Upper Extremity 1 Flashcards
Actions of the rotator cuff muscles
Supraspinatus, infraspinatus, teres minor: external rotation and abduction
Subscapularis: internal rotation
Stabilize shoulder by depressing humeral head against glenoid
What is the most commonly injury rotator cuff muscle?
Supraspinatus
Presentation of rotator cuff injury
Pain over anterior and lateral aspects of the shoulder (initially with overhead activity and then at rest)
ROM decreased
What tests should you do for a rotator cuff injury?
Drop arm, empty can (weakness)
Neers and Hawkins (pain)
Tendonosis vs tendonitis
Tendonosis: chronic degeneration of muscles typically with age
Tendonitis: inflammation associated with repetitive trauma associated with everyday movement of shoulder
Reasons for chronic rotator cuff tear
Degeneration, impingement, overload
Overhead occupations
Variations in shoulder structure can cause narrowing under outer edge of clavicle
Majority start as partial supraspinatus tear that can progress to rest of SITS and biceps tendon
Reasons for acute rotator cuff tear
Trauma
Suspicion of this with acute shoulder pain and negative radiographs
Usually significant amount of force (when person is younger than 30)
Often with labral pathology
What can tendonitis lead to?
Impingement (which can lead to chronic tear)
What does patient complain of in tendonitis/impingement?
Gradual deep ache in the lateral shoulder radiating to the deltoid
How can you distinguish impingement from a tear?
ROM is painful above 90 degrees and gets better with analgesics (with tear they still wouldn’t be able to do it)
In whom is a chronic rotator cuff tear usually seen?
Men over 40
Pain of chronic rotator cuff tear
Usually worse with overhead activities and at night (worsening pain with gradual weakness)
Subacromial tenderness/bursitis
Hallmark for rotator cuff tear
Weakness! (specifically abduction and external rotation)
How to distinguish between tendinopathy and tear?
Lidocaine injection test (10 ml of lidocaine injected in subacromial test and then Neers is performed and if still painful then tear)
Radiographs (elevation of humeral head over 1 cm if probably tear)
U/S has limited use
MRI (but only do if planning to do something about it)
Gold standard for evaluation of full thickness rotator cuff tear
MR arthrogram
Acute therapy for rotator cuff tear
Ice, NSAIDs, weighted pendulum stretching 5 min 2xday, restrict overhead movement, shoulder immobilization for short time (so don’t get frozen shoulder), maybe pt
When would you do a subacromial steroid injection with a rotator cuff tear?
When there is secondary bursitis
Surgery for rotator cuff tear
Arthroscopic repair Joint arthroplasty (replacement)- trade off for pain versus mobility after
Number 1 reason someone gets rotator cuff tendonitis
Shoulder impingement syndrome
Presentation of impingement
Nearly identical to rotator cuff tendonitis
Subacromial tenderness
Normal glenohumeral joint ROM (restricted due to pain)
Preserved strength
Hallmark finding of impingement
Pain reproduced by the painful arc of flexion-internal rotation maneuvers
Scale of impingement in Neers test
Pain at 90 degrees: mild
Pain at 60-70 degrees: moderate
Pain at 45 or below: severe
When do you use radiography in impingement?
For the patient’s first visit because do not want to miss bone problem
Tx of impingement
Ice, NSAIDs, activity modifications
No arm sling recommended
PT referral
May use corticosteroid injections if persistent pain
MOI for labral tear
Acute (FOOSH, sudden pull) Repetitive overuse (throwing athlete, laborer)
Clinical presentation of labral tear
Acute: pain
Chronic: clicking/catching
Bankart lesion
labral tear of inferior rim often associated with a dislocation
SLAP tear
Superior Labrum Anterior Posterior tear (extends anterior to posterior in curved fashion)
Physical exam during labral tear
Biceps tendon: pain
Glenohumeral joint: restricted internal/external rotation
Scapula: motion dysfunction
Specialized exams for labral tear
Anterior glide, speeds, o’brien’s
Preferred imaging for labral tear
MR arthrogram with arthroscopy as definitive for diagnosis
Tx for labral tear
Nonsurgical preferred
NSAIDs, acetaminophen and PT
What is adhesive capsulitis?
Chronic shoulder pain with gradual global limitation in ROM due to stiffened glenohumeral joint and may develop adhesions
Frozen shoulder
How to diagnose adhesive capsulitis?
Loss of ROM is mechanical restriction as opposed to pain restriction (abduction/external rotation)
ROM tests confirm its reduced at GH joint in 2 or more planes
Apley scratch test in adhesive capsulitis
Normal patients should be able to scratch their midback at T8-T10 (compare!)
What you will see in imaging of adhesive capsulitis?
Radiography (limited in diagnostics but usually ordered)
MRI or MRA not needed but may see thickening of joint capsule and ligaments
Tx of adhesive capsulitis
Treat any underlying, stretch lining of joint, restore ROM
Most are self-limiting and respond to conservative therapy
MOI for AC injury
Frequently injured in fall onto tip of the shoulder with arm tucked into side (will see a bump that is uncomfortable at bed time)
Test used in AC injury
Passive cross body adduction (cross-over) because see AC compression
AC sprain/separation grades
I- Sprain with no separation but pain but AC joint intact (probably only see widening of joint)
II-Separation of superior/inferior AC ligaments but coracoclavicular ligaments intact, instabililty with stress testing
III-separate AC ligaments and coracoclavicular ligaments (clavicle popping up)
Tx for AC sprain
Shoulder immobilizer 3-4 wks for comfort and restriction of overhead, reaching and weights
Ice, rest, NSAIDs and steroid injection if not better in 2-4 wks
Surgery when grade III and need fixation, ligament reconstruction or distal clavicle resection
Where do the majority of clavicle fractures occur?
Middle 1/3
What imaging is needed in a clavicle fracture?
Single AP radiograph of clavicle
When do you refer clavicle fracture as opposed to normal conservative tx?
Displaced mid claficle fx and all proximal/distal 1/3 fxs
Subacromial bursitis
Inflammation or degeneration of sack-like structure from repetitive movement or systemic disease (RA, gout, sepsis)
Presentation of subacromial bursitis
Global/achy pain with ROM and rest, localized TTP, some decreased ROM
Tx for subacromial bursitis
Fluid aspiration if needed if think sepsis
Ice and NSAIDs, restrict overused, aspiration and steroid injection
Clinical presentation of biceps tendonitis
Pain in anterior shoulder with abduction and external rotation, maximal tenderness along bicipital groove
Popping sensation due to inflamation
Weakness
See popeye deformity in rupture
Tests for biceps tendonitis
Yergasons, Speeds
Tx for biceps tendonitis
NSAIDs, rest, PT, steroid injection, surgery
Most common shoulder dislocation
Anterior
Tests for glenohumeral dislocation
Sulcus sign, glenohumeral instability assessment with apprehension and relocation test (gold standard)
When see them hold arm in position of protection
Radiography for GH dislocation
AP, Y and axillary views beneficial to see which direction it moved
Tx for GH dislocation
Reduction if needed, shoulder immobilizer for 2-4 wks, analgesics, pt, surgery with repeat dislocations
Special considerations with anterior shoulder dislocations
Bankart lesion, Hills Sachs lesion, axillary nerve
Hills Sachs Lesion
Cortical depression of posterolateral humeral head when humeral head is impacted by anterior rim of glenoid (fracture humerus)
