Shoulder Complex - Lecture Flashcards
What are the functions of the shoulder complex?
- To position the hand in space and as a result perform fine motor actions.
- Suspend the upper extremity
- To provide a fixed point so the upper extremity can move.
- to serve as a fulcrum for arm elevation.
Describe scaption.
the “backwards windshield whipper movement” of the scapula. Lateral, superior, and anterior movement of the scapula.
Name the bones and the joints of the shoulder complex.
Bones: Humerus, clavicle, scapula
Joints: Sternoclavicular, Acromial Clavicular, Glenohumeral
Psudojoint: Scapulothoracic articulation
What strucutre in the glenohumeral joint is vital to enlarging the glenoid fossa, thereby stabilizing the GH joint?
The Labrum:
The labrum of the GH joint increases the depth of the glenoid fossa by about 50%. (think of it like a suction cup around the humeral head).
What may we expect to see with a torn labrum?
Fluid Build-up (joint effusion)
Instability
Dislocation
Describe how the scapula sits on the thorax.
30° to the frontal plane,
3° superiorly relative to the transverse plane
20° forward in the sagittal plane
Name the muscles that attach to the scapula.
- Trapezius
- Levator Scap
- Biceps Brachii
- Rhomboid Major and Minor
- Lattissmus Dorsi
- Supraspinatous
- Infraspintous
- Deltoid
- Subscapularis
- Coracobrachilais
- Pectorialis Minor
- Serratus Anterior
- Long Head of the Triceps
- Teres Major
- Teres Minor
- Omohyoid
Which of the muscles that attach to the scapula actually act on the scapula to assist with movement or support?
1) trapezius
2) rhomboids
3) levator scapulae
4) serratus anterior
5) Latissimus Dorsi
6) Pectoralis Minor
Genearlly, what is the funtion of the other muscles that attach to the scapula?
- To stabilize the humerus
2. To move the glenohumeral joint
What does morphology mean?
The shape of
What is important about the morphology of the acromion?
There are 3 difference possible shapes
- flat undersurface
- Convex undersurface
- Hooked undersurface
When does the acromion predispose a patient to shoulder pathology? Why?
When the acromion is hooked it is more likely to rub/fray one of the tendons that run underneath it.
What are the attachments of the joint capsule in the glenohumeral joint.
Laterally: to the anatomical neck of the humerus
Medially: peripheral glenoid fossa and its labrum
Describe the strength of the joint capsule in relation to the age of the patient.
Inverse relationship:
The older the pt the weaker the joint capsule
Where in the shoulder is synovial fluid normally found?
within the joint capsule from the labrum to the neck of the humerus.
What other infection is herpes zoster associated with?
chicken pox
True or False: Herpers zolster never presents unilaterally.
False: ALWAYS unilateral
What are the characteristics of herpes zolster?
Sever Neuralgic pain Chills/fever malaise and lathergy eythrema of the skin tender regional lymph nodes vesicles apear apon the dermatomes when vesicles burst they are slow to heal.
What information that can be obtained from the history will be related to Shingles?
History of Chicken pox
Current stress/ reasons for a weakened immune system.
What pathology is associated with “waiter’s tip” position?
Erb’s Palsy
AKA Erb-Duchenne Paralysis
What nerve roots are associated with Erb’s Palsy?
C5-C6: upper brachial plexus.
What causes Erb’s Palsy?
Depression of the shoulder
- birth trauma
- later in life
What characteristics do you expect to see in patients with Erb’s Palsy?
internally rotated and adducted on the effected arm
biceps reflect is lost with muscle wasting
motion and the hand and elbow are still present
waiters tip position
What nerve roots are associated with Klmpke’s Palsy?
Lower cervical (C8-T1)
What causes Klumpke-Dejerine Paralysis?
(aka Klmpke’s Palsy)
Streching injury
-forcerful pulling during birth
-strech or tearing of the inferior part of the brachial plexus
What actions/muscles are affected by Klmpe’s Palsy?
Wrist Flexion/ movements of the intrinsic muscles of the hand.
What population is Scheuermann’s disease most typically seen in?
Adolescent males (13-17)
What is the AKA for scheuermann’s disease?
Juevnile Kyphosis
What biomechanical changes are seen in Scheuermann’s Disease?
3+ vertebrae are wedged anteriorly, creating an abnormal kyphosis of the mid and lower thoracic spine
What disorders are patients with scheuermann’s disease predisposed to?
