UE Part 1 Flashcards
What 3 things will lead to diagnosis of most shoulder disorders?
- A careful history
- A thorough physical examination
- Imaging
What are the msot common shoulder injuries <30 years old
- Traumatic injuries or joint instability
- Glenohumeral dislocations or AC joint separation
- Rotator cuff and impingement syndrome rarely occur
What are the most common shoulder injuries 30-50 years old?
- MC rotator cuff tears or impingement syndrome
- Dislocations are much less common and should raise a suspicion of a concomitant rotator cuff tear
What are the most common shoulder injuries >50 years old
- rotator cuff dysfunction/tear (MC)
- Impingement syndrome (MC)
- Degenerative arthritis (MC)
- Acute pain in elderly may indicate pathological fracture due to osteoporosis- common at proximal humerus
If a patient has shoulder pain <2-3 weeks in duration, what should you think?
- Acute
- Injury
- Fracture
- Dislocation
- Rotator cuff tear or biceps tendon rupture
If a patient has chronic shoulder symptoms, what should you think?
- May be due to injury, but typically associated with overuse or arthritis
Look at pain diagram for shoulder!
`
Pain along posterior clavicle: cervical radiculopathy, frozen shoulder
Pain along lateral shoulder: rotator cuff tear, shoulder instability
Pain on posterior triceps: cervical radiculopathy
Pain of posterior axillary area: fracture of scapula
Pain along acromion: acromioclavicular injuries
Pain of lateral or anterior shoulder: impingement syndrome, rotator cuff tear, frozen shoulder, arthritis, fracture of proximal humerus, thoracic outlet syndrome
What direction of instability is possible in shoulder injuries?
- Anterior
- Posterior
- Inferior
- Multidirectional
- Most common is anterior
What degrees of instability are possible?
- Partial (subluxation) with spontaneous reduction vs
- Complete (dislocation)
How should inspection of the shoulders be performed?
- Standing with shirt removed
- Assess contours and height of both shoulders
- Inspect both anteriorly and posteriorly
- Noteworthy findings: deformity, swelling, ecchymosis
How should palpation of the shoulders be performed?
- Start at the sternoclavicular joint and move laterally
- Assess all joints and bony structures
- Assess the subacromial bursa
- Assess long head of the biceps tendon
- Noteworthy findings: point tenderness, deformity, swelling
What are the 6 directions of movement of the shoulder
- Internal rotation
- External rotation
- Horizontal flexion
- Horizontal extension
- Abduction
- Adduction
How is ROM of the shoulder assessed?
- Active followed by passive ROM
- Note direction of limited ROM
- Assess fluidity and smoothness of movement
- Palpate for crepitus
- Consider functional disability
What factors may affect shoulder ROM exam?
- Pain
- Swelling
- Patient motivation
- Adaptation
Muscle testing of the deltoid
- Abduct shoulder at 90 degrees with elbow flexed at 90 degrees and the forearm parallel to the floor
- Ask patient to resist downward pressure to the elbow
Special tests for the supraspinatus
- Empty can test
- Abduct shoulder at 90 degrees with 30 degree forward flexion and internal rotation with the elbow extended
- In the thumbs down position
- Push down as the patient resists
- Weakness or pain is indicative of rotator cuff disease
Special tests for infraspinatus and teres minor
- Flex elbow to 90 degrees with shoulder in neutral position
- Support the elbow and attempt to externally rotate asking patient to resist movement
Special tests for subscapularis
“Gerber lift-off test”
Place the patient’s hand behind the small of the back, palm facing away from the back
Have the patient lift the hand off the back against resistance
Muscle testing serratus anterior
Stabilizes the scapula
Flex the shoulder above 90 degrees
Then with one hand, depress the arm posteriorly while the other hand palpates the scapula
The scapula should remain on the chest wall
Winging indicates muscle weakness
Muscle testing for rhomboid
Have patient place both hands on their sides, along side of iliac crest
Push arm forward as the patient resists your passive movement
Scapula should remain on chest wall
Winging indicates muscle weakness
Neer impingement test
With patient seated, depress the scapula with one hand and elevate the arm with the other
This compresses the rotator cuff tendons between the greater tuberosity and the anterior acromion
Discomfort represents rotator cuff tear or impingement syndrome
Hawkins-Kennedy test
Forward flex the shoulder to 90 degrees and the elbow flexed to 90 degrees
Internally rotate the shoulder
Pain indicates impingement of the Supraspinatus tendon
Performing crossover test
Elevate the shoulder to 90 degrees
Adductor the arm across the body in the horizontal plant
What does discomfort over AC joint on the crossover test suggest?
