UE part 1 - Exam 1 Flashcards
What are the top 2 things a pt could say that would make you think shoulder?
pain or instability
may have decreased ROM, strength or function
If a pt is less than 30 years old, what UE dx are more likely?
MC - traumatic injuries or joint instability
think glenohumeral dislocations or AC joint separations
If a pt is 3-50 years old, what UE dx are more likely?
MC - rotator cuff tears or impingement syndrome
If a pt is older than 50 years old, what UE dx are more likely?
MC - rotator cuff dysfunction / tear, impingement syndrome and degenerative arthritis
acute symptoms should think _____ vs chronic symptoms should think ______
acute = injury
chronic= overuse or arthritis
What direction if shoulder instability is MC?
anterior
Is a first time shoulder dislocation more or less likely to spontaneously reduce?
first time are LESS likely to reduce spontaneously
When preforming shoulder PE, how should the pt be positioned? Where should you start your palpation? Need to palpate for _____
standing with shirt removed
Start at the sternoclavicular joint and move laterally
crepitus
How do you properly palpate a subacromial bursa?
What are the 6 directions of movement that should be assessed during a shoulder PE?
flexion
extension
abduction
adduction
internal rotation
external rotation
both active and passive ROM
How many degrees of shoulder forward flexion should the patient have? Extension?
180 degrees
60 degrees
How many degrees should the patient have of internal and external rotation?
90 degrees of each
What is the deltoid muscle PE test?
What is the supraspinatus muscle testing PE test?
What is the infraspinatus and Teres minor muscle PE test?
Hornblower’s sign
What is the subscapularis muscle PE test?
What is the serratus anterior special muscle test? What does winging indicate?
muscle weakness
What is the rhomboid special test? What does winging indicate?
What is the Neer impingement test? What does a positive result indicate?
positive = discomfort represents rotator cuff tear or impingement syndrome
What is the Hawkins- Kennedy test? What does a positive result indicate?
positive = looking for impingement of the supraspinatus tendon
What is the crossover test? What does a positive result indicate?
Discomfort over the AC joint suggest arthritis or AC joint pathology
What is the Apprehension sign? What does a positive result indicate?
anterior instability: report a sense of impending dislocation
need to perform test bilat
discomfort w/o apprehension doesnt tell you anything
What is the sulcus sign? What does a positive result indicate?
inferior subluxation: show a widening of the sulcus between the humerus and the acromion
need to pull down HARD at the elbow
What does the jerk test testing? What does a positive result indicate?
posterior instability: posterior subluxation or dislocation
What are the 3 first line xray views you should order for the shoulder?
AP (can also be ordered with internal and external rotations)
Scapular “Y” view
Axillary view (shoots up into armpit)
What does the Scapular “Y” view show?
Helpful for shoulder dislocation, proximal humerus fracture and scapular fracture
provides a better view of the scapula
What does an internal AP view of the shoulder show? External?
internal: lesser tubercle of humerus
external: greater tubercle (rotator cuff attaches here)
What does the axillary view of the shoulder show?
Provides a view of the relationship of the humeral head and the glenoid
What is the point of the rotator cuff? What are the 4 muscles involved? Which muscle is the MC one affected?
Group of muscles and their tendons that act to STABLIZE the shoulder, holding the humerus into the fossa of the glenoid
Supraspinatus¹ - MC affected
Infraspinatus²
Teres Minor³
Subscapularis⁴
What movement of the arm are the 4 muscles of the rotator cuff responsible for?
Supraspinatus - abduction
Infraspinatus - external rotation
Teres Minor- external rotation with weak adduction
Subscapularis - internal rotation (assists in abduction and adduction)
_______ is the MC cause of shoulder pain and disability
rotator cuff disorders
What is the general flow a rotator cuff disorder that eventually results in a full thickness tear?
If the source of pain is coming from a rotator cuff impingement disorder, where will movement be painful?
A rotator cuff impingement disorder is inflammation of the ______ and ______. That results from ______ of the structures under the _______
subacromial bursa and rotator cuff tendons
repetitive compression
coracoacromial arch
Gradual onset of shoulder pain
anteriorly and laterally
pain is worse with overhead activity
can be worse with reaching behind the back
night pain
difficulty sleeping on the affected side
What am I?