Thoracic disc herniation
degenerative changes
Radiographic features of Juevinale Kyphosis?
Anterior Vertebral wedging
irregular vertebral endplates
loss of intervertebral disc hight
Etiology of Scheuermann’s Disease?
Idopathic
What congenital abnormality is characterized by a partially undescended scapula?
Sprengel’s Deformity
When does Sprengel’s Deformity develop?
Before the 3rd month of skeletal development
What would you expect to see upon examination of a patient with sprengel’s deformity?
Elevation of scapula
reduced ABduction of the arm
What demographic is predominately effected by sprengel’s deformity?
Females
What progression of symptoms do those with scoliosis experience?
Fatigue in the lumbar region after sitting or standing for an extended period of time. Fatigues will be followed by muscular backaches in areas of strain. Eventually pain may become persistant as the irritation to the ligaments increases.
If the scoliosis is sever the patient will often suffer from carsiovascular and pulmonary diseases in response to the reduced thoracic cage volume
What physical changes generally accompanies the lateral curvature of the spine in scoliosis?
Rotation of the vertebral bodies
What is another name for Tietze’s Syndrome?
Costochondritis
What would you expect to find upon examination of a patient with costochondritis?
Pain and Swelling over the costocartilages (onset can be gradual or sudden).
Overlying skin is red
Pain may radiate to the shoulder, neck, or arm
No x-ray findings (remember it is cartilage)
You’re patient has been suffering from Tietze’s Syndrome for a few weeks. The pain is no longer preset. Would you expect the swelling in the area to have subsided as well?
Maybe, but swelling can continue long after pain and tenderness subside.
What in the patients history be related to/the cause of Tietze’s syndrome?
Direct Trauma
Upper respiratory infections - coughing attacks
What is the AKA for frozen shoulder?
Adhesive Capsulitis
What is frozen shoulder?
and inflammation of the synovial layers causing an outpouring of secretion of exudate, which contains proteins. The microscopic fibers attach from adjacent synovial layers, which then multiply, thicken, and shorten.
What motion is lost in Adhesive Capsulitis?
Glenohumeral motion - all ABduction will come from scapulothoracic motion.
What complications may accompany frozen shoulder?
Complete ankolosing (or fusion) of the joint Muscular Atrophy (from disuse)
What demographic is most at risk for Adhesive Capsulitis?
Men 50-60
Women 40-50
How do patients with Frozen shoulder describe the pain?
Deep boring, even at rest or during sleep. Patient will be prevented from sleeping on the effected side.
This is usually a sign of cancer. To help distinguish look for the shoulder girdle dysfunction vs general pain/dysfunction .
What muscle is typically involved in scapular winging? What may have happened to weaken that muscle?
Serratus Anterior
Could be: damage to the long thoracic nerve (direct trauma to the side of the neck at the base of the cervical vertebrae), there could be an injury (stretching during heavy lifting), there could have been a surgical complication (most often seen with a masectomy), etc.
What do we expect to see upon inspection of a patient with scapular winging?
The medial boarder of the scapula is sitting abnormally posterior.
What muscle is involved in scapular flaring?
Rhomboids Major and Minor
What do we expect to see upon inspection of a patient with scapular flaring?
The inferior border of the angle is sitting abnormally laterally.
What ligament prevents the separation of the AC Joint?
Coracoacromial ligament
How many heads does the Coracoacromial ligament have?
2 heads
What are the boarders of the Coracoacromial arch?
Anterior Inferior Acromion
Coracoacromial ligament
Inferior Surface of the AC joint
What are the AKAs for the Coracoacromial Arch?
Subacromial Space
Suprahumeral Space
In what position/motion is the Suprahumeral space smallest?
ABduction (specifically 60-120 degrees) with internal rotation of the humers (reaching overhead with the palm facing AWAY from the body)
What causes the Subacromial space to decrease when the arm is ABducted and internally rotated?
The greater tuberosity of the humerous moves into that space, significantly decreasing the available area for the tendons and bursa.
Specifically, how does the rotation of the humurs effect the tendon of supraspinatous?
