Shoulder Fx Flashcards
Acromioclavicular Joint Injury
Acromioclavicular Osteoarthritis
Subacromial Bursitis
Rotator Cuff Tendon Sprain/Tear
Labral Tear
Shoulder Dislocation
Adhesive Capsulitis
Biceps Tendonitis/Rupture
Thoracic Outlet Syndrome
Shoulder: Acromioclavicular Joint Injury
general
Etiology: A.K.A “shoulder separation”
Microtears or large tears of ligaments connecting the acromion and clavicle
Disruption of the acromioclavicular (AC) and coracoclavicular (CC) ligaments
Most common in male athletes
Mechanism: Direct blow to shoulder or fall onto shoulder
Common symptoms/complaints:
Pain at superior shoulder over the AC joint
Decreased strength
Shoulder: Acromioclavicular Joint injury
PE and testing
Physical exam:
Tenderness with palpation of AC joint
Edema at AC joint
Diminished strength and ROM
Testing:
X-rays will show varying degrees of separation depending on type of injury
Bilateral shoulder radiographs are helpful
Acromioclavicular Joint injury
Shoulder: Acromioclavicular Joint injury
Tx and complictions
Treatment:
Depends on severity of displacement
Type I, II and III (< 2cm of clavicle displacement) –> Sling, rest, ice, NSAIDs
Goal: Early ROM – regain function @ 6 w, back to normal activity @ 12 weeks
Type IV, V, VI – surgical fixation: hook plate, screw, CC screw, dog bone
Goal: Immobilize for 6 weeks & back to normal activity 6 months
Complications:
AC joint arthritis
Chronic instability
Shoulder: Acromioclavicular Joint Arthritis (OA)
General
Etiology: repetitive microtrauma resulting in degenerative loss of cartilage at the joint due to wear and tear
More common with age & weightlifters (heavy overhead activities)
Common symptoms/complaints:
Pain with overhead motion
Pain with sleeping on side
Grinding sensation at AC joint
Shoulder: Acromioclavicular Joint Arthritis
PE and testing
Physical exam:
TTP at AC joint
Pain with cross arm test
Testing:
X-rays will show joint space narrowing, osteophytes and maybe subchondral cysts
Shoulder:Acromioclavicular Joint Arthritis
Tx and complications
Treatment:
NSAIDs
Physical therapy – avoid overhead movements/strengthen shoulder girdle
Steroid injection – temporary relief
Surgical resection of the end of the clavicle (must take care not to take too much and destabilize the joint)
Complications:
AC joint instability
Persistent pain (incomplete resection)
Heterotopic ossification (HO)
Shoulder: Subacromial Impingement
general
Most common complaints
Referred pain?
Etiology:
Diminished space between the end of the acromion and the humerus
Compression of rotator cuff muscles by superior structures causing “pinching” of the structures beneath resulting in inflammation (bursitis)
A.K.A – Subacromial Bursitis
Common symptoms/complaints:
Pain with overhead activity
Referred pain into the deltoid and mid- arm
Shoulder: Subacromial Impingement
PE and testing
Physical exam:
Pain with overhead AROM and PROM (forward flexion and abduction)
+ Neer & Hawkins Tests
Testing:
Little findings on x-ray, might be able to see a small amount of spurring on acromion or diminished clearance between acromion and humerus (think hooked acromion)
MRI will show inflammation of the bursa
Shoulder: Subacromial Impingement
Tx
Treatment:
NSAIDs,
Steroid injection,
Surgical subacromial decompression if no improvement with conservative tx
(removal of bursa and acromial spurring)
Shoulder: Rotator Cuff Tendon
Strain/ Tear
general
Common complaints
Etiology:
Tear of rotator cuff tendon related to repetitive trauma (think impingement) or acute trauma
Common symptoms/complaints:
Pain with shoulder motion overhead activities
Deltoid pain
Diminished AROM with decreased strength
Shoulder: Rotator Cuff Tendon
strain/tear
PE and testing
Physical exam:
+ Neer, Hawkins, empty can, drop arm
Good PROM, poor AROM
Testing:
MRI, injecting with contrast (arthrogram) will improve visibility of tears, X-Ray will show proximal migration of humeral head
Shoulder: Rotator Cuff Tendon
Srain/ Tear
Tx
Treatment:
Full thickness tears require surgery to prevent osteoarthritis and restore proper function – debridement and repair (8-to-12-week recovery, 6-to-12 month return to normal activity)