What are the highlighted symptoms?
Where will there be TTP?
What ROM will be painful?
impingement disorder
pain worse with overhead activity
night pain and difficulty sleeping
Tenderness over the greater tuberosity and subacromial bursa
Pain with abduction (between 90-120°) and when lowering arm back down
What 2 special tests should you perform if you suspect an impingement disorder? What will the xrays show?
Neer and Hawkins-Kennedy
X-rays typically normal
Y-view x-ray could demonstrate subacromial spur
_____ is the most sensitive and specific for shoulder eval
MRI
You can do a _______ when diagnosing impingement disorder in the office. Describe it. What does it indicate?
Diagnostic anesthetic injection
If strength assessment improves impingement is more likely than tear
What procedure? What are they testing for?
subacromial space injection
if empty can testing get better post injection, impingement disorder is the likely cause
What is the management of an impingement disorder? ______ should be done if no improvement after 4-6 weeks. What are the referral indications?
What is the etiology of rotator cuff tendonitis?
Repetitive overhead motions increase the demand on the shoulder and the musculotendinous junctions
What are the 4 risk factors for rotator cuff tendonitis? Which one is MC?
Repetitive overhead activity (pitching, swimming, tennis, throwing, golf, weight lifting, volleyball, gymnastics)- MC
Increased BMI
DM
Hyperlipidemia
What is the pathophys behind rotator cuff tendonitis?
In rotator cuff tendonitis with internal impingement, excessive _____ and _____ cause compression of the _______ and ______
excessive abduction and external rotation
Compression of the supraspinatus and infraspinatus
What are the major differences between stage I and stage II tendonitis? What are the tx for each?
I: aching and soreness with repetitive activity
pain with ADLs but IMPROVES with rest
tx: REST no weight training/throwing for 10 days, then go back to intermittent throwing, PT
II: loss of ROM (abduction and external rotation) and rest is NOT EFFECTIVE
tx: REST and PT referral, complete shoulder rest until after PT has been completed
Where will pts with rotator cuff tendonitis be TTP? What is their ROM? What PE testing should be done?
Tenderness along the affected muscles, subacromial space
Pain above 90° abduction
Passive ROM > active ROM
will have + empty can
maybe (+) Neer and Hawkins if associated impingement
What will the xray show of a pt with Rotator Cuff Tendonitis? Give both early and later xrays.
early: will be normal
later: Sclerosis along greater tuberosity and glenoid rim later in disease
If an US is preformed in rotator cuff tendonitis, what will it show? What will MRI show?
US: Will show thickening (>5 to 6 mm), hypoechogenicity, and heterogeneity
MRI: inflammation and edema
**_____ of the rotator cuff muscles is the tendon most commonly injuried
supraspinatus
What is the etiology behind a rotator cuff tear?
age related degeneration
chronic mechanical impingement
altered blood supply to tendons
usually older than 40 with a hx of trauma or injury
What are the 4 kinds of rotator cuff tears?
articular surface
bursal surface
interstitial tear
full thickness tear
What kind of tear?
partial thickness articular surface tear
What kind of tear?
partial thickness bursal surface tear
What kind of tear?
interstitial tear
What PE finding may be present in full thickness rotator cuff tear?
humerus can migrate up if one of the rotator cuff tendons has completely torn
What are some s/s of rotator cuff tear?
chronic shoulder pain
Associated weakness, catching, and crepitus when lifting the arm overhead
INABILITY to fully perform ADLs
or may be asymptomatic in older pts
Why can older patients with a rotator cuff tear NOT have any symptoms?
full thickness tears do NOT have to be painful
partial thickness tears usually ARE PAINFUL
Where will rotator cuff tears have the greatest TTP? What will ROM show?
tenderness along the greater tuberosity
Limited, painful/weak active ROM but full passive ROM
+drop arm test
(+) Empty can, Neer’s, Hawkins
What will xrays with rotator cuff tear show? ______ are highly accurate in detecting full-thickness rotator cuff tears
acromial spur or sclerosis (hardening or thickening) of the humeral head. Evidence of shallow space between acromion and humerus indicative of chronic rotator cuff tear
US
When are injections indicated for rotator cuff tears? What is the limit?
