity
  • limited active ROM due to pain
  • pain with firing of rotator cuff
  • full passive ROM not as painful as active ROM
  • weakness of cuff is due to pain only - NO TRUE WEAKNESS (unlike rotator cuff tear)
45
Q

calcific tendonitis treatment

A
  • NSAIDS, ice, rest
  • PT can be done to prevent stiffness, but not typically helpful
  • Subacromial steroid injection with Needling of calcium deposit (use needles to suck calcium deposits out of the tendon)
  • Surgical decompression and debridement of calcium deposit
46
Q

liquid / tooth paste phase vs chalk consistency phase of calcific tendonitis

A

⦁ During Liquid / tooth paste phase = more painful & inflammatory

⦁ During chalk consistency phase = more dormant, no inflammation

47
Q

ADHESIVE CAPSULITIS

A

= “Frozen Shoulder” = loss of motion of the shoulder as a result of tightening and shrinking of the shoulder capsule (joint capsule)

  • may follow a trauma to the shoulder
48
Q

Cause of adhesive capsulitis

A

idiopathic

  • may follow a trauma to the shoulder
49
Q

Risk factors of adhesive capsulitis

A

RISK FACTORS
⦁ Female
⦁ Diabetic
⦁ Hypothyroidism

  • usually in the 50’s+
  • think its therefore hormonally related
50
Q

3 phases of adhesive capsulitis

A

⦁ Freezing - painful
⦁ Frozen - stiff
⦁ Thawing - getting better slowly

51
Q

CLINICAL PRESENTATION OF FROZEN SHOULDER

A

⦁ insidious onset of pain & progressive loss of motion
⦁ may follow a trauma, but normally idiopathic
⦁ pain at end range of motion
⦁ night pain
⦁ can’t reach into back pocket

52
Q

CLINICAL EXAM OF ADHESIVE CAPSULITIS

A

⦁ loss of both passive & active ROM

⦁ pain at end range of motion

53
Q

TREATMENT OF ADHESIVE CAPSULITIS

A
  • PT to work on capsular stretching
  • glenohumeral steroid injection in early stages to decrease inflammation of the capsule
  • manipulation under anesthesia
  • arthroscopic capsular release - surgery
54
Q

LABRAL INJURY

A
  • injury to the soft tissue cartilage ring around the socket of the shoulder which provides stability to the shoulder
  • common in throwers as an overuse injury, or traumatic in football, wrestling, volleyball, tennis
55
Q

clinical presentation of labral injury

A
  • common complaint = “painful pop” in the shoulder
  • difficulty throwing a ball
  • mild sense of instability
56
Q

most common labral tear

A

SLAP tear = superior labral, anterior to posterior

57
Q

TEST FOR LABRAL TEARS

A

OBRIEN TEST - for SLAP tear

⦁ Obrien test will be positive for impingement (rotator cuff tendonitis / rotator cuff tear) too, but if everything else is negative (neer / hawkins / empty can etc) and positive Obrien test, and right patient demographic - young athlete = more likely Labral Tear

Obrien test = arm straight out, pronated, and adducted across body

58
Q

exam for labral injury

A
  • full range of motion
  • crepitus with internal & external rotation
  • POSITIVE OBRIEN TEST = SLAP tear
    ⦁ Obrien test will be positive for impingement (rotator cuff tendonitis / rotator cuff tear) too, but if everything else is negative (neer / hawkins / empty can etc) and positive Obrien test, and right patient demographic - young athlete = more likely Labral Tear
59
Q

treatment for labral injury

A
  • conservative - no significant time off is needed from sports
  • PT for rotator cuff strength and stabilization
  • if pain persists despite conservative measures = surgical repair
60
Q

IMPINGEMENT

A
  • Posterior impingement is common in throwers due to increased laxity to the anterior shoulder capsule during cocking phase of throwing & tightness in the back
  • most will complain of pain in the back of shoulder that is worse while throwing
  • treated with aggressive stretching program for the anterior capsule of the shoulder, and strength program for the rotator cuff
  • *Due to lax anterior capsule but tight posterior capsule - pain in back of shoulder that is worse when throwing
  • have increased external rotation, but decreased internal rotation