Partial thickness tears typically non-operative and managed with physical therapy and cortisone injections
Pearls:
Supraspinatus is most common
Usually distinct injury with young, healthy people and slow, degenerative problem with middle-aged and elderly patients
Shoulder: Labral Tear
general
Etiology:
Tear of the labrum
Tears related to dislocation are often assoc. with Bankart and Hill-Sachs lesions (next slide)
Tears related to pulling from the long head of the biceps tendon are superior labrum, anterior to posterior (SLAP tear)
Common in weightlifters, swimmers, football lineman, gymnasts, wrestlers
Common symptoms/complaints:
Some are asymptomatic, some have pain and instability w/ posterior directed forces, some just have pain, clicking/popping w/ ROM
Shoulder: Labral Tear
PE and testing
Physical exam:
Posterior joint line tenderness
Posterior apprehension test
Testing:
Hill-Sachs & Bankart lesions can be seen on x-rays and MRI (arthrogram is good here)
Will need MRI to diagnose most labral tears, sometimes will need contrast if nothing shows up with simple MRI
Shoulder: Labral Tear
Tx
Treatment:
Sling, rest immediately after injury
First line – NSAID’s, PT, activity modification
Surgical repair for instability and prevent dislocations if related to dislocation
SLAP tear surgical repair is debated, as is PT
Shoulder: Dislocation
general
Etiology:
Humeral head is forced out of the glenoid fossa/ cavity
Common symptoms/complaints:
Diffuse shoulder pain
Edema
Decreased strength and motion
Can usually recall the injury/cause
Shoulder: Dislocation
PE and testing
Physical exam:
Acute pain
Obvious deformity
Diminished ROM
+ Apprehension test
Testing:
X-rays: obvious dislocation and possibly HS & Bankart lesion
MRI is helpful to determine soft tissue damage
Rotator cuff and labrum
Shoulder (Glenohumeral) dislocation
general
Most common major joint dislocation:
- Anterior (95-97%)
- Posterior (2-4%)
May be associated with:
- Fracture dislocation
- Rotator cuff tear
Neurovascular injury (Axillary & Musculocutaneous Nerve)
Hill Sachs deformity
Bankart lesion
Pre-reduction neurovascular exam and x-ray.
Procedural sedation/ intra-articular anesthesia.
Immobilize: Shoulder immobilizer
Shoulder injection (ASPIRATION)
Posterior Approach
- Palpate the posterior lateral edge of the acromion process
- Mark a spot 2cm inferior to this edge
- Inject the shoulder with 10 mL’s of anesthetic targeting the coracoid process
Anterior shoulder dislocation
general
Classification: Subcoricoid, subglenoid, subclavicular, Intrathoracic.
Mechanism of injury: Abduction, extension, and external rotation.
Signs and symptoms: Prominence of acromion process and flattening of normal contour of the shoulder.
X-rays: Standard series = AP shoulder + Scapular Y. Post-reduction - *Axillary lateral.
Reduction of Anterior shoulder dislocation
Stimson
Prone position
Arm hanging
Traction in forward flexion using 5, 10 or 15 pound weight (15-30 min)
Use with scapular manipulation
Reduction of Anterior shoulder dislocation
Scapular Manipulation
Stimson technique
Scapular tip medially
Slight dorsal displacement of scapular tip
Reduction may be subtle
Reduction of Anterior shoulder dislocation
Leidelmeyer
Supine
Arm adducted
Elbow flexed 90°
Gentle external rotation
Reduction of Anterior shoulder dislocation
Milch
Forward flexion or abduction until arm is directly overhead
Longitudinal traction
Slight external rotation
Manipulate humeral head upward into glenoid fossa
Reduction of Anterior shoulder dislocation
Traction-counter-traction
Supine
Bed sheets tied
Slight abduction of arm
Continuous traction
Gentle external rotation
Gentle lateral force to humerus
Change degree of abd
Posterior shoulder dislocation
general
Classification: (commonly missed) Subacromial, subglenoid, subspinous.
Mechanism of injury: Seizures or electric shock, fall on forward-flexed, adducted and internally rotated arm. IR > ER musculature.
Signs and symptoms: Anterior flatness, posterior fullness and prominence of the coracoid process.
X-rays: Axillary lateral, when in doubt obtain CT.