Only in patients who are NOT surgical candidates
Limited to 3-4
What are the surgical indications for a 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 the conservative approach for a rotator cuff tear?
rest
NSAIDs
PT (min of 6 weeks)
injections
What is the medical term for frozen shoulder? What is the underlying cause? active and passive ROM?
adhesive capsulitis
A painful loss of both AROM and PROM due to IDIOPATHIC inflammation of the joint capsule
Who is the MC pt type for adhesive capsulitis?
women 40-60 with T1DM
What are the risk factors for adhesive capsulitis? Which one is MC?
**DM I - MC
Hypothyroidism
Dupuytren’s disease
Cervical disc disease
Parkinson’s
Cerebral hemorrhage
What are the 2 different phases of adhesive capsulitis? How will each present?
“Freezing” phase:
Progressive loss of ROM and pain
“Thawing” phase:
Gradual improvement in ROM and discomfort
How long does the thawing phase of adhesive capsulitis typically last? Where are they typically TTP?
6 months - 2 years
deltoid insertion but tenderness may be diffuse
What will the xrays of a pt with adhesive capsulitis show? What will the MRI show?
normal!!
“contracted capsule and loss of inferior pouch” but only indicated if presentation is atypical
What is the management of adhesive capsulitis?
NSAIDs
MOIST HEAT compresses to help break up adhesions
stretching
intra-articular steroid injections (limit 3-6 total)
PT
consider TENS unit
What is the next step in management for a pt with adhesive capsulitis that fails conservative therapy for ____ months. What is the prognosis for a full recovery?
3 months
surgical repair via Arthroscopic capsular release
1-2 years for full recovery
What is the difference between shoulder subluxation and dislocation?
Subluxation - the humeral head PARTIALLY slips out of the glenoid cavity
Dislocation: the humeral head becomes completely dislodged from the glenoid cavity
What direction of instability for the shoulder is MC?
Anteriorly (MC)
What is a common mechanism of injury that would result in an anterior dislocation of the shoulder? What special PE test should you perform?
Blow to abducted, externally rotated and extended arm
blocking basketball shot
Apprehension test (anterior instability)
What is the clinical presentation of an anteriorly dislocated shoulder?
Arm is slightly abducted and externally rotated
Loss of the normal rounded appearance of the shoulder
No ROM
What is a common mechanism of injury for a posterior shoulder dislocation?
Blow to the anterior portion of the shoulder
Axial loading of an adducted and internally rotated arm
Violent muscle contractions following a seizure or electrocution
What is the clinical presentation for a posteriorly dislocated shoulder? What special PE test should you perform?
Arm is adducted and internally rotated with an inability to externally rotate
Shoulder prominence posteriorly with flattening anteriorly
The coracoid process may be more prominent
Jerk Test (posterior instability)
What is the mechanism of injury for an inferiorly dislocated shoulder?
Axial loading with the arm fully abducted or forceful hyperabduction of the arm
likely due to overhead grasp of object to keep from falling
What is the clinical presentation of an inferiorly dislocated shoulder? What special PE test should you perform?
Arm is held above the head, pronated with the inability to adduct
Sulcus sign (inferior instability)
________ instability the pts can voluntarily dislocate shoulder
multidirectional instability
______ is a complication of shoulder instability. How will each present? What do you always need to check?
axillary nerve damage
Sensory: numbness over the lateral arm and deltoid dysfunction
motor: weakness of the teres minor and deltoid
ALWAYS perform NV exam!!
What are the 4 complications of shoulder instability?
axillary nerve damage
Hill-Sachs lesion
Bankart lesion
greater tuberosity fracture
What is a Hill-Sachs lesion? What type of dislocation is MC?
Depression fracture of the humeral head created by the glenoid rim during dislocation
MC in anterior dislocations
What is Bankart Lesion? Who is the MC pt? What may happen as a result?
