Shoulder/Elbow Disorders

Question 1

Glenohumeral Dislocations: Overview

Answer 1

• Most common joint to dislocate. Anterior is the most common type of dislocation (95%)
  
  • Risks: young male with violent force/trauma (sports), older patient with lower mechanism
• PE:
  
  • Distal neurovascular eval before** & **after reduction
  • -sulcus sign: elbow grasped and traction applied inferiorly→ depression below the acromion)
• Tx:
  
  • conscious sedation, reduction & immobilization (keeping upper extremity internally rotated across chest)
  • -Repeat neurovascular exam
  • -Post-reduction x-rays
  • -PT & referral to ortho
• Complications:
  
  • -axillary nerve injury: this is why we do a neurovascular exam

Question 2

Anterior Glenohumeral Dislocation

Answer 2

• Mechanism:
  
  • most common after a blow to an abducted, externally rotated, & extended extremity
• S/sxs:
  
  • shoulder pain
• PE:
  
  • Inspect: arm held in abduction & external rotation, loss of deltoid contour
  • Palpate: sunken anterior soft tissues +/- humeral head palpable
• Dx:
  
  • Xray: **STAT
  • *axillary & scapular “Y” view
  • -Hill-Sachs lesion: groove fracture of the humerus
  • -Bankart lesion: glenoid rim fracture
• Tx: see glenohumeral dislocations overview

Question 3

Posterior Glenohumeral Dislocation

Answer 3

• Mechanism: posteriorly directed force when the arm is in an adducted and internally rotated position
• Risks: seizures, electric shock, trauma
• Sxs:
  
  • shoulder pain
• PE:
  
  • -Inspect: arm held in adduction & internal rotation
  • -Anterior shoulder appears flat with a prominent humeral head
• Dx:
  
  • Xray: **STAT
  • **Axillary & Scapular “Y” views
  • -”Light bulb” sign: appearance of humeral head looks like a light bulb
• Tx:
  
  • see glenohumeral dislocation overview

Question 4

AC Joint Injuries

Answer 4

• Mechanism:
  
  • result from a fall onto the tip of the lateral shoulder with the arm tucked in (bicycle, football)
• Anatomy:
  
  • the acromioclavicular (AC) ligament provides horizontal stability, the coracoclavicular (CC) ligament provides vertical stability
• Types:
  
  • Type I: AC/CC intact, no separation
  • -Type II: Partial AC/CC intact, some widening
  • -Type III: both AC/CC torn, complete separation
  • -Type IV-VI: involves deltoid, trapezius, periosteal injury (rare)
• S/sxs:
  
  • pain over AC joint, pain with lifting arm, obvious deformity with types III-IV
• PE:
  
  • pt supporting arm in adducted position
  • tenderness to palpation, swelling, & deformity over AC joint
  • crepitus, instability
• Dx:
  
  • xray:
    
    • mild separations (may need to compare both shoulders(
    • with type I → strain, so xray will be normal
• Tx:
  
  • Type I-II: sling immobilization x 2-3 weeks, ice, NSAIDs, activity modification, recheck before resuming sports
  • -Type III: may respond to conservative tx, but if young/heavy demand patient consider surgery
  • -Type IV-VI: surgical referral

Question 5

Rotator Cuff Injuries

Answer 5

• Etiology: traumatic injury, chronic erosion, impingement of the supraspinatus tendon
• Risks:
  
  • >40 yo, athletes & laborers performing repetitive overhead movements, smoking
• Injury:
  
  • tendonitis: inflammation associated with subacromial bursitis
  • rotator cuff tear
  • Supraspinatus = most commonly involved tendon
• S/sxs:
  
  • Anterolateral shoulder pain
  • -Decreased ROM (especially with overhead activities, external rotation or abduction)
  • -Night pain & difficulty sleeping on affected side
  • -Weakness, atrophy, & continuous pain
• PE:
  
  • Drop Arm Test: pain with inability to lift arm above shoulder level or hold it or when slowly lowering it
  • -Empty Can test: arm elevated to 90 degrees with full internal rotation & pronation of forearm (thumb down pouring liquid out of can), examiner applies downward force while patient resists
  • -Positive Neer & Hawkins
  • -Decreased forward flexion & ABD, Decreased Strength
• Dx:
  
  • xray = negative
  • MRI = if tear is highly suspected
• Tx:
  
  • conservative: PT shoulder program, NSAIDs, corticosteroid injections, shoulder immobilizer, Ice, rest, NSAIDs and re-evaluate at 7-10 days after acute phase
  • -Arthroscopy with C repair: refractory (6 months) or complete tear)
  • Tendinitis:
    
    • -Shoulder pendulum or wall climbing exercise, ice, NSAIDs, d/c offending activity

Question 6

Shoulder Impingement Syndrome

Answer 6

• Definition:
  
