Upper Extremity Injuries - Shoulder Flashcards
What are the basic orthopedic treatments?
- NSAIDs
- Ice
- Activity restriction, rest, immobilization (specific to each injury)
- PT
- OT
How can the extent of fractures be described?
- complete
- incomplete: crack/hairline, buckle, greenstick
descriptions of configurations of fractures
- transverse: straight across
- oblique: at an angle
- spiral: wrapping around the bone
- comminuted: into many pieces
- segmental: more than one area
displaced vs. non-displaced fracture
displaced can be angulated, translated, rotated, distracted, shortened, or overriding
what is very important and one of the first things you not on a fracture?
open vs closed
*affects management of fracture and care
what is the classification scheme for pediatric fractures w/ open epiphyseal plates?
- Salter-Harris
- Type 1-V
define the classifications of the salter-harris scheme
- 1: strait across
- 2: above growth plate
- 3: below the plate
- 4: two or through the plate
- 5: growth plate crushed together
95% of glenohumoral dislocations are what kind?
anterior in nature
what is the most common nerve injured during a shoulder dislocation?
axillary n.
complications d/t injured axillary n
- loss of sensation to deltoid
- loss of flexion of the wrist
what is the most common cause of a shoulder dislocation?
fall on abducted, externally rotated shoulder
PE of shoulder dislocation
- will appear slightly abducted and externally rotated
- loss of rounded appearance at acromion
- will resist movement d/t pain
what films to get w/ a shoulder dislocation
-3 view XR of should w/ axillary view
or
-scapular “Y” view*** specific for shoulder dislocation
anatomically speaking, what forms the scapular Y?
- body, spine, and coracoid process
- glenoid should fall in the center of the Y and be obscured by the humeral head
how does the scapular Y appear in dislocations?
humeral head appears medial to the “y”
what injuries are associated w/ shoulder dislocations and define them
- hill-sachs deformities: defect of humoral head caused by hitting the glenoid rim during dislocation
- bankart lesions: labral tears w/ bony fragment avulsion
tx of a shoulder dislocations
- closed reduction through manipulation of humeral head
- then post reduction XRs
- sling/immobilization w/ PT/OT
when to operate shoulder dislocations
if they are recurrent or chronic
what are the reduction techniques for shoulder dislocations?
- scapular manipulation
- upright technique
- Mitch, stimson, fares
- traction/counter traction** the one he uses
- what every you have to do to get it back in! (that’s what she said)
What is an AC joint injury?
- injury to the acromioclavicular joint involving the CC and AC ligaments
- sprains range from type I - VI
what type of injury commonly causes AC joint injury?
- fall or direct trauma to acromion
- a typical case presentation: QB gets hit and lands on his shoulder
PEs for AC joint injury
- TTP of AC joint
- crossbody adduction test
- AC shear test
crossbody adduction test
- active: pt reaches hand across to shoulder
- passive: examiner passively flexes shoulder to 90 degrees then horixontally adducts the shoulder as far as possible
- resisted: examiner resists patient’s attempt to horizontally abduct shoulder
AC shear test
- interlock fingers w/ hand on distal clavical and spine of scapula
- pain in AC joint when hands are squeezed together = positive test
- he didn’t recommend this one
radiology for AC joint injury
- get XR of shoulder
- text book: Zanca view allows AC joint to be seen w/o overlapping images - not really seen in practice
Which classifications of AC join injuries are treated conservatively vs operatively
- type I-III: conservatively w/ immobilization and PT
- type IV-VI: operative tx w/ repair of damage
what patients most commonly present w/ proximal humerus fx
elderly
common cause of proximal humerus fx
- fall or trauma
- most are treated non-operatively
PE of proximal humerus fx
-swelling, TTP, pain w/ ROM
nerve commonly injured in proximal humerus fx
axillary n.
radiology for proximal humerus fx
- 2 view XR or humerus
- or
- 3 view XR of shoulder
NEERS classification for proximal humerus fx
- Based on the anatomical relationship of the 4 major segments of the proximal humerus; anatomical neck, surgical neck, greater tuberosity, and the lesser tuberosity
- classified as one, two, three or four part
define the different parts of the NEERS classification for proximal humerus fx
- One-part: no fragments are displaced
- Two-part: one displaced fragment
- Three-part: Two displaced fragments, but humeral head remains in contact with the glenoid
- Four-part: Three or more displaced fragments and dislocation of the articular surface from the glenoid.
conservative tx vs. ORIF in proximal humerus fx
- one part: can tx conservatively
- two part and up: need ORIF
- for acute management: immobilize w/ sling and pain control
what is a possible complication of proximal humerus fx?
adhesive capsulitis (frozen shoulder)
What nerve is most commonly injured in a mid-shaft humerus fx?
radial n. **
possible complications when radial n. is injured?
