Shoulder disorders & injuries Flashcards
1
Q
Scapular Fx etiology
A
- Result of HIGH ENERGY trauma
- Fall, MVA, pedestrian accident, shoulder dislocation
2
Q
Clinical presentation of a scapular fracture
A
- Patient holding arm close to their side
- Pain with movement of the upper arm
3
Q
PE for a scapular fracture
A
- Ecchymosis
- Swelling/deformity
- Tender to palpation
- Possible crepitus
- Limited ROM
- Check other systems
4
Q
Scapular Fx diagnostics
A
- X-ray
- Often these patients are not able to sit upright
- Obtain a chest & shoulder films
- CT
- Any poorly visualized fracture
- Any fracture involving the joint itself
- (glenoid fractures)
5
Q
Scapular Fx treatment
A
- Non-operative
- arm in a sling
- Early ROM as tolerated
- Scapular body fx consider admission due to pulmonary contusions
6
Q
Scapular Fx referral flags
A
- Displaced fracture >2 mm
- Glenoid fracture (articulating surface)
- Fractures of the neck of the scapula (>30 degrees angulation)
- Acromion fractures with impingement signs
7
Q
Clavicular Fx etiology
A
- Most often occurs in children and young adults
- Can result as indirect or direct trauma to the clavicle
8
Q
Most common shoulder fx in children and young adults
A
Clavicular fx
9
Q
Medial clavicle fx’s usually occur due to _____
A
anterior chest trauma
10
Q
Distal clavicular fx’s & AC joint disruption are associated with ______
A
direct blows to the distal clavicle or acromion
11
Q
Clavicular Fx presentation
A
- History of an injury
- Outstretched arm or direct impact
12
Q
Physical Examination of a clavicular fx
A
- Decreased ROM of the shoulder with pain
over Fx when palpated - Ecchymosis
- Shoulder droop or the patient will hold it
higher - Deformation, tissue tenting
- Feel gliding of the clavicle
- Crepitus possible
- Examine NEUROVASCULAR FUNCTION
13
Q
How to examine neurovascular function of a clavicular fx
A
- Distal to the fracture
- Axillary, musculocutaneous, median, ulnar, and radial nerves
- Sensation of the UE’s
- Muscle strength in the UE’s
- Reflexes: Brachioradialis, Biceps, Triceps
- Look for evidence of decreased perfusion
- Skin color changes, diminished pulses, decreased cap refill
14
Q
Clavicular Fx Diagnostic Testing
A
- X-ray
- AP view (10° cephalic tilt) for most clavicle fx’s
- CT scan
- For suspected medial clavicle fx’s
15
Q
Clavicular Fx treatment (outpatient)
A
- Most mid-shaft fx’s are nonsurgical
- Simple shoulder sling: Worry for skin breakdown, and neurovascular injury
- After ~3-4 weeks start gentle shoulder exercises.
- NSAIDs for pain
- Ice packs initially and then heat once swelling is down
- PT referral if continued decreased ROM
16
Q
When to reduce/not reduce a clavicular fracture
A
- Middle third is almost never required: Manipulation can cause neurovascular injury
- Displaced proximal or distal third fx’s requires orthopaedic referral for
reduction - Open fractures, severe displacement with skin at risk, fx’s with neurovascular
injury may require open reduction and internal fixation (ORIF) - Nonunion over 4 months = further evaluation (orthopaedics)
17
Q
When to send a clavicular fracture to surgery
A
- Displaced fx of the distal clavicle
- Any proximal clavicular fracture
- Comminuted or severely shortened overall clavicle length: >2cm if over 12 y.o.
- Open fx’s
- Neurovascular involvement
- Skin over fracture is at risk
18
Q
Clavicular Fx adverse outcomes
A
- Neurovascular complications (rare)
- Nonunion (common)
- Malunion – visual or palpable bump
- Degenerative arthritis if AC intra-articular involvement
- Surgical repair can have increased chance of:
- Infection
- Hardware issues (loosening or breaking)
- Skin and/or Neurovascular complications.