If the arm is elevated while internally rotated,
the supraspinatus tendon passes under the
coracoacromial ligament, whereas if the arm is
externally rotated, the tendon passes under the
acromion itself
What passes though the suprahumeral space?
long head of the biceps tendon Supraspinatous upper margin of Infraspinatous upper margin of subscapularis upper margin of the subaccromion and subdeltoid bursas
What abnormalities can narrow the subacromial space?
Muscle imbalances (impingment syndrome) Inflamation of the bursas
True or False: Subaccromial bursitis and subdeltoid bursitis will not have a significant effect on each other or on the tendons in the region.
FALSE FALSE FALSE
The 2 bursas are actually connected by a small network of capillaries so inflammation in one can lead directly to inflammation in the other.
When these are inflamed they will further decrease space in the suprahumeral space, which will increase the wear and tear that the tendons of the region (especially supraspinatous) undergo –> increasing the chances of tendonitis.
What is the difference between the GH painful arch and the AC painful arch
GH = 60-120 degrees of ABduction AC = 170-180degrees of ABduction (AC separation)
An older patient walks into your office. They are able to complete the arch of ABduction, but they find the whole range of motion to be painful. What disorder do you expect?
Degenerative Joint Disease (DJD)
AKA Osteoarthritis
What is impingement syndrome?
pain in subacromial space when the humerus is elevated or internally rotated.
Why?
During humeral flexion, the supraspinatus tendon (ans sometimes infraspinatous) and bursa become entrapped between the anteroinferior corner of the acromion (and coracoacromial ligament) and
the greater tuberosity.
How is impingement syndrome related to bicipital tendonitis?
If supraspinatous cannot assist in raising the are at the beginning of humerual ABduction, the biceps will try to compensate. This abnormal work load placed on the biceps will lead to tendonitis and possibly rupture of the tendon.
The effect is even greater if the infraspinatous tendon is impinged as well.
What condition does impingement syndrome precipitate?
Rotator cuff tears - especially of supraspinatous.
Where is the hypovascular zone of the suprahumeral space located?
Just before (proximal to) the supraspinatous insertion
What clinical findings do you expect to see with impingement syndrome?
pain will often become worse at night, as the subacromial bursa becomes hyperemic (increase blood supply) after activity or use.
Test to evaluate impingement syndrom?
Impingement Sign Apply's Abbot-Sanders Yergoson's Speed Test
What structures do the subacromial bursa adhere to?
Deltoid: superiorly
Rotator Cuff: inferiorly
Cancer, Frozen Shoulder, and Impingment sign all present as pain at night. How can you distingus between them?
Cancer: Diffuse pain - especially upon palpation their will be pain because of the increased rate of cellular turn over
Frozen Shoulder: XXXX need to ask/email.
Impingement: Localized pain with edema present. Pain will be worse in overuse situation
What is an incidental finding?
When information other than what you are testing for is uncovered.
What nerve root does the supply to the AC joint originate from?
C4
Where does the majority of the sympathetic innervation to the shoulder region arise from?
T2-T8
What disease process presents with a flat or atrophied hand?
Klumpke’s Palsy
Name the major vascular supply to the shoulder.
Rotator Cuff: the thoracoacromial, suprahumeral, and subscapular arteries
Biceps Brachii - Brachial Artery
What is the close-packed position of the glenohumeral joint?
90° of glenohumeral abduction and full external
rotation; or full abduction and external rotation,
depending on the source
What is the open-packed position of the glenohumeral joint?
55° of semiabduction and 30° of horizontal adduction
If my patient is injured when their arm is at 90 degree’s of GH ABduction and full external rotation, what type of injury would I expect to occur?
Fraction/dislocation
If my patient is injured when their arm is at 55 degrees of semiabduction and 30 degrees of horizontal adduction, what type of injury would I expect?
sprain/strain.
What are the main classifications of shoulder girdle muscles?
scapular pivoters,
humeral propellers,
humeral positioners,
shoulder protectors
What muscles are the Scapular pivoters?
trapezius, serratus anterior, levator scapulae, & rhomboids
major and minor
What joint do the scapular pivioters work at?
The Scapulotheracic articulation.
Which muscles are humeral propellers?
Lats
Teres Major
Pec Major
Pec MInor
Which muscles are humeral positioners?
All three parts of the Deltoid
Which muscles are shoulder protectors?
The rotator cuff muscles: Supraspinatous Infraspinatous Teres Minor Subscapularis
And Biceps brachii
What is the scapulohermal rhythm?
the combined movements in the scapula and humerus during elevation of the arm.
