Upper Extremity Orthopedic Conditions Flashcards
shoulder pain possible causes
Impingement
- Subacromial bursitis
- Rotator cuff tendonitis
- Biceps tendonitis
Rotator Cuff Tear
-Partial or full thickness tear
Arthritis of Glenohumeral Joint or Acromioclavicular Joint
clinical symptoms of shoulder pain
- Pain with attempts at overhead or “impingement” type motion
- Pain that prevents them from sleeping on affected side
- Radiating pain into bicep and down into forearm
- Associated upper back and neck pain
- Loss of strength
- Loss of shoulder range of motion
shoulder pain physical exam
- Inspect for any visible deformity
- Palpate for any point tenderness over biciptal groove, AC joint, posterior subacromial area
- Passive and active ROM
- Strength testing
- Special tests: Jobe (empty can), Neer, Hawkins, Speeds, Cross-body Adduction, Drop Arm
shoulder pain diagnostics
- Xray shoulder: AP, lateral and axillary view to r/o arthritic changes, evaluate shape of acromion, previous trauma
- MRI if suspect tear of rotator cuff (non contrast)
- Use contrast for instability work up
shoulder pain treatment if pain is suspected from impingement
- Oral NSAID course (4-6 wks), activity modification, physical therapy to strengthen rotator cuff and scapular musculature
- Cortisone injection: subacromial, posterolateral approach: Diagnostic as well
- No benefit from injection after 3-4 weeks then consider MRI to r/o tear of rotator cuff
- Can give cortisone injections every 3-4 months
shoulder pain treatment if pain is suspected from biceps tendonitis
- Oral NSAID course (4-6 wks), activity modification, physical therapy to strengthen rotator cuff and scapular musculature
- Cortisone injection: do not inject directly into tendon!
shoulder pain treatment if pain suspected due to rotator cuff injury
- MRI to confirm diagnosis
- Consider cortisone injection (subacromial) for pain control
- Full thickness tear, surgical referral if pt wants surgery
- Partial tear, suggest conservative treatment (see impingement)
shoulder pain treatment if pain suspected due to AC joint or GH joint arthritis
- Depending on severity may end up going straight to cortisone injection of affected area
- If extremely severe and failed conservative treatment, surgical consult
glenohumeral dislocation anterior
o Anterior dislocation most common
o Occur from either external rotation or abduction force on the humerus, a direct posterior force to the proximal humerus or posterolateral blow to the shoulder
o Anterior capsule becomes stretched or torn
glenohumeral dislocation posterior
o Posterior less common
o Posterior capsule torn or stretched
o Caused by posterior force when arm is adducted and internally rotated
o “party trick” where patient is able to sublux shoulder in and out: Subscapularis can be injured at insertion
glenohumeral dislocation clinical symptoms and physical exam
Clinical Symptoms
- Painful for patient, often associated w trauma
- Will likely be gaurding and holding arm at their side
Physical Exam
- Difficult due to pain
- Careful assessment of axillary nerve (document clearly!)
glenohumeral dislocation diagnostics and treatment
Diagnostics
- Xray of shoulder to rule out fracture of glenoid or humeral head
- Post reduction films necessary!
Treatment
-Needs to be reduced! Leave that to ER lecture
hill sachs lesion
o Hill Sachs lesion: a compression fracture of the posterolateral articular surface of the humeral head.
o Created by the sharp edge of anterior glenoid as the humeral head dislocates over it.
o Reverse Hill Sachs lesion: anterior articular surface of humerus
why do we care about dislocations
o Buzz words associated with dislocations, instability and shoulder surgery
o When large both the Hill Sachs and Bankhart lesions may predispose patient to recurrent instability with external rotation and abduction of shoulder
after shoulder dislocations are reduced
Orthopedic management: anterior
- Anterior dislocation: conservative management
- Short period of immobilization
- Gradual advance to passive rom, then active rom, then advance to strengthening
- Can be a long 3-5 month process
- If continued instability 6 months plus after injury than refer to surgeon
Orthopedic management: posterior
-Not as common, I always review these with surgeon on first visit and defer to their treatment plan
Increased chance to repeat dislocation
AC joint injury
o Typically caused by direct downward blow to the tip of the shoulder
o Severity of injury dependent on structures that are compromised
-Grade I
-Grade II
-Grade III
-Grade IV-VI
AC joint injury grades
Grade I
- Partial tear of acromioclavicular joint ligament
- No superior separation of clavicle from acromion
Grade II
- Full tear of acromioclavicular joint ligament, coracoclavicular ligament may be partially torn
- Subluxation or partial separation of clavicle from acromion
Grade III
- Both acromioclavicular joint and coracoclavicular ligaments are torn
- Complete separation of the clavicle from the acromion
Grade IV-VI
AC joint injury clinical symptoms and physical exam
Clinical Symptoms
- Focal pain and swelling over AC joint
- Pain with attempt at overhead motion of arm or cross-body adduction
Physical Exam
- Inspect for deformity over AC joint
- Focalized tenderness over AC joint
- With mild injuries can access AC joint with cross body abduction (may be too painful for grade II or higher)
AC joint injury diagnostics and treatment
Diagnostics
- Xrays: AP, lateral and axillary
- AP of both shoulders helpful if displacement or widening of joint not obvious
Treatment
- Non operative (grade I-III)
- Brief period of immobilization, followed by passive range of motion of shoulder and gradually progress to active range of motion with focus on strengthening surrounding structures
thoracic outlet syndrome
o Compression of brachial plexus and/or subclavian vessels as they exit the space between the superior shoulder girdle and the first rib
o More commonly affects females between ages 20-50
o Cause may be secondary to congenital abnormalities
thoracic outlet syndrome clinical symptoms and physical exam
Clinical symptoms
- Symptoms often vague
- May mimic distal nerve entrapment
- Symptoms from vascular compression cause intermittent swelling or discoloring of skin
- Fatigue and/or aching may be worse with arm overhead
Physical exam
o Inspect for swelling or discoloration of skin
o Compare distal pulses
o Thorough nerve function test
o Elevated Arm Stress Test (EAST): with shoulders abducted at 90 deg and braced somewhat posteriorly have patient open and close fists at moderate speed for 3 minutes. Reproduction of neurologic and/or vascular symptoms is a positive test. Fatigue wo neuro or vascular symptoms is inconclusive or negative.