19
Q
Humeral Fx etiology
A
- Usually in children and osteoporotic patients
- High energy trauma in adults
- Fall on outstretched hand that is abducted
- Direct trauma to the proximal humerus
20
Q
Proximal Humerus Fx’s Clinical Presentation
A
- History of mechanism of injury that could potentially cause a fx
- fall, osteoporosis, blunt force trauma…
- Severe pain (even with slight movements)
- Swelling
- Find out the dominant hand – may change treatment in pts who use it for
their occupation
21
Q
Physical Examination for Proximal Humerus Fx’s
A
- Ecchymosis
- Arm may be rotated
- Neurovascular testing
- Inspect for any lacerations, contusions, or signs of an open fx
22
Q
Proximal Humerus Fx’s Diagnostic
A
- Trauma series of the shoulder
- AP, Axillary view, Scapular Y
23
Q
Proximal Humerus Fx’s treatment
A
- Minimal displacement = sling with exercise program after 3 weeks and signs of
healing - Early ROM is important to decrease chance of frozen shoulder
- PT with humeral fracture protocols your clinic has developed
24
Q
When to refer Proximal Humerus Fx’s to surgery
A
- Surgical treatment if any part is angulated >45° or >1 cm displacement
- Displacement of the greater tuberosity > 0.5cm needs surgical consult
- Any displaced 2-part fractures
- All 3 and 4-part fractures
- Any neurovascular involvement
25
The four parts of a humeral fracture being
1. Greater tuberosity
2. Lesser tuberosity
3. Humeral head
4. Humeral shaft
26
Proximal Humerus Fx’s Adverse outcomes
* Nonunion
* Malunion
* Persistent stiffness
* Dislocation of shoulder (check each time you see this fracture)
* Get an Axillary view – this will show you alignment of the humeral head
and the glenoid fossa
27
Humeral Shaft Fx’s etiology
* Result of a direct blow to the arm
* MVA, Fall, Impact sports
28
Humeral shaft fx treatment
* Usually treated non-surgically
* ~100% union
* Worry about radial nerve entrapment
29
Humeral Shaft Fx’s clinical presentation
* Severe pain and swelling
* Deformity
* Palpation often results in movement of shaft
* Radial nerve entrapment: (RARE)
* Causing radial nerve palsy
* Unable to extend the wrist or fingers
* Can have loss of posterior hand sensation
* Assess neurologic function
* Ulnar, radial, and median nerves
* Assess radial pulse
30
Humeral Shaft Fx’s Diagnostics
* AP and Lateral views of the Humerus
* Obtain the shoulder and elbow films too
31
Humeral Shaft Fx’s treatment
* 20° angulation is acceptable
* Fx’s <2 cm displacement can be splinted for a few weeks and then transitioned to a humeral fracture brace
* Brace for additional 6 weeks or until healed
* Sling the distal arm
* Encourage ROM of the elbow, wrist, and hand
32
Humeral Shaft Fx’s Surgical indications (ORIF)
* Open fractures
* Neurovascular involvement
* If the radius and ulna are also fx’d
* Displaced comminuted fractures
* > 20º angulation
* > 2cm displacement
* Nonunion > 3 months of tx
* Associated Head injury/seizures
33
Humeral Shaft Fx’s Adverse Outcomes
* Radial nerve injury (Rare)
* Stiff shoulder and/or elbow
* Splint irritating skin
* Nonunion
34
Subacromial Impingement Syndrome etiology
* Due to repetitive movements
* Common in athletes with overhead activities
* Overhead work related activities
35
Subacromial Impingement Syndrome epidemiology
Mostly seen in middle age
36
Subacromial Impingement Syndrome presentation
* Gradual onset
* Anterolateral aspect of the shoulder
* Overhead movement increases pain
* Pain at night, can’t sleep on affected side
37
Subacromial Impingement Syndrome PE
* Palpation over distal acromion and greater tuberosity
* Worse pain at 90 -120° of abduction of the shoulder
* Neer Impingement sign
* Hawkins Impingement sign
* Testing supraspinatus strength is also important
* Jobe/empty can test
* Sulcus sign
38
_______: Have pt lock elbow straight, internally rotate arm. Examiner grabs wrist and flexes the shoulder. Free hand is on scapula to stabilize it. The greater tuberosity can compress against the anterior acromion, what sign is this?