- decreased wrist, finger, and thumb extension
- sensory loss at dorsum of hand
radiology for mid-shaft humerus fx
-2 view of humerus
tx of mid-shaft humerus fx
- initially: splint and/or immobilization w/ sling
- surgical tx w/ ORIF
possible complications from mid-shaft humerus fx
- radial n. palsy
- non-union
an example of how to present a mid shaft humerus fx:
“I’ve got a closed fx of the mid shaft humerus that appears to be comminuted”
or
“i’ve got a closed comminuted mid shaft fx of the left humerus. no nerve palsy, pain is controlled, will you see her in your clinic in a few days?”
supracondylar fx of the humerus
- uncommon in adults
- more info in peds
clavicle fx
- typical in who?
- MC site
- typical in young children
- MC in middle third
clavicle fx is commonly caused by what?
fall on shoulder
PE of clavicle fx
- pain/swelling to localized area
- possible hematoma formation
what is a sign of significant displacement of the clavicle?
tenting of skin
radiology in clavicle fx
- XR of shoulder w/ widened view to include clavicle
- want to assess shoulder for additional injury
indications for emergent ortho referral in clavicle fx
- tenting of skin
- open fx
location of clavicle fx in relation to tx
- middle third: tx conservatively
- distal third: need ortho eval and possible surg
rotator cuff is made up of the tendons of what muscles?
SITS
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
rotator cuff tendonitis
- source of morbidity
- types of activities
- common in manual laborer and athletes
- over head activities: swimming, tennis, baseball/softball, weight lifting, etc
PE of rotator cuff tendonitis
- shoulder pain w/ overhead motions
- pain w/ ABduction > 90 degrees w/ internal rotation
special tests for rotator cuff tendonitits
- Neer
- Hawking
- Empty can
- Lift off/ belly press test
- note: can have pain in these tests from many shoulder problems - not just specific to rotator cuff
neer’s test
- place hand on pts scapula, other on forearm
- pt fully internally rotates (thumb points down)
- passively forward flex arm through full ROM
- pain = impingement
hawking test
aka hawkins-kennedy test
- flex arm to 90 degrees
- stabilize shoulder w/ one hand
- forcibly internally rotate shoulder, thumb pointed down
- pain = impingement
tx for rotator cuff tendonitits
- non-operative:
- basic ortho care
- steriod injections: don’t exceed 3-4 per year d/t risk of tendon necrosis
- PT/OT: underused!!
rotator cuff tear
-same tendons as rotator cuff tendonitis, just separated from the bone
what radiologic modality to order to confirm rotator cuff tear?
MRI of shoulder
tx of rotator cuff tear
surgery
what is the labrum
cartilaginous tissue around the edge of the glenoid
when do labrum tears often occur?
- in shoulder dislocations
- overuse injury
SLAP tear
- superior labrum anterior and posterior
- common in pitchers
what is the special test for a SLAP tear?
O’brien’s sign
O’brien test
- aka active compression test
- pt. flexes GH joint to 90 degrees and horixontally adducted 15 degrees from sagittal plane
- downward pressure is applied w/ humerus fully internally rotated and externally rotated
- if pain w/ internal rotation but decreases w/ external rotation and there is clicking = SLAP
special test for anterior labrum injury
apprehension test
apprehension test
-as should is moved passively into max external rotation in abduction and foward pressure is applied to posterior aspect of humeral head, pt complains of pain or instability
special test for posterior labrum injury
jerk test
impingement syndrom
- combo of shoulder sx that cause limited ROM and pain secondary to impingement
- very very painful
PE of impingement syndrome
- positive Neers and Hawking’s sign
- pain w/ ROM above head and should ABduction > 90 degrees
tx for impingement syndrome
- conservative: 4-6 mo.
- if conservative fails: operative
what is the MC form of impingement syndrome?
subacromial decompression
adhesive capulitis
- GRADUAL development of global limitation of active and PASSIVE ROM
- literally cannot move shoulder
what is a common presentation of adhesive capsulitits
-50-60 yo women w/ DM
PE of adhesive capsulitis
-nagging pain at night and progressive global stiffness in the absence of other pathology
tx of adhesive capsulitis
- conservative
- surgery not typically helpful
- manipulation under anesthesia has been proven effective
