Upper Extremity 1

Question 1

Actions of the rotator cuff muscles

Answer 1

Supraspinatus, infraspinatus, teres minor: external rotation and abduction
Subscapularis: internal rotation
Stabilize shoulder by depressing humeral head against glenoid

Question 2

What is the most commonly injury rotator cuff muscle?

Answer 2

Supraspinatus

Question 3

Presentation of rotator cuff injury

Answer 3

Pain over anterior and lateral aspects of the shoulder (initially with overhead activity and then at rest)
ROM decreased

Question 4

What tests should you do for a rotator cuff injury?

Answer 4

Drop arm, empty can (weakness)

Neers and Hawkins (pain)

Question 5

Tendonosis vs tendonitis

Answer 5

Tendonosis: chronic degeneration of muscles typically with age
Tendonitis: inflammation associated with repetitive trauma associated with everyday movement of shoulder

Question 6

Reasons for chronic rotator cuff tear

Answer 6

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

Question 7

Reasons for acute rotator cuff tear

Answer 7

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

Question 8

What can tendonitis lead to?

Answer 8

Impingement (which can lead to chronic tear)

Question 9

What does patient complain of in tendonitis/impingement?

Answer 9

Gradual deep ache in the lateral shoulder radiating to the deltoid

Question 10

How can you distinguish impingement from a tear?

Answer 10

ROM is painful above 90 degrees and gets better with analgesics (with tear they still wouldn’t be able to do it)

Question 11

In whom is a chronic rotator cuff tear usually seen?

Answer 11

Men over 40

Question 12

Pain of chronic rotator cuff tear

Answer 12

Usually worse with overhead activities and at night (worsening pain with gradual weakness)
Subacromial tenderness/bursitis

Question 13

Hallmark for rotator cuff tear

Answer 13

Weakness! (specifically abduction and external rotation)

Question 14

How to distinguish between tendinopathy and tear?

Answer 14

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)

Question 15

Gold standard for evaluation of full thickness rotator cuff tear

Answer 15

MR arthrogram

Question 16

Acute therapy for rotator cuff tear

Answer 16

Ice, NSAIDs, weighted pendulum stretching 5 min 2xday, restrict overhead movement, shoulder immobilization for short time (so don’t get frozen shoulder), maybe pt

Question 17

When would you do a subacromial steroid injection with a rotator cuff tear?

Answer 17

When there is secondary bursitis

Question 18

Surgery for rotator cuff tear

Answer 18

Arthroscopic repair 
Joint arthroplasty (replacement)- trade off for pain versus mobility after

Question 19

Number 1 reason someone gets rotator cuff tendonitis

Answer 19

Shoulder impingement syndrome

Question 20

Presentation of impingement

Answer 20

Nearly identical to rotator cuff tendonitis
Subacromial tenderness
Normal glenohumeral joint ROM (restricted due to pain)
Preserved strength

Question 21

Hallmark finding of impingement

Answer 21

Pain reproduced by the painful arc of flexion-internal rotation maneuvers

Question 22

Scale of impingement in Neers test

Answer 22

Pain at 90 degrees: mild
Pain at 60-70 degrees: moderate
Pain at 45 or below: severe

Question 23

When do you use radiography in impingement?

Answer 23

For the patient’s first visit because do not want to miss bone problem

Question 24

Tx of impingement

Answer 24

Ice, NSAIDs, activity modifications
No arm sling recommended
PT referral
May use corticosteroid injections if persistent pain

Question 25

MOI for labral tear

Answer 25

``` Acute (FOOSH, sudden pull) Repetitive overuse (throwing athlete, laborer) ```

Question 26

Clinical presentation of labral tear

Answer 26

Acute: pain Chronic: clicking/catching

Question 27

Bankart lesion

Answer 27

labral tear of inferior rim often associated with a dislocation

Question 28

SLAP tear

Answer 28

Superior Labrum Anterior Posterior tear (extends anterior to posterior in curved fashion)

Question 29

Physical exam during labral tear

Answer 29

Biceps tendon: pain Glenohumeral joint: restricted internal/external rotation Scapula: motion dysfunction

Question 30

Specialized exams for labral tear

Answer 30

Anterior glide, speeds, o'brien's

Question 31

Preferred imaging for labral tear

Answer 31

MR arthrogram with arthroscopy as definitive for diagnosis

Question 32

Tx for labral tear

Answer 32

Nonsurgical preferred | NSAIDs, acetaminophen and PT

Question 33

What is adhesive capsulitis?

Answer 33

Chronic shoulder pain with gradual global limitation in ROM due to stiffened glenohumeral joint and may develop adhesions Frozen shoulder

Question 34

How to diagnose adhesive capsulitis?

Answer 34

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

Question 35

Apley scratch test in adhesive capsulitis

Answer 35

Normal patients should be able to scratch their midback at T8-T10 (compare!)

Question 36

What you will see in imaging of adhesive capsulitis?

Answer 36

Radiography (limited in diagnostics but usually ordered) | MRI or MRA not needed but may see thickening of joint capsule and ligaments

Question 37

Tx of adhesive capsulitis

Answer 37

Treat any underlying, stretch lining of joint, restore ROM | Most are self-limiting and respond to conservative therapy

Question 38

MOI for AC injury

Answer 38

Frequently injured in fall onto tip of the shoulder with arm tucked into side (will see a bump that is uncomfortable at bed time)

Question 39

Test used in AC injury

Answer 39

Passive cross body adduction (cross-over) because see AC compression

Question 40

AC sprain/separation grades

Answer 40

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)

Question 41

Tx for AC sprain

Answer 41

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

Question 42

Where do the majority of clavicle fractures occur?

Answer 42

Middle 1/3

Question 43

What imaging is needed in a clavicle fracture?

Answer 43

Single AP radiograph of clavicle

Question 44

When do you refer clavicle fracture as opposed to normal conservative tx?

Answer 44

Displaced mid claficle fx and all proximal/distal 1/3 fxs

Question 45

Subacromial bursitis

Answer 45

Inflammation or degeneration of sack-like structure from repetitive movement or systemic disease (RA, gout, sepsis)

Question 46

Presentation of subacromial bursitis

Answer 46

Global/achy pain with ROM and rest, localized TTP, some decreased ROM

Question 47

Tx for subacromial bursitis

Answer 47

Fluid aspiration if needed if think sepsis | Ice and NSAIDs, restrict overused, aspiration and steroid injection

Question 48

Clinical presentation of biceps tendonitis

Answer 48

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

Question 49

Tests for biceps tendonitis

Answer 49

Yergasons, Speeds

Question 50

Tx for biceps tendonitis

Answer 50

NSAIDs, rest, PT, steroid injection, surgery

Question 51

Most common shoulder dislocation

Answer 51

Anterior

Question 52

Tests for glenohumeral dislocation

Answer 52

Sulcus sign, glenohumeral instability assessment with apprehension and relocation test (gold standard) When see them hold arm in position of protection

Question 53

Radiography for GH dislocation

Answer 53

AP, Y and axillary views beneficial to see which direction it moved

Question 54

Tx for GH dislocation

Answer 54

Reduction if needed, shoulder immobilizer for 2-4 wks, analgesics, pt, surgery with repeat dislocations

Question 55

Special considerations with anterior shoulder dislocations

Answer 55

Bankart lesion, Hills Sachs lesion, axillary nerve

Question 56

Hills Sachs Lesion

Answer 56

Cortical depression of posterolateral humeral head when humeral head is impacted by anterior rim of glenoid (fracture humerus)