Neer Impingement sign
39
_______- Reinforces Neer testing. Shoulder is flexed to 90°, Elbow at 90°, now ratchet the arm internally, what sign is this?
Hawkins Impingement sign
40
Sulcus sign indicates _____
Muscle atrophy of the posterior and superior aspect indicates a cuff tear
41
Subacromial Impingement Syndrome diagnostic
* AP and Axillary x-rays are usually
normal due to these conditions being
soft tissue
* Clues of narrowing space between
humeral head and inferior aspect of
the acromion on AP films
42
Subacromial Impingement Syndrome treatment
* NSAIDS and rest
* Stretching program
* Posterior capsular stretching
* Home PT program for ~ 6 weeks if showing consistent
improvement
* Formal PT if treatment not helping within 3-4 weeks
* Subacromial corticosteroid injection if pt is continuing to have
discomfort, or not improving after 6 weeks of either PT
program
43
When to refer a Subacromial Impingement Syndrome
* Substantial weakness of the rotator cuff
* Significant weakness with empty can sign. Not just pain
* Failure of 2-3 months of PT
44
Adverse outcomes of a Subacromial Impingement Syndrome
* NSAID dyspepsia/ ulceration/ hepatic issues
* Tear of rotator cuff or biceps tendon
* Can happen with repeat injections
* Try not to give an injections sooner than 12 weeks apart
45
Adhesive Capsulitis aka
Frozen Shoulder
46
Adhesive Capsulitis (Frozen Shoulder)
*Idiopathic loss of both active and passive ROM
*Different from post traumatic shoulder stiffness
* 40-60 year-olds at highest risk
* More frequent in women
* Type 1 DM is greatest risk factor
47
Type 1 DM is greatest risk factor for ______
Adhesive Capsulitis (Frozen Shoulder)
48
Adhesive Capsulitis (Frozen Shoulder) clinical presentation
* Freezing Phase: Pain with movement of the shoulder, ROM starts to decrease
* Frozen stage: Pain diminishes, but ROM continues to decrease
* Thawing Phase: Slow return of ROM
* The three phases can take from 6 to 24 months (or longer in some cases)
* ROM may not completely return
49
Adhesive Capsulitis PE
* Physical exam shows at least 50%
reduction in Passive & Active
ROM (PROM & AROM)
* Pathognomonic for frozen
shoulder: Affected arm is usually at the
pt’s side and lacks external
rotation, Coracohumeral ligaments
is usually contracted
* Pain at the insertion of the deltoid
is common
* The shoulder is also diffusely
tender to palpation
50
Adhesive Capsulitis diagnostics
* X-ray: AP and Axillary films to check joint
surfaces are free of obstruction
* MRI can substantiate adhesive capsulitis
* See a contracted capsule and loss of
inferior pouch of axillary recess
51
Adhesive Capsulitis treatment
* NSAIDs
* Non-narcotic analgesics
* Moist heat
* Ice after stretching to minimize inflammation
* Corticosteroid injection avoiding multiple injections
* TENS unit
* Home stretching program or consult PT
* Educate about recovery period could be 6mo - 2yrs (sometimes longer)
* Resolves on own 80-85% of the time
* Surgical tx involves arthroscopic capsular release
* PT
52
Adverse Outcomes of Adhesive Capsulitis
* NSAID adverse effects
* Aggressive therapy can worsen the condition
* Aggressive therapy can cause fracture of the humeral head
53
When to Refer Adhesive Capsulitis
* No substantial change with 3 months of consistent rehab
* Failure of nonsurgical treatment
54
Disclocation vs. Subluxation
* Dislocation = an abnormal separation of the joint
* Subluxation = a partial dislocation
55
Two different modes of dislocation
* Traumatic
* Atraumatic
56
Instability in a dislocation can be
* Anterior (Most common traumatic dislocation)
* Posterior
* Inferior
* Multidirectional (most common atraumatic dislocation)
57
Clinical Presentation of shoulder dislocation
* Pt states joint slipped out
* Initial anterior subluxation is from substantial
trauma
* Fall or forceful throwing motion
* Subsequent dislocations, pt may feel
instability with overhead activities
* Multidirectional, pt can have vague symptoms
* Usually related to activity
* Some pts can voluntarily dislocate shoulder
58
Physical Exam for a Shoulder Dislocation
* Acute dislocation
* Pain with movement
* Anterior dislocation – arm held in neutral
position - Squared-off appearance
* Posterior dislocation – arm is often
adducted and internally rotated
* External rotation is impossible for all
intents and purposes
* Axillary nerve needs to be assessed pre & post
reduction
59
What is an Apprehension Sign?