Arthritis or AC joint pathology
How is apprehension sign performed?
Place arm in supine position
Place arm in 90 degree abduction with elbow flexed at 90 degrees
Apply maximal external rotation
What would be an abnormal sign on apprehension sign?
Anterior instability reports sense of impending dislocation
Discomfort without apprehension is nonspecific
How is sulcus sign performed?
Apply traction in an inferior direction with the arm relaxed at the patients side
What is an abnormal sulcus sign and what does it indicate?
Inferior instability: inferior subluxation of the humeral head and a widening of the sulcus between the humerus and the acromion
How is the jerk test performed?
Place arm in 90 degree flexión and maximum internal rotation with the elbow flexed at 90 degrees
Adductor arm across the body in the horizontal plane while pushing the humerus in the posterior position
What is an abnormal jerk test finding and what does it mean?
Posterior instability: posterior subluxation or dislocation
First line imaging for the shoulder
Radiographs
Benefits of each type of shoulder radiograph
AP view: can add on internal and external rotation views
Scapular view: helpful for shoulder dislocation, proximal humerus fracture and scapular fracture, better view of scapula
Axillary view: provides view of relayionship of humeral head and the glenoid
What is the purpose of the rotator cuff
Muscles and tendons stabilize the shoulder, holding the humerus into the fossa of the glenoid
Rotator cuff muscles
SITS
supraspinatus
Infraspinatus
Teres minor
Subscapularis
What is the most common cause of shoulder pain and disability?
Rotator cuff disorders
What do rotator cuff disorders consist of?
Impingement
Tendonitis
Tears
Pathophysiology and progression of rotator cuff disorders
Overuse
Edema
Inflammation
Fibrosis
Microscopic tear
Partial thickness tear
Full thickness tear
What is impingement disorder?
An inflammation of the subacromial bursa and rotator cuff tendons
What causes impingement disorder?
Repetitive compression of subacromial bursa and rotator cuff tendons under the coracoacromial arch
Presentation of impingement disorder
Gradual onset of shoulder pain anteriorly and laterally
Pain worse with overhead activity, can also worsen when reaching behind the back
Night pain and difficulty sleeping on affected side
Prolonged cases: weakness and SITS muscle atrophy
Physical exam of impingement disorder
Inspection: usually normal, atrophy if prolonged condition
Palpation: tenderness over the greater tuberosity and subacromial bursa
ROM: pain with abduction (between 90-120 degrees) and when lowering arm back down, crepitus with movement
Special testing: + Neer and Hawkins-Kennedy
Diagnostics for impingement disorder
X-rays typically normal
Y-view x-ray could demonstrate subacromial spur
MRI is most sensitive and specific but most money
Diagnostic anesthetic injection
What is diagnostic anesthetic injection
Assess muscle strength with empty can test
Injection 10 mL of 1% lidocaine into the subacromial space
Repeat empty can
If strength assessment improves impingement is more likely than tear
Management of impingement disorder
Rest and NSAIDs - mainstay
Home exercise program: 6-8 weeks of exercises 3-4x daily, should not have increase in pain, muscle soreness and stretching sensation are normal, ice application after exercises
Corticosteroid injection if no improvement after 4-6 weeks
What are referral indications for impingement disorder?