  • inflammation of rotator cuff & subacromial bursa d/t pinching between the acromion, coracoacromial ligament, & AC joint.
• Anatomy:
  
  • rotator cuff is formed by 4 muscles-infraspinatus, supraspinatus, subscapularis, & teres minor (SITS)
• Risks:
  
  • middle-aged, overhead activity
• Most common cause of shoulder pain
• S/sxs:
  
  • *Gradual onset
  • -Anterolateral shoulder pain exacerbated by overhead activity
  • -Night pain & difficult sleeping on the affected side
  • -Atrophy of muscles about the top & back of shoulder (if occurring for several months)
• PE:
  
  • -Inspection: Normal appearance
  • -Palpation: tenderness to lateral acromion
  • -No gross instability
  • -Positive Neer Test: arm fully pronated with pain during forward flexion (shoulder held down)
  • -Positive Hawkins Test: elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with lateral rotation
  • -Negative Empty can Test
• Dx:
  
  • Clinical dx, or MRI if unsure
• Tx:
  
  • *Most do not require surgery
  • -Conservative: activity medication, ice, NSAIDs, PT shoulder program → evaluate in 6-8 weeks
  • -Corticosteroid injection (subacromial bursa)
  • -If severe, persistent & poor response to tx → arthroscopy with SA decompression
• Complications:
  
  • -Rotator cuff tear
  • -Calcific tendonitis

Question 7

Clavicle Fractures

Answer 7

• Most common bone injury (esp in children, adolescents, & newborns during birth).
• Classifications:
  
  • -Group I: middle ⅓ (most common)
  • -Group II: lateral (distal) third
  • -Group III: proximal (medial) third (rare usually caused by major trauma)
• Etiology:
  
  • trauma, direct impact or fall, MVA
• S/sxs:
  
  • pain & swelling @ clavicle
  • deformity at site
  • pain with ROM
• PE:
  
  • Inspect: deformity, swelling, skin tenting, open wound
  • -Palpate: tenderness, crepitance, ROM
  • -Check sternocleidomastoid & AC joint
  • -Check chest, ribs, lungs
  • -Distal neurovascular exam
• Dx:
  
  • Xray confirms fracture
• Tx:
  
  • Middle ⅓: non-operative, sling immobilization, figure 8 splint in children x 3-4 weeks in children or x 6-8 weeks in adults → repeat films, PT
  • **Surgical indications: severely shortened, displaced, segmental, open, young athlete requesting surgical consult, delayed union, persistent pain
  • Proximal ⅓ = ortho consult
    *

Question 8

Proximal Humerus Fracture

Answer 8

• Etiology:
  
  • young patient = significant trauma; old patient = osteoporosis & mild trauma
• Classifications*2-4 part system
  
  • ** 4 segments include: greater tuberosity, lesser tuberosity, humeral head, shaft
  • -2 part fracture: humeral neck (most common, heals without fixation), anatomic neck or isolated fracture of one of the tuberosities
  • -3 part fracture: humeral head + shaft + one of the tuberosities
  • -4 part fracture: involve all 4 segments
• s/sxs:
  
  • severe pain, swelling, & bruising around the upper arm, shoulder, or forearm worse with any movement of the arm
  • -Nerve injury: loss of feeling in the arm
• PE:
  
  • Patient holding arm in adducted position
  • -Inspect: swelling, ecchymosis, & deformity of the proximal upper arm
  • -Palpate: tenderness over fracture, crepitance
  • -Decreased ROM
  • -Check: ACJ, clavicle, acromion, signs of dislocation, distal neurovascular exam
• Dx:
  
  • Xray: = initial test; need lateral and axillary view
  • -CT scan for further eval PRN
• Tx:
  
  • If they are minimally displaced (common) → non surgical
  • -Sling immobilization, analgesics, ROM (after 2 weeks), & PT (after 3-4 weeks) → repeat films & serial exams
• Surgical consult:
  
  • -3-4 part fractures
  • -Tuberosities, humeral head
  • -Intraarticular, open, neurovascular compromise (the usual)

Question 9

Frozen Shoulder (Adhesive Capsulitis)

Answer 9

• Definition:
  
  • idiopathic shoulder stiffness due to inflammation
• Risks:
  
  • 40-60 yo, DM,hypothyroidism, Dupuytren’s, Parkinson
• S/sxs:
  
  • Shoulder pain & stiffness
  • -Decreased ROM (especially external rotation)
  • -Gradual return of ROM over 6-24 months (freezing & thawing)
• PE:
  
  • -Inspection: normal appearing
  • -Palpate: diffuse tenderness over deltoid, GHJ, & GT TTP
  • -Resistance on passive ROM on affected side
  • -Decreased strength
• Dx:
  
  • Xray to find underlying source of pain (if any)
• Tx:
  