Reduction of posterior shoulder dislocation
Tx
Treatment:
Reduction, sling/shoulder immobilizer, physical therapy, referral to orthopedist
- Young patients: immobilize longer 4 weeks
- Older patients: early ROM (pendulum exercises to prevent stiffness)
Surgical repair for significant soft tissue damage or dislocations that will not reduce, recurrent dislocations
Shoulder: Glenohumeral Arthritis
general
Etiology: degenerative/ mechanical wear & tear of articular cartilage at humeral head and glenoid fossa
Primary osteoarthritis
Secondary arthritis: post traumatic (dislocation/fx)
Increases with age, more common in patients over 60
More common in women
Common symptoms/complaints:
Pain and stiffness of shoulder, worse with activity
Often no pain at rest
Shoulder: Glenohumeral Arthritis
PE and testing
Physical exam:
Diminished PROM and AROM – IR/ER
Palpable grinding/ crepitus with ROM
Testing:
X-rays: joint space narrowing, osteophytes and possibly subchondral cysts
AP/Axillary lateral views
Shoulder: Glenohumeral
Arthritis
Tx
Treatment:
NSAIDs
Gentle exercise, physical therapy
Steroid injections
Surgical replacement – TSA, rTSA, hemi
Pearls:
Use reverse shoulder replacement if RCTs are present with arthritis (uses deltoid for motion and control)
Shoulder: Adhesive Capsulitis
general
Commonly associated with
Etiology: A.K.A “Frozen Shoulder”
Capsule is inflamed; it then scars and remodels (becomes smaller, tighter)
Due to little or no trauma
Commonly associated with diabetes and thyroid disease
Common symptoms/complaints:
Pain out of proportion to physical exam findings
Stiffness – loss of AROM & PROM exercises
Shoulder: Adhesive Capsulitis
PE and testing
Physical exam:
Diminished AROM and PROM (very tight and painful)
Compare to contralateral extremity
Testing:
Essentially negative x-rays and MRI – order to rule out other etiology
Shoulder: Adhesive Capsulitis
Tx and pearls
Treatment:
Physical therapy and manipulation under anesthesia (MUA)
Sometimes NSAIDs help but not often
Treating underlaying DM & thyroid disease
Pearls:
Commonly seen in patients 40 to 60 years of age
More common in women than men, especially in peri-menopausal women or in patients with endocrine disorders, such as diabetes mellitus or thyroid disease
Shoulder: Biceps Tendinitis & Rupture
general
Etiology:
Tendinitis: inflammation of the tendon within the groove
Rupture: tear of the tendon (typically long head)
Common symptoms/complaints:
Tendinitis: anterior shoulder pain, may radiate down biceps, weakened elbow flexion because of pain
Rupture: felt a pop and then pain improved, sometimes has weakened elbow flexion
Shoulder: Biceps Tendinitis & Rupture
PE and testing
Physical exam:
Tendinitis
Pain in bicipital groove
+ Speed’s test - pain with elbow flexion against resistance
Rupture
“Popeye” deformity
ecchymosis
Testing:
MRI will confirm tear or tendinitis
Shoulder: Biceps Tendinitis & Rupture
Tx
Treatment:
Tendinitis:
- Rest, NSAIDs, caution with steroid injection not to inject tendon
- Surgery: tenodesis versus tenotomy
Rupture:
- Surgery
Shoulder: Thoracic Outlet Syndrome
general
Common complaints
Etiology:
Intermittent or continuous pressure on elements of the brachial plexus and the subclavian or axillary vessels by anatomic structures of the shoulder girdle region (often between the anterior or middle scalene muscles and a normal first thoracic rib or a cervical rib)
Common in athletic males – overhead motion
Anatomical predisposition, neck trauma
Common symptoms/complaints:
Pain, numbness and weakness in the arm
Sensitivity to cold and paleness in the arm
Shoulder: Thoracic Outlet Syndrome
PE and testing
Physical exam:
Neck, trapezius * , shoulder pain
Weakness, numbness, paresthesia
UE heaviness feeling, cyanosis
Symptoms can be provoked with holding arm overhead for 60 seconds
Testing:
Chest radiography identifies presence of cervical rib, C7 transverse process, Pancoast tumor
MRI with arms held in different positions useful in identifying sites of impaired blood flow
Angiography confirms intra-arterial or venous obstruction
Shoulder: Thoracic Outlet Syndrome
Tx
Treatment:
Therapeutic Procedures
- Conservative measures: physical therapy, activity modification, TENS unit to relieve compression of neurovascular bundle
Surgery
Required by < 5% of patients
Failed conservative tx for >6 months with muscle atrophy
1st rib resection, scalenectomy, neurolysis
Vascular intervention – heparin, +/- embolectomy (large vessel), TPA (small vessel), systemic
More likely to relieve neurologic rather than vascular component that causes symptoms