* Used to assess recurrent
anterior instability
* Done with Jobe's Relocation
* Stabilizes joint during test
60
Andrews Instability
Laxity/Instability of joint capsule
61
Jerk test use
Used to assess posterior laxity
62
Shoulder Dislocation diagnostics
* X-ray
* AP, Scap-Y, & axillary views
63
Bankart lesion
* Injury to the anterior and inferior aspect of the glenoid labrum
* Can create a space that the humeral head can slip into
64
Hill-Sachs lesion
Depression Fracture of the posterior humeral head
65
Shoulder Dislocation treatment
* Reduction of the subluxation/dislocation
* Ideally the shoulder would be reduced as close to the time of injury as possible
* First time dislocation/reduction
* Atraumatic dislocations
66
Adverse Outcomes for a shoulder dislocation
* 80% of posterior dislocations are missed on initial eval
* Deltoid dysfunction
* Osteoarthritis
* Recurrent episodes (more frequent with multiple episodes)
67
Referral considerations for a shoulder dislocation
* Closed reduction fails
* Recurrent dislocations ≥2 despite 3 months or more of rehab
* Neurologic involvement
68
Acromioclavicular Joint Separation
* Common among physically active people
* Commonly caused by a fall directly on tip of the shoulder
69
AC Joint Separation type I
* Partial disruption
* Coracoclavicular (CC) ligaments are
intact and strong
* No superior separation
70
AC Joint Separation type 2
* AC ligaments torn
* CC ligaments are intact
* CA ligament intact
* Widening of the AC joint compared to
contralateral side
* Movable anterior to posterior
directions
* Spring sign (Piano key) may be present,
but minimal
71
AC Joint Separation type 3
* AC ligaments completely torn
* CC ligaments are torn
* Wide CC joint
* Superior displacement
* 30% or Greater
* Spring sign evident
72
AC Joint Separation type 4/5
(uncommon)
* AC ligaments completely torn
* CC ligaments are torn
* CA ligament intact
* Superior and Posterior
displacement
* Type 5 is more superiorly
than posteriorly displaced as
in type 4
73
AC Joint Separation type 6
All messed up!