Glenoid labrum is disrupted during dislocation and may tear the labrum of the glenoid fossa requiring surgery
MC in patients <30 y/o
bone fragment avulsion
can be seen in combo with Hill-Sachs lesion
_____ complication of shoulder instability occurs in 10% of patients
Greater tuberosity fracture
When is a CT needed in a shoulder dislocation? When is a MRI done?
Indicated only if plain films do not clearly define direction of dislocation
Performed after reduction if soft tissue injury is likely. Think bankart lesion is pt is less than 30 or rotator cuff tear if less than 40 with traumatic dislocation
What are the anterior dislocation reduction techniques?
Stimson technique
longitudinal traction : arm is externally rotated while another person applies traction on the shoulder
What method is used to reduce inferior dislocations? Posterior dislocations?
inferior: Axial traction
posterior: traction/countertraction
Once the shoulder dislocation has been reduced, what 4 things are part of the management? **Which one is the most important?
Reassess NV status
Obtain post-reduction films to verify successful reduction DO NOT FORGET THIS ONE
Immobilize shoulder in sling for 3 wks
Refer to PT for strengthening
What is the mechanism of injury for an acromioclavicular (AC) Injuries?
Fall directly onto adducted shoulder
How are AC injuries classified? Which type is MC?
by severity of separation
grade I-VI
type I is MC
What is considered a type I AC sprain?
AC joint ligaments are partially disrupted and the strong coracoclavicular (CC) ligaments are intact
NO SEPARATION of clavicle from acromion
What is a type II AC injury?
AC ligaments are torn but the CC ligaments are intact
Partial separation of the clavicle from the acromion
What is a type III AC injury?
Both AC and CC ligaments are completely disrupted
Complete separation of clavicle from acromion
How are types IV-VI classified? How common are they?
Classified based upon degree and direction of separation
rare
What type of AC injury?
Type I
What type of AC injury?
Type II
What type of AC injury?
Type III
What type of AC injury?
type IV
What type of AC injury?
type V
What type of AC injury?
type VI
How will an AC injury present? What view is good to order?
Pain in the AC joint on abduction
TTP over AC joint
Zanca view
What is the Zanca view? What will type I show? type II-VI?
AP with a 10-15 degree cephalic tilt
type I = normal
type II-VI will show separation on imaging
What is the management for AC injuries type I and II?
Ice compresses
NSAIDs
Sling with rest x 2-3 days
ROM exercises and gradual return to activity as pain allows
full return in 2-4 weeks
What is the tx for grade III AC injuries? When should you refer? How soon is full return expected?
conservative therapy like in grade I and II
start ROM as soon as pain is tolerable
refer for surgical consideration if injury affects career
6-12 weeks after injury
What is the tx for grade IV-VI AC injuries?
Refer to ortho surgical repair
Emergent if NV compromise!!!
If pt is presenting with a winged scapula, what nerve is likely involved?
long thoracic nerve
What is the mechanism of injury that would result in an anterior sternoclavicular injury? How does it present?
anterolateral force applied to the shoulder with a rolling movement (sports)
The medial clavicle is prominent compared to sternum
What is the mechanism of injury that would result in a posterior sternoclavicular injury? What are they associated with? What do you need to consider?
crushing forces to the chest
May be associated with mediastinal injuries
Consider airway assessment
What is considered a sternoclavicular sprain? dislocation?
sprain: Mild-moderate pain, tenderness and swelling with no change in joint structure
dislocation: Severe pain, swelling, ecchymosis, decreased ROM
How will a posterior sternoclavicular dislocation present?
The medial clavicle is less visible/palpable
Hoarseness, dysphagia, dyspnea, upper extremity paresthesias
What do need to order to dx sternoclavicular injuries? Why?
CT chest +/- contrast to r/o mediastinal injuries
X-ray is not sensitive for detecting SC dislocation
What is the management for sternoclavicular sprain?
Rest, sling, ice, NSAIDS
Gradual return to activities (same as AC Grade I)
What is the tx for anterior sternoclavicular injury?
Reduction!
After procedural sedation (informed consent)
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
What is the tx for posterior sternoclavicular dislocation?
IMMEDIATE ortho consult
more than likely going straight to OR
When are these braces used?