PT: no improvement after 3-4 weeks of home exercise
Orthopedic: no improvement after 2-3 months of PT, possible consideration of surgical subacromial decompression
Etiology of rotator cuff tendonitis
Repetitive overhead motions increase demand on shoulder and musculotendinous junctions
Risk factors for rotator cuff tendonitis
AKA overhead throwing shoulder
MC- repetitive overhead activity (ex pitching)
Increased BMI
DM
Hyperlipidemia
Rotator cuff tendonitis pathophysiology
Overuse
Damage to rotator cuff-glenohumeral relationship
Humeral head instability
Superior translocation of the humeral head
Compression of the subacromial bursa and rotator cuff tendons
Fraying of the rotator cuff tendons
Partial-tear of rotator cuff tendons
Full thickness tear
Pathophysiology of internal impingement in rotator cuff tendonitis
Excessive abduction and external rotation —> compression of the Supraspinatus and infraspinatus
Early symptoms of rotator cuff tendonitis (stage I tendonitis)
Aching and soreness with repetitive activity (throwing) in anterior shoulder
Athletes have decreased pitching speed and accuracy
Pain with ADLs ie showering or washing hair
Improves with rest
Late symptoms of rotator cuff tendonitis (stage II tendonitis)
Posterior shoulder pain with activity and at night
Loss of ROM-abduction and external rotation
Rest no longer effective
Physical exam findings for rotator cuff tendonitis
Inspection: most patients normal, atrophy of Supraspinatus or infraspinatus in long-standing disease
Palpation: tenderness along the affected muscles, subacromial space
ROM: pain above 90 degree abduction, passive ROM > active ROM
Special testing: + empty can, + Neer and Hawkins if associated impingement
Imaging of rotator cuff tendonitis
Shoulder x-ray with internal and external AP views
MSK ultrasound
MRI shoulder
Findings on internal and external AP view shoulder X-ray in rotator cuff tendonitis
Normal early in disease
Sclerosis along greater tuberosity and glenoid rim later in disease
Findings on MSK ultrasound in rotator cuff tendonitis
Requires trained technician; operator dependent
Inexpensive, convenient, no radiation exposure
Will show thickening (>5 to 6 mm), hypoechogenicity, and heterogeneity
Indications for MRI shoulder in rotator cuff tendonitis
Unclear presentation (clinical diagnosis questionable)
Inadequate response to conservative therapy
What will MRI shoulder show in rotator cuff tendonitis
Inflammation and edema
Management of stage I rotator cuff tendonitis
Rest- no overhead weight training or throwing x 10 days
After 10 days of rest- intermittent throwing
Physical therapy
Management of stage II rotator cuff tendonitis
Rest and refer to PT
Complete shoulder rest until after PT has been completed
Referral indications for rotator cuff tendonitis
Failure of conservative therapy
What is a rotator cuff tear?
Tear in one or more of the 4 rotator cuff muscles (SITS)
Ranges from partial to full thickness tear
Supraspinatus tendon is most common injured
Pathophysiology/etiology of rotator cuff tear
Often multifactorial
Age-related degeneration
Chronic mechanical impingement
Altered blood supply to tendons
What is the epidemiology of rotator cuff tear
Uncommon in persons <40 years old and may or may not have history of trauma/injury
Presentation of rotator cuff tear
Chronic shoulder pain ranging from mild-debilitating
Worse with activity and at night
Associated weakness, catching, and crepitus when lifting arm overhead
Inability to fully perform ADLs: washing/styling hair, putting on shirt/jacket/bra, reaching for items in higher shelves/cabinets
Older patients may be asymptomatic
Physical exam of rotator cuff tear
Inspection: atrophy of posterior shoulder if chronic
Palpation: tenderness along greater tuberosity
ROM/muscle strength: limited, painful/weak AROM with abduction and external rotation, internal rotation limited if subscapularis tendon is involved
Full PROM
+ Drop Arm
+ Empty can, Neer’s, Hawkins
Imaging for rotator cuff tear
X-rays: rule out other pathologies
US: highly accurate in detecting full-thickness rotator cuff tears
MRI: helps determine size, location, and characteristics of rotator cuff pathology, less sensitive for partial-thickness tears
Arthrography: less expensive than MRI; invasive, high sensitivity with full thickness tears, sensitivity decreases with partial tears
What will be present on X-ray of rotator cuff tear?
May show acromial spur or sclerosis of humeral head
Evidence of shallow space between acromion and humerus in chronic rotator cuff tear
Management of rotator cuff tear
Rest- avoid overhead activities
NSAIDs
Physical therapy for a minimum of 6 weeks
Glucocorticoid injections only in patients who are not surgical candidates, limited to 3-4
Surgery if indicated
What are surgical indications for rotator cuff tear
Tear in patients <55 y/o
Acute, full-thickness traumatic tear in healthy individual
Acute on chronic tear with loss of function
Failure of conservative therapy after 3-6 months
What is adhesive capsulitis?