* AC and CCs separated
* Clavicle is entrapped under the
Biceps and coracoid process
74
AC Joint Separation presentation
* Complain of pain over the AC joint
* Pain with lifting the arm
* Physical deformity in type 3 through 6
* Patient usually holds arm in adduction
* Any motion induces pain especially abduction
75
AC Joint Separation PE
* Tender to palpation over the AC joint
* May have palpable deformation with type 2
* Definite deformation with Type 3-6
* Elevation of the arm can reduce the AC separation
* Spring test or piano key sign
76
AC joint separation diagnostics
* X-rays with and without weights
* AP of both shoulders
* Type 1 appear as normal x-rays
* Type 2 – 5 will indicate separation of AC joint and elevation
77
AC joint separation treatment (Type 1 and 2)
* NSAIDS
* Sling until pain subsides (only a couple of days)
* Ice for the first 48 hours
* Return to activity as pain allows (4-6 weeks)
78
AC joint separation treatment (Type 3)
* Could be treated nonsurgical or surgically
* If the person is not very physically active you may treat nonsurgical
options with good results
* Young, manual labor or similar type of patient may require surgery
79
AC joint separation treatment (Type 4-6)
* Require referral and surgical repair
* PT referral for shoulder strengthening and ROM
80
AC joint separation adverse outcomes
* Stiffness due to prolonged sling use
* If tape (i.e. KT tape) there could be skin breakdown
* AC arthritis – can happen regardless of treatment type
81
Sternoclavicular joint injury
* Torn soft tissue of the joint
* Capsular tears lead to subluxation or dislocation
* Posterior dislocation less common than anterior
* Anterior dislocations most common, and complications are rare
82
Sternoclavicular joint injury clinical presentation
– Anterior
* Hx of Trauma to upper chest wall or strike to the shoulder
* Tenderness over the proximal clavicle
* Prominence of the proximal clavicle
– Posterior
* Hx of trauma to the chest wall
* May have hoarseness, dysphagia, or severe respiratory distress
83
Diagnostics for a Sternoclavicular joint injury
– X-rays are difficult - due to overlying skeletal structures
– CT is very sensitive, do it if x-ray is uncertain & you suspect it
84
Treatment for a Sternoclavicular joint injury
– Closed reduction
* Anterior – nonsurgical, sling it, but it is hard to
maintain the reduction
* Posterior – reduce early for stable reduction.
– NSAIDs
– 2-3 weeks of immobilization in a sling
– DO NOT elevate arm for at least 3 weeks
– ROM exercises at 3 weeks
85
Rotator Cuff Tears (RCT) include the SITS muscles which are:
* Supraspinatus: lifts and stabilizes the humerus, assists in abduction
* Infraspinatus: main external rotator, also helps extend the arm
* Teres minor: smallest muscle of the cuff, assists in external rotation
* Subscapularis: Stabilize the shoulder, internal rotator and adductor
86
RCT etiologies
* Tears can happen due to acute trauma or chronic issues
* Chronic impingement
* Age related degeneration
* Most tears happen in the supraspinatus tendon
* With progression anteriorly and/or posteriorly along the cuff
87
RCTs clinical presentation
* Complaint of shoulder pain for several months with insidious onset or acute with a
trauma
* Most can relate an injury or incident when the pain started
* Pain when sleeping and unable to sleep on affected side are characteristic for rotator
cuff tears
* Complaints of weakness, a catching or grating feel in the shoulder especially when
raising the arm overhead
88
Rotator Cuff Tears (RCT) PE
* Passive ROM is normal or near normal
* Active ROM may be limited
* With large tears, the patient can’t abduct the affected arm (supraspinatus)
* There is a shrug of the shoulder in the attempt to abduct (deltoid compensation)
* However, depending on the location of the tear, the pt may be able to abduct the arm
* Atrophy of the infraspinatus – May see sunken shoulder blade
* Drop Arm Test on ROM exam- With large tears, pt may struggle in keeping the arm
abducted at 90
89
Muscle testing – Supraspinatus
* Drop arm test- Basic shoulder exam video
* Help Patient abduct the shoulder and ask them to slowly lower it
* Positive test is when the arm drops
90
* Muscle testing – Infraspinatus & Teres Minor
* Testing external rotation
* Pt positioned with arm to the side (neutral position)
* Elbow flexed at 90°
* Ask pt to resist your pressure
* Pain and/or weakness is a positive test
91
Muscle testing – Subscapularis
* Lift-off test
* Pt position – arm internally rotated with the
back of the hand in small of back
* Pt is asked to lift their hand off their back
against your resistance
* Resistance to internal rotation can also elicit
pain
* Pain and/or weakness is + sign
92
Hornblowers test tests which muscle?