Sternoclavicular Injuries
How are clavicle fractures classified?
by location divided in 3rds
Proximal (medial) ⅓, middle ⅓, distal (lateral) ⅓
How will a clavicle fracture present?
pain, swelling, deformity
skin tenting with tenderness along fracture site
decreased ROM
from lecture: can also complain of shoulder pain and it be coming from the clavicle
When attempting ROM with a clavicle fracture, what will you find?
decreased ROM with grinding sensation noted over fracture site with attempted ROM
What should you order next if clavicle xray is non-confirmatory?
10 degree AP cephalic view if AP is non-confirmatory
CT chest with contrast if medial fx is suspected
What is the tx for an uncomplicated clavicle fracture?
Figure 8 strap, sling, ice, analgesics
begin gentle ROM exercises after 2-3 weeks as pain allows
When does ortho need to be consulted for a clavicle fracture?
Medial fracture
Tenting of the skin
100% displacement
Displaced distal ⅓ fractures
Severe comminution
______ is a common inflammatory process of the long head of the biceps tendon. What is the mechanism of injury? What are these patients likely to also have?
biceps tendinopathy
overuse
95% of patients with biceps tendinopathy have impingement syndrome
How does biceps tendinopathy present? When? Active and passive ROM?
Pain reported in the anterior shoulder radiating to the elbow
Night pain is common
Pain with both active and passive ROM
What special test should be done with biceps tendinopathy? What is considered a positive test?
What is the management of biceps tendinopathy?
conservative therapy and injections
PT
Medication cocktail injected at subacromial space or bicep tendon sheath carry risk of ______
risk of tendon rupture
Where is the MC location of Rupture of the Long Head of the Biceps Tendon (LHBT)? What is the MC pt?
proximal end of the long head
MC in older adults with chronic shoulder pain or impingement
What is the presentation of rupture of the LHBT?
sudden onset of pain with an audible span
ecchymosis
then bulge that is worse with flexion of elbow against resistance
What is the term for the bulge created with rupture of the LHBT? When does it get worse?
“popeye deformity”
Accentuated with flexion of elbow against resistance
What is the management for rupture of the LHBT? What is the prognosis? When do you need to sx repair?
rest, ice, NSAIDs, PT
loss of appx 10% of elbow flexion and forearm supination strength
Unacceptable deformity
Young athletes or laborers (<40 y/o)
How are humeral fractures classified?
based on location
proximal, shaft or distal
What locations of the humerus are considered the proximal humerus? distal?
proximal: Greater tuberosity, lesser tuberosity, humeral head, anatomical neck, surgical neck, proximal shaft
distal: supracondylar and epicondylar
How will a humeral fracture present? What do you need to access?
pain, swelling, ecchymosis, TTP, limited ROM
neurovascular status!!
What NV components do you need to assess in each? proximal and shaft fractures
proximal: Axillary nerve/artery
shaft: Radial nerve (shaft/distal fx)
What xrays should you order if you are concerned about a humeral fracture?
need to order shoulder and humerus
be sure there are views of the elbow
always need to look at the joint above and below the fracture!!!
What is the tx for a minimally displaced proximal humeral fx?
minimal displacement: SLING for 3 weeks then part time as pain allows
refer to PT after 3 weeks
What are the 3 sx indications for a proximal humeral fracture? When is a prosthetic replacement indicated? Why?
- Displacement of > 1 cm or > 45° angulation
- Displacement of greater tuberosity > 0.5 cm
- Affects rotator cuff muscles
Prosthetic replacement indicated for 4-part fractures due to risk of blood supply disruption of the humeral head
What is the management for a humeral shaft fracture with angulation less than 20 degrees?
Splinting with U-shaped coaptation splint for 2wks followed by a humeral fracture brace for 6 wks
Encourage ROM of the fingers, wrist and elbow
U shaped coaptation splint is indicated for a ______ fx with angulation less than ______
humeral shaft fracture
less than 20 degrees
What are the 4 sx indications for a humeral shaft fracture?
- Open fracture
- NV compromise
- Pathologic fractures
- Ipsilateral forearm fractures