Frozen shoulder
Painful loss of both AROM and PROM due to idiopathic inflammation of the joint capsule
Epidemiology of adhesive capsulitis
MC in women 40-60 y/o
Risk factors for adhesive capsulitis
DM I - MC
Hypothyroidism
Duputyren’s disease
Cervical disc disease
Parkinson’s
Cerebral hemorrhage
Presentation of adhesive capsulitis
Freezing phase: progressive loss of ROM and pain
Thawing phase: gradual improvement in ROM and discomfort, lasting 6 months - 2 years
Exam findings of adhesive capsulitis
Significant reduction (>50%) in both AROM and PROM
Tenderness at the deltoid insertion, may be diffuse
Imaging for adhesive capsulitis
X-rays: normal, utilized to r/o Ddx
MRI: indicated only if presentation atypical, will reveal contracted capsule and loss of inferior pouch
Management of adhesive capsulitis
NSAIDs
Moist heat compresses
Home stretching program for 3-4 weeks, ice application after stretching
Image guided intra-articular steroid injection: fluoroscopy or US, limited (3-6 total) over course of disease
Physical therapy: transcutaneous electrical nerve stimulation unit
Surgery if indicated
Patient education
What type of surgery is performed for adhesive capsulitis? What are indications for surgery?
Arthroscopic capsular release
Indicated for failure of conservative therapy with no improvement in symptoms after 3 months of consistent rehab
Patient education in adhesive capsulitis
Takes 1-2 years for full recovery
What can shoulder instability lead to?
Subluxation or dislocation
Subluxation: humeral head partially slips out of glenoid cavity
Dislocation: humeral head becomes completely dislodged from glenoid cavity
What are possible directions of shoulder instability?
- Anterior (MC)
- Posterior
- Inferior
- Multidirectional
What is the mechanism of injury of a anterior dislocation?
Blow to abducted, externally rotated and extended arm
Clinical presentation of anterior shoulder dislocation
- Arm slightly abducted and externally rotated
- Prominent acromion
- Loss of normal rounded appearance of the shoulder
- No ROM
Posterior shoulder dislocation mechanism of injury
- Blow to anterior portion of the shoulder
- Axial loading of an adducted and internally rotated arm
- Violent muscle contractions following a seizure or electrocution
Clinical presentation of posterior shoulder dislocation
- Arm adducted and internally rotated with inability to externally rotate
- Shoulder prominence posteriorly with flattening anteriorly
- Coracoid process may be more prominent
Mechanism of injury of inferior dislocation
- Axial loading with arm fully abducted or forceful hyperabduction of arm
- MC: overhead grasp of object to keep from falling
Clinical presentation of inferior dislocation of shoulder
- Arm held above head
- Pronated with inability to adduct
Characteristics of multidirectional shoulder instability
- Patients can typically voluntarily dislocate shoulder
- Poor prognosis for surgical treatment
Physical exam for assessing shoulder instability
- Apprehension test (anterior instability)
- Jerk test (posterior instability)
- Sulcus sign (inferior instability)
Complications of shoulder instability
- Axillary nerve damage
- Hill-Sachs lesion
- Bankart lesion
- Greater tuberosity fracture
What would you see if a patient has axillary nerve damage due to shoulder instability?
- Sensory: numbness over the lateral arm and deltoid dysfunction
- Motor: weakness of the teres minor and deltoid
What is a Hill-Sachs lesion?
- Depression fracture of the humeral head created by the glenoid rim during dislocation
- MC seen in anterior dislocations
What is a Bankart lesion?
- Glenoid labrum is disrupted during dislocation
- MC in patients <30 y/o
- May result in a bone fragment avulsion
Diagnostics for shoulder instability
- X-ray: AP, Y view, axillary view
- CT if plain films do not clearly define direction of dislocation
- MRI after reduction if soft tissue injury likely, looking for Bankart lesion if <30 and rotator cuff if <40 with traumatic dislocation
How would an anterior shoulder dislocation be reduced?