Teres minor
93
Abdominal Compression test also called the belly press, tests which muscle?
Internal rotation/ Subscapularis
94
Painful Arc Test
Have pt slowly abduct laterally with palms forward
For assessing RCT
95
Rotator Cuff Tears diagnostics
* X-rays
* May see osteophytes (Bone Spurs) on the acromial border
* Cephalization of the humerus in the joint (elevated toward the acromion)
* MRI
* Confirms suspicion
* Good for seeing the soft tissue
96
Rotator Cuff Tears treatment- partial tears
* NSAIDS
* PT
* Corticosteroid injections judiciously (temp relief of pain)
* If no help in about 3-6 months of conservative tx, then refer to ortho
* PRP or BMAC is also an alternative between conservative Tx and surgical consult
97
Rotator Cuff Tears treatment- full thickness tears
* ASAP, but non-emergent referral to Orthopaedics for surgical consult
* The longer you wait the greater the chance of muscle atrophy become adipose
* This is irreparable and makes for poor repairs.
98
Rotator Cuff Tears adverse outcomes
* Loss of motion in the shoulder
* Chronic pain/ weakness
* Joint degeneration
* NSAID adverse effects
* Surgical failure and complications
99
Rotator cuff tendonitis
* Over head activities that require force will involve all 4 muscles
* Due to repetitive stress of the cuff to seat the humeral head in the glenoid under
force, inflammation can occur
* Excessive wear and force can lead to deformation of the cuff and capsule
100
Biceps tendinopathy (tendonitis)
* Inflammation or irritation of the long head
of the biceps
* Transverse humeral ligament can become
inflamed or torn
101
SLAP lesion
* SLAP (Superior Labrum Anterior to Posterior)
* Usually caused by the Biceps (long head) being stretched and pulled to extremes
* More substantial force in throwing with hyperextension (throwing)
102
Biceps tendinopathy (tendonitis) Clinical Presentation
* Complaint of pain in the anterior shoulder
* Hx of throwing or over the shoulder activities
103
Biceps tendinopathy (tendonitis) PE
* Pain to palpation of the biceps tendon, especially over the bicipital groove
* May feel the tendon slip in and out of the groove
* Weakness may be due to pain, but usually retain full ROM
* Speeds Test
* Obrien Test
* Yergason test or Resisted supination- subluxing or pain of biceps tendon
104
Speeds Test
Pain over bicep groove indicates biceps tendinitis, maybe positive with a SLAP lesion
105
Obrien Test
Labrum injury eg. SLAP lesion
106
Biceps tendinopathy (tendonitis) diagnosis
* Usually made clinically
* MRI may show inflammatory changes to the long head of the bicipital tendon or
the rotator cuff insertions if cuff tendonitis
107
Biceps tendinopathy (tendonitis) treatment
* Ice initially (48 Hours) and after activities, then heat if it helps
* NSAIDs if tolerated
* Corticosteroid injection
* Subacromial or intra-articular shoulder injection for rotator cuff tendonitis
108
Biceps tendinopathy (tendonitis) surgical treatment
* failed conservative therapies
* Biceps tenotomy
* Surgically sever the long head of the biceps
* Biceps Tenodesis
* Severed long head tendon is attached to bone
109
Calcific tendonitis
* Calcium deposition in the tendons of the rotator cuff
* Body reacts to stressed tendon and deposits calcium
* PE resembles that of impingement syndrome
* X-ray evidence
* Can see on ultrasound
110
Calcific Tendonitis treatment
NSAIDs, injections, barbotage, PT, time, rarely surgery
111
Rupture of the long head of the Biceps
* Most likely to happen in older adults
* Most with a Hx of rotator cuff issues
* The tendon sheath is contiguous with the capsule of the shoulder
* Inflammation of the capsule can cause biceps pain
112
Rupture of the long head of the Biceps clinical presentation
* Sudden pain in the anterior shoulder
* Possible audible ”POP”
* Bulge in arm – “Popeye arm”
113
Rupture of the long head of the Biceps PE