POSTERIOR IMPINGEMENT

  • over stretch of the anterior capsule in the cocking phase (laxity of anterior capsule - so able to hyperextend backwards)
  • pain & impingement occurs in the acceleration and deceleration phase (due to tightness of posterior capsule - hurts when moving arm forward till release)
61
Q

impingement problems due to _______ of anterior capsule and _________ of posterior capsule

A

lax anterior capsule

tight posterior capsule

62
Q

which shoulder dislocation is more common

A

anterior

63
Q

shoulder dislocation occurs most often due to

A

occurs most often due to elevation & external rotation of the shoulder (arm cocked in upward 90 degree angle, then hit)

64
Q

can occur as a result to seizure & electrocution

A

posterior dislocation (more common to get anterior dislocation, but for testing purposes - if person has a seizure or is electrocuted / tasered = posterior dislocation)

65
Q

ANTERIOR DISLOCATION = worried about ____ nerve

A

axillary

- can end up losing sensation in deltoid muscle - need to pop humerus back in asap

66
Q

**if pt has dislocated their shoulder, the pt has a

A

torn rotator cuff until proven otherwise

67
Q

CLINICAL EXAM OF ANTERIOR DISLOCATION

A

⦁ + Apprehension sign
⦁ + Relocation test
⦁ Increased anterior translation
⦁ Pain with range of motion, and guarding with reached overhead

68
Q

TREATMENT OF ANTERIOR DISLOCATION OF SHOULDER

A
  • 1st time dislocation = reduction of dislocation & early immobilization
  • PT to work on shoulder stabilization with rotator cuff strengthening
  • if continue to have recurrent dislocations = surgery
  • need to do XRAY to check for Bony Bankart (glenoid fracture) and Hillsach’s deformity
  • return to play about 4-6 weeks later; may require bracing to prevent re-dislocation
  • MRI of shoulder if 50+ to rule out rotator cuff tear
69
Q

fracture of the glenoid cavity

A

Bony Bankart

  • glenoid inferior rim fracture
70
Q

posterolateral humeral head compression fracture, typically secondary to recurrent anterior shoulder dislocations, as the humeral head comes to rest against the anteroinferior part of the glenoid.

A

Hill sachs deformity

  • compression fracture on humeral head from impact against glenoid
71
Q

with anterior dislocations = want to do xray to confirm no

A

bony bankart or hill sachs deformities

72
Q

POSTERIOR SHOULDER DISLOCATIONS

A
  • less common than anterior; remember to think seizures / electrocution
  • treated conservatively with reduction and immobilization
  • PT to work on rotator cuff strength exercising
  • bracing may help with prevention
  • recurrent dislocation = requires surgery to stabilize

Posterior dislocations = most common in football linemen due to blocking or being blocked

  • the shoulder gets forced out the back by getting struck in the shoulder, or by blocking an immovable object
  • can also occur with MVA, seizures, or electrocutions
73
Q

with anterior shoulder dislocation = must rule out

A

AXILLARY NERVE INJURY - get pinprick sensation over deltoid

74
Q

diagnosis of anterior dislocation

A

axillary & “Y” view

75
Q

appearance of posterior shoulder dislocation

A
  • arm is adducted and internally rotated

- anterior shoulder is flat, and humeral head is prominent posteriorly

76
Q

multi-joint laxity

A

SHOULDER MULTIDIRECTIONAL INSTABILITY

77
Q

SHOULDER MULTIDIRECTIONAL INSTABILITY

A
  • may have multi-joint laxity
  • report recurrent shoulder dislocations, but have never had to go to the ER to have shoulder reduced
  • will also complain of a dull ache in the shoulder

Have loose, saggy joint capsule. Can contort their arm or dislocate their arm

78
Q

SHOULDER INSTABILITY TREATMENT

A
  • aggressive PT to strengthen scapular stabilizers as well as the rotator cuff
  • surgery = last treatment option
79
Q

glenohumeral osteoarthritis isn’t as common as knee or hip OA because

A

the shoulder is a non-weight bearing joint

80
Q

risk factors for shoulder OA

A

⦁ previous trauma such as dislocation
⦁ instability issues
⦁ hereditary
⦁ heavy laborer