- Stimson technique
- Longitudinal traction
- With procedural sedation or intra-articular lidocaine injection
- Informed consent required
Inferior dislocation reduction
Axial traction
Posterior dislocation reduction
Traction-countertraction
General shoulder instability management
- Reduction
- Reassess NV status
- Obtain post-reduction films to verify successful reduction
- Immobilize shoulder in sling for 3 weeks
- Refer to PT for strengthening
- Refer to ortho if concern for complications
What causes acromioclavicular injuries?
Trauma to AC joint resulting in ligamentous disruption
Mechanism of injury of acromioclavicular injuries
Fall directly onto adducted shoulder
How are acromioclavicular injuries classified?
I-VI based upon severity of separation
Type I AC injury
- Sprain
- Most common
- AC joint ligaments partially disrupted and coracoclavicular ligaments intact
- No separation of clavicle from acromion
Type II AC injuries
- AC ligaments torn but CC ligaments intact
- Partial separation of clavicle from the acromion
Type III AC injuries
- Both AC and CC ligaments are completely disrupted
- Complete separation of clavicle from acromion
Type IV-VI AC classification
- Rare
- Classified based upon degree and direction of separation
Presentation of AC injuries
- Pain in AC joint on abduction
- Supports arm in an adducted position
- Deformities Grade III-VI
- Tenderness over the AC joint
- Assess neurovascular status
Imaging of AC injuries
- AP shoulder and zanca view radiographs
- Type I will be normal
- Types II-VI separation noted on imaging
What is a Zanca view radiograph?
AP with a 10-15 degree cephalic tilt
Management of grade I and II AC injuries
- Ice compresses
- NSAIDs
- Sling with rest x 2-3 days
- ROM exercises and gradual return to activity as pain allows, start within 7-10 days with expectation of full return within 2-4 weeks
Management of grade III AC injuries
- Conservative as in I and II
- SLing use x 2-3 weeks
- Start ROM exercises as soon as tolerable limited by pain only
- Expectation of return to full activity in 6-12 weeks
- Refer for surgical consideration if injury affects career
- Acceptable deformity is likely without surgical intervention
Management of grade IV-VI AC injuries
- Refer to ortho surgical repair
- Emergent if NV compromise
- Deformity and weakness likely without intervention
Sternoclavicular injuries description
- Ligament trauma to joint connecting sternum and clavicle
- Ranges from microscopic tears (sprain) to complete disruption of ligaments (dislocation/subluxation)
Mechanism of injury of anterior sternoclavicular injuries
Anterolateral force applied to the shoulder with a rolling movement
Mechanism of injury of posterior sternoclavicular injuries
- Crushing forces to the chest
- May be associated with mediastinal injuries
- Consider airway assessment
Sternoclavicular sprain presentation
- Mild-moderate pain
- Tenderness
- Swelling
- No change in joint structure
Dislocation of sternoclavicular injuries presentation
- Severe pain
- Swelling
- Ecchymosis
- Decreased ROM
- Anterior dislocation: medial clavicle prominent compared to sternum
- Posterior dislocation: medial clavicle less visible/palpable with hoarseness, dysphagia, dyspnea, upper extremity paresthesias
Diagnosis of sternoclavicular injuries
- X-ray not sensitive for detecting SC dislocation
- CT chest
- Consider IV contrast CT to R/O mediastinal injury
Management of Sternoclavicular sprain
- Rest
- Sling
- Ice
- NSAIDs
- Gradual return to activities (same as AC grade I)
Management of sternoclavicular anterior dislocation
- Reduction after procedural sedation
- Place rolled towel between scapula and table/bed and apply posterior traction to the affected arm
- Reduction may not remain in place due to instability of joint
- Place in sling/swathe or figure 8 clavicle harness
- Ice and analgesics
Management of posterior dislocation of sternoclavicular joint
- Immediate ortho consult for open vs closed reduction
- Consult trauma/general/vascular/thoracic surgeon for associated injury case based
What is MOI of clavicle fracture
- Direct blow to clavicle or lateral blow to shoulder
How is a clavicle fracture classified?