What is the scapulaohumeral ratio?
2:1 at the GH: scupla.
That means that to get to the full 180 degrees of abduction the GH is responsible for about 120 degrees and the scapula is responsible for about 60 degrees
What is reverse Reverse Scapulohumeral
rhythm?
The scapula moves more than the humeras during ABduction.
What does Reverse Scapulohumeral
rhythm look like? What condition is associated with reverse scapulohermal rhythm?
The patient will hike the shoulder up to raise the arm. This is associated with Frozen shoulder (AKA adhesive capuslitis)
What muscles are responsible for the upward rotation of the scapula during the first 30 degrees of ABduction?
Traps and Serratus Anterior
How many forced couples are involved in the upward rotation of the scapula at the beginning of ABduction?
2
1: upper traps + upper serratus ant
2: lower traps + lower serratus ant
What are the 3 possible causes of shoulder girdle dysfunction (assuming systemic/orthopedic causes have been ruled out)?
Comprimise of:
- Passive restraint components of the shoulder girdle
- neuromuscular systems control of shoulder girdle motion
- one or more of the neighboring joints that contribute to the shoulder girdle
What are the most common complants associated with shoulder pathologies?
pain instability stiffness deformity locking swelling
What does MOI stand for?
Mechanism of injury
What does FOOSH stand for?
Falling on an outstretched hand
What disorders are commonly associated with overhead repetitive motion?
subacromial bursitis
impingement
syndromes
rotator cuff problems
What disorders are assciated with FOOSH injuries?
sprain/strains, A/C separation clavicular fractures G/H fx dislocations
What disorders are associated with falling on the tip of the shoulder?
AC joint seperation
What direction does the GH joint normally dislocated?
Anterior and inferior (about 95% of all GH dislocations move in this direction).
Why does the GH joint normally dislocated in the way that is does?
An AP force will move though the GH joint to the scapula, where the scapula stops the force and sends it back in the opposite direction. That change of direction in force pushes the head of the humerus anterior and inferior.
Your patient is 23 years old and has a history of GH dislocations. What is the likelyhood that he will dislocated the GH joint again?
<95% recurrence rate when the first dislocation occurs in patients 25 and younger.
What is a complication of recurrent dislocation?
Degenerative arthritis
With each dislocation the ligeaments will waken and pull on the bones with more force leading to DJD
What is the Ruler of Hamilton describing?
The “squaring off” appearance of the shoulders after anterior dislocation. A straight edge will be able to rest simultaneously on the accromial tip and the lateral epicondyle of the elbow. This is possible because with the hummerus out of the socket we can see more of the accromiaon than we shoulder be about to
Your patient has a noticeable bump on the shoulder, approximately at the location of the acromion. What are you concerned may have happened?
Grade 3 AC joint seperation.
What are the symptoms associated with AC joint seperation?
Tenderness Pain Swelling A noticeable bump Bruising
Symptoms vary between grades. Anything higher than a grade 2 and you are legally requires to refer out.
What are the signs associated with a clavicular fracture?
FOOSH injury or a fall or blow to the point of the shoulder
difficulty elevating the arm past 60 degrees
Deformity observable
Horizontal adduction is painful
X-ray confirmation
Where does the clavical typically fracture?
Where the medial 2/3 meet the lateral 1/3. The fewest muscles overlap in this space.
In what situations should we as DCs be particularly worried that the shoulder problems are not strictly orthopedic in nature?
insidious (graudual/subtle onset) onset of symptoms,
complaints of numbness or paresthesia in the upper extremity
What are some insidious causes of shoulder pain?
RA lupus gallbladder liver disease chronic respiratory conditions cardiovascular conditions
What joint loses motion in Frozen Shoulder?
GH motion
Where should the scapula normally sit?
Medial Boarder: 5-9cm lateral to the thoracic SP
Spine of the scapula: level of T3 sp
Inferior angle: T7 sp (ur) T6 sp (laying down)
What muscles of the shoulder complex are prone to tightness?
Upper Trapezius Levator scapulae Pectoralis Major and Minor Upper Cervical Extensors SCM Scalenes Teres Major and Minor
Which muscles of the shoulder complex are prone to inactivity/lengthening?
Middle & Lower Trapezius Rhomboids Serratus Anterior Deep Neck Flexors Subscapularis Supra and Infraspinatus