81
Q

CLINICAL PRESENTATION OF SHOULDER OA

A
  • insidious onset of shoulder pain - located anterior lateral or posterior
  • pain is typically achy with sharp overtones
  • loss of range of motion - may not be obvious to the patient
  • pain at end range of motion with sudden movement
82
Q

CLINICAL EXAM OF SHOULDER OA

A
  • loss of range of motion, especially external & internal rotation
  • normal strength
  • crepitus with range of motion of glenohumeral joint - “cogwheeling” (also occurs with labral tear)
  • tender over the anterior and posterior capsule of the shoulder
83
Q

SHOULDER OA TREATMENT

A

⦁ NSAIDS, Tylenol (while NSAIDS work better, tylenol = preferred initial tx in elderly with bleeding risk and mild/mod dz)
⦁ Terminal stretching to prevent further stiffness
⦁ Glucosamine / Chondroitin
⦁ Activity modification
⦁ Glenohumeral steroid injection
⦁ Total shoulder replacement

84
Q

PARSONAGE TURNER SYNDROME

A

cause unknown

  • brachial plexus neuritis or neuralgic amyotrophy - inflammation of a network of nerves that innervate the muscles of the chest / shoulders / arms = “suprascapular nerve”

may experience paralysis of affected areas for months, or in some cases, years, but recovery is usually eventually complete

85
Q

PARSONAGE TURNER SYNDROME paralyzes the ____________ nerve

A

suprascapular nerve = paralyzed

this nerve innervates supra and infraspinatus

86
Q

CLINICAL PRESENTATION OF PARSONAGE TURNER SYNDROME

A

⦁ first experience severe pain across the shoulder and upper arm

⦁ within a few hours to days = weakness, wasting (atrophy) & paralysis may affect the shoulder muscles

  • the supraspinatus and infraspinatus muscles start to atrophy - can start to feel the spine of the scapula on the back
  • can take a year or two to get back to normal strength
87
Q

CLINICAL EXAM OF PARSONAGE TURNER

A
  • atrophy of supraspinatus & infraspinatus muscles
  • significant weakness of affected muscles
  • usually non-tender
  • if in acute phase, the patient may not tolerate palpation - in extreme pain
88
Q

TREATMENT OF PARSONAGE TURNER

A

ORAL CORTICOSTEROIDS***

  • EMG or MRI studies may be helpful to exclude cervical radiculopathy, or rotator cuff tear
  • ORAL CORTICOSTEROIDS
  • neurontin
  • pain meds
  • PT
89
Q

***usually follows an upper respiratory infection (but can also occur after vaccinations)

A

PARSONAGE TURNER SYNDROME

90
Q

“popeye”

A

long head biceps rupture

91
Q

“scapular winging”

A

long thoracic nerve injury

92
Q

women are prone to _______________ with age

A

proximal humerus fractures

93
Q

injury prevention

A
  • Most overuse shoulder injuries can be prevented with strengthening and stretching programs
  • Unfortunately many of the exercises necessary to prevent shoulder injury are neglected during routine strengthening work outs and lifting programs.
94
Q

SUPRASPINATUS EXERCISES

A
  • empty can exercises with thumb down - can be performed with light dumbbells or rubber tubing
95
Q

ROTATOR CUFF EXERCISES

A
  • the rotator cuff muscles are not significantly large, and don’t carry the notoriety of other muscles of the body, such as the pec major
  • it is important to add rotator cuff strengthening programs to the daily regimen of athletes to prevent injury from occurring
96
Q

INFRASPINATUS & TERES MINOR EXERCISES

A
  • cable or rubber tubing exercises to externally rotate - with elbow at side, arm externally rotates against resistance
97
Q

strongest rotator cuff muscle

A

subscapularis

98
Q

SUBSCAPULARIS EXERCISES

A
  • strongest of the rotator cuff muscles
  • best strengthened with cables or rubber tubing
  • internal rotation
99
Q

STRETCHING PROGRAMS

A
  • remember that the shoulder needs balance; too much strength on one side may lead to instability or impingement on the other
  • stretching = key to shoulder function, yet it goes overlooked in many work out programs
100
Q

disruption of shenton’s line

A

rotator cuff tear

101
Q

cystic changes to greater tuberosity of the humerus

A

chronic rotator cuff disease

ORTHO (15 decks)

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