- Location of fracture either in proximal 1/3, middle 1/3 or distal 1/3
Presentation of clavicle fracture
- Pain
- Swelling
- Deformity
- Skin tenting
- Tenderness along fracture site
- Decreased ROM: grinding sensation noted over fracture site with attempted ROM
Clavicle fracture imaging
- Clavicle X-ray in AP
- 10 degree AP cephalic view if AP is non-confirmatory
- CT chest with contrast if medial fracture is suspected
- Look for associated mediastinal injury
Management of uncomplicated clavicle fracture
- Figure 8 strap
- Sling
- Ice
- Analgesics
- Strap/sling x 3-4 weeks (age 12 and under
- 6-8 weeks for adults
- Begin gentle ROM exercises after 2-3 weeks
When would ortho consult for closed or open reduction with internal fixation be required for clavicle fracture
- Medial fracture
- Tenting of the skin
- 100% displacement
- Displaced distal 1/3 fractures
- Severe comminution
Common inflammatory process of the long head of the biceps tendon
Biceps tendinopathy
MOI of biceps tendinopathy
- Overuse
- Commonly coexisting with other conditions, 95% have impingement syndrome
Presentation of biceps tendinopathy
- Pain in anterior shoulder radiating to the elbow
- Worsened by activity: lifting, pulling, or repetitive overhead activities
- Night pain is common
- Symptoms relieved with rest and ice
- Tenderness along bicipital groove
- Pain with both active and passive ROM
- Yergason’s test +
What is Yergason’s test?
- Elbow flexed at 90 degrees
- Arm in pronation
- Patient supinates against resistance
- Pain is + test
Diagnosis of biceps tendinopathy
- Clinical, imaging of no value
Management of biceps tendinopathy
- Rest/modification of activities
- Ice
- NSAIDs
- Glucocorticoid injection may be considered after failure of conservative therapy, directed at subacromial space or bicep tendon sheath
- PT if symptoms don’t improve with conservative management
Corticosteroid injection has risk of tendon rupture
What is the most common location of rupture of the long head of the biceps tendon?
- Proximal end of long head
- Distal rupture may occur but much less common
Who is more likely to have rupture of the long head of the biceps tendon
- Older adults with chronic shoulder pain or impingement
- May occur in weight lifters or throwing sport athletes
Presentation of rupture of the LHBT
- Sudden onset of pain in the upper arm
- Audible snap may be felt and heard
- Ecchymosis noted initially
- Bulge “popeye deformity” accentuated with flexion of elbow against resistance
- Tenderness in bicipital groove
Diagnosis of rupture of the LHBT
- Xray of the shoulder may be used to rule out other ddx
- MRI to rule out rotator cuff tear
Management of rupture of the LHBT
- Conservative for most patients: Rest Ice, NSAIDs
- Exercise programs (home or PT) as pain allows
- Prognosis: loss of appx 10% of elbow flexion and forearm supination strength
- Surgery if indicated
Surgical repair of rupture of LHBT indications
- Unacceptable deformity
- Young athletes or laborers (<40 y/o)
What typically causes a humeral fracture
- Direct blow to the arm
- examples MVA or falling on an outstretched arm
How are humeral fractures classified?
- Proximal: greater tuberosity, lesser tuberosity, humeral head, anatomical neck, surgical neck, proximal shaft
- Shaft
- Distal: supracondylar (MC in children), epicondylar
Presentation of humeral fractures
- Pain
- Swelling
- Ecchymosis
- Look for evidence of open fracture
- Tenderness to gentle palpation over fracture site
- Limited ROM of the shoulder
- Proximal fracture: axillary nerve/artery
- Shaft: radial nerve shaft/distal fracture
Imaging of humeral fractures
X-ray of shoulder (proximal fracture) and humerus (shaft fx)
Management of proximal humeral fractures
- Minimal displacement: sling full time x 3 wk then part time as pain allows
- Begin exercise program or refer to PT after 3 weeks
- ORIF as indicated
- Prosthetic replacement indicated for 4-part fractures due to risk of blood supply disruption of the humeral head
Indications for ORIF in proximal humeral fracture
- Displacement of >1 cm of >45 degree angulation
- Displacement of greater tuberosity > .5 cm affecting rotator cuff muscles
Management of humeral shaft fracture
Angulation <20 degrees:
* Splinting with U-shaped coaptation splint for 2 weeks followed by a humeral fracture brace for 6 weeks
* Encourage ROM of the fingers, wrist, and elbow
* Surgery if indicated
Surgical indications for humeral shaft fracture
- Open fracture
- NV compromise
- Pathologic fractures
- Ipsilateral forearm fractures