* Visual bulgy bicep compared to contralateral side
* Possible ecchymosis
* Palpating the bicipital groove may feel empty or void of tendon
* Palpate the bicipital groove at ~10° external rotation may cause pain
114
Rupture of the long head of the Biceps diagnostics
* X-rays can help rule out a fx
* With a Hx of shoulder issues and pain, consider MRI to r/o cuff pathology and
confirm full rupture
* May be seen on ultrasound
115
Rupture of the long head of the Biceps treatment
* Most patients will not require surgery
* Many will not have loss of function
* Most deformities are acceptable
* Exercise program to regain full elbow flexion strength
* Also evaluate for rotator cuff tears, especially in athletes and older patients
* Surgical repair can be done for patients who are laborers or need the extra
strength
116
Brachial Plexus Syndrome
* Includes a broad array of neurologic dysfunction
* From momentary paresthesia to flailing upper limbs
* MOI = diverse; from MVA, gunshot wounds, falls, sports injuries
117
Burners and Stingers
* Transient stretch injuries to the
upper trunk of the brachial plexus
* Involves C5 and C6 nerve roots
118
Brachial Plexus Syndrome clinical presentation
* Hx of something similar to the following:
* Football player receiving a direct blow to the head, neck and shoulder
* Complains of a sharp, burning, shoulder pain that radiates down the arm
following the corresponding nerve root
* Weakness in the arm and tends to hold the affected arm
119
Brachial Plexus Syndrome PE
* Neurologic examination
* Head, neck, clavicles, shoulder, & humerus examination
* Any sign of bilateral burners and/or radicular complaints into other extremities
* Treat as a spinal cord injury until proven otherwise
120
Brachial Plexus Syndrome diagnostics
* X-rays of C-spine and shoulders if injury to these areas is suspected
* C-spine with flex/ext films to rule out instability
* If any film is abnormal – GET AN MRI
121
Brachial Plexus Syndrome treatment
* Nonsurgical
* Surgical treatment of C-spine pathology, fractures, or nerve impingements
* All symptoms must be resolved & FROM regained before allowing return to athletics
* Recurrent episodes must be referred for further evaluation
122
Adverse Outcomes of Brachial Plexus Syndrome
* Cervical stenosis
* Persistent pain
* Sensory loss
* Paresthesia
* Weakness
* Paralysis
* Ganglion root avulsions
123
Thoracic Outlet Syndrome
* Compression of:
* Brachial plexus
* Subclavian artery and/or vein
* Narrow space between first rib and clavicle
* More common in women 20-50 yo
124
Thoracic Outlet Syndrome etiology
* Accessory cervical rib
* Abnormally long C7 transverse process
* Fibrosis of scalenes or fibromuscular band in the thoracic outlet
125
Thoracic Outlet Syndrome clinical symptoms
* Sx’s mimic distal nerve entrapment
* Aching neck with radiation into the shoulder, arm, forearm, & fingers
* Vascular issues
* Swelling of the affected arm
* Discoloration
* Diminished pulse compared to contralateral side
126
Thoracic Outlet Syndrome PE
* Visual inspection
* Palpation of the supraclavicular fossa
* Checking for masses
* Auscultate for bruits
* Check pulses bilaterally
* Neurofunction
* Individual Provocative tests
127
Thoracic Outlet Syndrome PE
* X-rays may find anatomic abnormalities such as an acc. cervical rib or C7 TPs
* MRI if pt complains of other shoulder or C-spine issues
128
Thoracic Outlet Syndrome treatment
* 3-6 months of home exercise program for muscle strengthening and posture
education helps most patients
* Avoid straps that may increase pressure over the shoulder
* NSAIDs, TENS units, muscle relaxants can decrease severity
* PT referral
* Every effort should be taken to avoid surgery
129
Thoracic Outlet Syndrome adverse outcomes
* Vascular compromise
* Muscle atrophy
* Loss of coordination
* Chronic headaches
* Raynaud phenomenon
* Inability to work overhead