  • Conservative: PT, NSAIDs, intraarticular corticosteroid injections
  • -Refractory: manipulation under anesthesia

Question 10

Shoulder Instability

Answer 10

• Due to the shoulder’s shallow glenoid & loose capsule it has exceptional mobility, but also instability. All individuals have varying degrees of laxity, that can become an instability when affected by trauma or overuse
• Patients with shoulder instability have recurrent episodes of subluxation & dislocation. anterior/multidirectional = most common
• Types:
  
  • Unidirectional: acute, traumatic
  • -Multidirectional: atraumatic
• S/sxs:
  
  • Sensation of shoulder slipping out of joint when the arm is abducted & externally rotated.
  • -Ask patient whether he or she can voluntarily dislocate the shoulder (multidirectional instability)
• PE: (Acute)
  
  • Patient supports arm in neutral position, any movement → pain
  • -Assess neurovascular function (axillary nerve → deltoid area (where an officer may have a badge))
• PE: (Recurrent)
  
  • Apprehension test: patient in supine elbow to 90 degrees & shoulder abducted to 90 degrees, examiner applies external rotation force → patient is apprehensive → anterior instability
  • -Sulcus test: with patient’s arm relaxed at side the examiner applies traction inferior → inferior shoulder laxity
  • Assess for general ligamentous laxity
• Dx:
  
  • Xray: AP & axillary, check for Hill-Sachs & Bankart
  • -MRI: if RC/labral tear suspected
  • -CT: shows bony lesions better
• Tx:
  
  • shoulder exercise program, PT, activity modification
  • -Ortho referral (consider surgical stabilization)
• Dx:
  *

Question 11

Thoracic Outlet Syndrome

Answer 11

• Definition:
  
  • idiopathic compression of the brachial plexus (most common), subclavian vein, or subclavian artery as they exit the narrowed space between the shoulder girdle & first rib (at T1)
• Risks:
  
  • women 20-50yo
• Etiology:
  
  • may be secondary to congenital abnormalities such as a cervical rib or long transverse process of C7, or fibrotic restriction (scalene muscle)
• S/sxs:
  
  • Nerve Compression:
    
    • ulnar neuropathy
    • -pain or paresthesia to the forearm or arm
  • Vascular Compression:
    
    • Intermittent swelling & discoloration of the arm (especially with abduction of the arm)
  • *Symptoms worse with arms overhead
• PE:
  
  • Inspect: swelling & discoloration of distal extremity
  • -Palpate: supraclavicular fossa (for mass)
  • -Auscultate for bruits
  • -compare neurovascular with contralateral side
  • -Elevated arm stress test: both shoulders should be abducted to at least 90 degrees → patient opens & closes fists for 3 minutes → reproduction of of symptoms
  • -Adson sign: loss of radial pulse with head rotated to affected side
• Dx:
  
  • CXR to r/o apical tumor or infection
  • -Cervical spine Xray to identify cervical ribs & long C7 transverse process
• Tx:
  
  • Physical therapy, avoid heavy shoulder straps, avoid strenuous activity
  • -Referral to vascular/neurosurgery if persistent

Question 12

Dislocation of the Elbow

Answer 12

• Mechanism: FOOSH (fall on outstretched hand)
  
  • usually posterior
  • Most common joint dislocation in pediatrics
• S/sxs:
  
  • Extreme elbow pain & swelling
  • -Decreased ROM
  • -Flexed elbow & inability to extend
  • -Marked olecranon prominence
• PE:
  
  • Inspect: swelling, ecchymosis, trauma
  • -Neurovascular exam
• Dx:
  
  • Radiology STAT to r/o associated fractures (radial head, coronoid process)
• Tx:
  
  • Stable: emergent reduction with posterior splint at 90 degrees with orthopedic f/u
  • -Unstable: open reduction, internal fixation
• Complications:
  
  • injury to brachial artery
  • -Injury to medial, ulnar, or radial nerves
  • -Compartment syndrome

Question 13

Radial Head Fracture

Answer 13

• Mechanism: FOOSH
• Types:
  
  • Type I: nondisplaced
  • -Type II: 2mm articular displacement or neck angulation
  • -Type III: comminution
• S/sxs:
  
  • Lateral elbow pain & swelling
  • -Decreased ROM
• PE:
  
  • -Inspect: trauma, swelling, posture of arm
  • -Palpate: tenderness over radial head that is worse with rotation of the wrist, crepitance, mechanical clicking
  • -Check forearm, distal radioulnar joint, & wrist for injury
  • **Verify that there is no capsular tear with mechanical blocking → locking, popping, clicking felt on exam with passive ROM of wrist. ** If they have this and then are put into a sling then their elbow will freeze→ need to refer them to surgery
• Dx:
  
  • **notoriously challenging to visualize the fracture on xray
  • -Positive posterior or displaced anterior fat pad sign (sail sign) on xray
• Tx:
  
  • Type I: immobilization (sling) for 1-2 weeks, re-evaluate in 2 weeks with repeat Xrays to ensure callus formation, no displacement, and no new mechanical sxs or findings. with early ROM/PT
  • Type II: if < 30% articular surface & 2mm displaced then treat as type I
  • Type III: surgical referral

Question 14

Lateral Epicondylitis (Tennis Elbow)

Answer 14

• Definition:
  
  • inflammation of the tendon insertion of the extensor carpi radialis brevis muscle d/t repetitive pronation of the forearm & excessive wrist extension
• Risks:
  
  • 35-50 yo, racquet sports, screwdriver/ hand tool work, painting
• S/sxs:
  
  • *Gradual onset
  • -Lateral elbow pain: worse with gripping, forearm pronation
  • -May radiate down forearm
• PE:
  
  • Palpate tenderness over epicondyle & distal tendon
  • -Pain reproduced by performing wrist extension against resistance
• Dx:
  
  • Xray to r/o OA, loose bodies, mass
  • MRI if dx is uncertain
• Tx:
  
  • Conservative: ice/heat, stabilizing band, activity mods, NSAIDs, PT
  • -Corticosteroid injections (controversial b/c may be a degenerative process and not inflammatory process so could make it worse)
  • -Surgery if refractory to tx

Question 15

Medial Epicondylitis (Golfer’s Elbow)

Answer 15

Mini Golf is Fun; M = medial; golf = golfers; F = flexion

• Definition:
  
  • inflammation of the pronator teres-flexor carpi radialis muscles d/t repetitive overuse & stress at the tendon insertion of the flexor forearm muscles
• Risks:
  
  • 40-60yo, golfers, household chores
• S/sxs:
  
  • *Gradual onset
  • -Tenderness over the medial epicondyle: worse with pulling activities
• PE:
  
  • Palpate: tenderness over epicondyle & distal tendon
  • -Pain reproduced by performing wrist flexion against resistance
• Dx
  
  • Xray to r/o OA, loose bodies, mass
  • MRI if dx is uncertain
• Tx:
  
  • Conservative: ice/heat, stabilizing band, activity mods, NSAIDs, PT
  • -Corticosteroid injections (controversial b/c may be a degenerative process and not inflammatory process so could make it worse)
  • -Surgery if refractory to tx

Question 16

Olecranon Bursitis

Answer 16

• Anatomy/definition: The Olecranon bursa is at a superficial location over the extensor surface that easily becomes inflamed
• Etiology:
  
  • -Trauma: fall, direct impact
  • -Inflammation: RA, gout, CPPD
  • Infection: septic bursitis (S. aureus)
  • -Chronic: leaning on elbows (COPD)
• S/sxs:
  
  • *Acute or subacute onset
  • -”Goose egg” boggy swelling to the posterior olecranon process area
  • -Chronic: minimally tender, full ROM
  • -Infectious: erythema, warmth, tenderness with painful ROM
• PE:
  
  • -Inspect: swelling over olecranon process, erythema
  • -Palpate: warmth, tenderness, fluctuance
  • -Limited ROM d/t pain & swelling
  • -Distal neurovascular exam
• Dx:
  
  • Clinical dx in most patients
  • Xray to r/o fracture, foreign body, osteophytes, erosive changes
  • Bursa aspiration if septic bursitis or gout is suspected (caution: don’t want to do this unless high suspicious b/c can introduce bugs into sterile bursa) → (WBC, GS, Cx, Crystals)
• Tx:
  
  • Avoid pressure & leaning on elbows, protective padded sleeve, NSAIDs
  • -Cellulitis: ice, NSAIDs, abx
  • -Chronic: surgical bursectomy

Question 17

Distal Biceps Rupture

Answer 17

• Less common than proximal biceps rupture but is more debilitative. Occurs at the insertion of the radial tuberosity
• Risks:
  
  • men > 40yo (think of Bert Kreisher) , hx of previous degenerative biceps injury
• S/sxs:
  
  • *Acute onset
  • -Severe sharp anterior elbow pain during load on flexed elbow (curls, heavy lifting)
  • -Bruising, swelling & deformity of biceps
• PE:
  
  • -Inspect: anterior elbow & upper arm for deformity, ecchymosis, & swelling
  • -Palpate: anterior fossa, radial head, biceps, & tendon for step-off
  • -Pain with active ROM
  • -Weakness with flexion
• Dx:
  
  • Xray to r/o fracture
  • MRI = gold standard
• Tx:
  
  • If rupture is incomplete it may be missed initially
  • *if partial tear, it may heal with conservative tx
  • -Immobilization, ice, & compression
  • -Referral to ortho
  • *consider surgery in young athletes & heavy laborers