Orthopedics
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| Shoulder: 4 joints: | SC, AC, GH, Scapulothoracic
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| Acromion process Type I: | Flat, smooth acromion at clavicular joint; normal subacromial space
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| Acromion process Type II: | Hooked acromion; subacromial space mildly decreased
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| Acromion process Type III: | Hooked acromion with spur; subacromial space significantly decreased
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| Shoulder Hx: unusual aspects | hand dominance; Night pain; Clunks, pops; Neck pathology
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| Scapular winging/trauma = | Serratus or Trapezius dysfxn
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| Unable to externally rotate = | Posterior dislocation
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| Supra/infraspinatus wasting = | RCT or suprascapular n. palsy
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| Dec. cervical ROM, pain below elbow = | Cervical disc disease
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| Throwing athletes/ ant. Pain = | Instability
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| Pain or “clunk” w/ motion = | Labral tear
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| Generalized laxity = | Multidirectional instability
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| Shoulder Exam: significant: | Asymmetry; Atrophy; Apley scratch test
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| Rotator cuff: tests for impingement | Neer; Hawkins (both passive)
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| Test of AC joint | crossover (passive)
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| Tests for biceps tendonitis | Speeds; Yergason (both active)
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| Tests for anterior shoulder instability | Sulcus; apprehension & relocation (both passive)
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| Tests for labral tears | Obrien; anterior slide; crank
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| Circulation tests | Adson; Allen; Roos
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| Shoulder imaging: Standard views: | AP and axillary
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| Imaging: Can get Y view if: | suspected dislocation or scapular fx (trauma)
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| On shoulder imaging: may see: | bony bankhart, Hill-Sachs (uncommonly), or spur; tumor or fx; elevated humeral head (RCT); AC separation or DJD
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| Best imaging for RCT | CT arthrogram good, but MRI is better (invasive)
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| CT is good for: | bone abnormality; tumors
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| MRI for RCT | 95% sensitivity & specificity in detecting RCT
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| MRI good for: | RCT; SLAP lesions (Arthrogram); Soft tissue
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| Ultrasound: Positives | Non-invasive; Cost; Portable
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| Ultrasound: Negatives | Quality; User dependent
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| Shoulder Injections | Depo medrol w/ lidocaine & bupivacaine HCl (total of 10 mL); 25 gauge 1.25-1.5 needle
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| Common Injection Solutions | Depo Medrol, Celestone; Dexamethasone; Kenalog
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| Depo Medrol, Celestone = | shorter acting, less irritating
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| Dexamethasone = | Medium (duration)
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| Kenalog = | Long acting, slightly more painful initially; mix with lidocaine & marcaine
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| 5% of all fractures seen by FP = | Clavicle Fx
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| Clavicle Fx: MOA | FOOSH, onto shoulder, direct trauma
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| Clavicle Imaging | AP, 45 degree cephalic tilt
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| Grades of AC Separations: | 6 different grades
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| AC Separation: MOA | Usually direct blow to shoulder
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| AC Separation: PE: | step deformity, TTP AC joint, (+) crossover sign
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| AC Separation: Radiographs: | AP, Zanca (100 cephalic tilt), axillary
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| AC Separation: Grade 3 & above: | Refer for poss surgical fixation, otherwise conservative care (sling)
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| AC Separation: RTP when: | pain-free with abduction, crossover
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| Anterior SC Dislocation: MOA | Anterior usually MVA
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| Anterior SC Dislocation: PE: | TTP SC joint, deformity
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| Anterior SC Dislocation: Radiographs: | AP, 40 degree cephalic view
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| Anterior SC Dislocation: Mgmt | Usually conservative; Sling, ROM
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| Posterior SC Dislocations: MOA | Usually fall on flexed and adducted shoulder
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| Posterior SC Dislocations: Concern | Can be life-threatening; immediate referral and CT
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| Posterior SC Dislocations: Mgmt | Closed reduction or surgical reduction
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| 95% of shoulder dislocations are: | Anterior Dislocations
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| Anterior Shoulder Dislocations: usually held in: | ext. rotation and abduction
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| Cf to anterior, posterior shoulder dislocations have: | limited external rotation
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| Anterior Shoulder Dislocations: Radiographs: | AP and axillary or Y
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| Anterior Shoulder Dislocations: Mgmt | Acute: reduction (Stimpson or Kocher)
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| Anterior Shoulder Dislocations: Complications: | recurrent dislocations, bony injury (Hill Sachs, or Bankhart), RCT , NV injury, arthropathy (later)
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| Anterior Shoulder Dislocation: Tx | once reduced, sling w/ mobilization in 2 wks
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| Rotator cuff disorder: age of most pt | usually > 40 y.o. unless traumatic
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| Rotator cuff disorder: S/S | Insidious onset, worse w/ overhead activity, night pain
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| Rotator cuff disorder: PE: | ROM, RC strength, Hawkins/Neer, Jobe
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| Rotator cuff disorder: Tx & CI | Injections contraindicated if there is a partial tear
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| Rotator cuff disorder: Tx (conservative) | NSAIDs, ice, avoid painful activity, PT, injections
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| Rotator cuff disorder: Tx (surgical) | arthroscopy vs open
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| Biceps Tendonitis: usu assoc with: | other pathology (RCT, SLAP tear); may rupture if RCT worsens
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| Biceps Tendonitis: Tx | NSAIDs, corticosteroid injection, PT
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| Biceps Rupture: age of pt | Usually > 50 yrs old
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| Biceps Rupture: usually involves: | long head of biceps (short head rupture rare)
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| Biceps Rupture: S/S | pop, ecchymosis
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| Adhesive Capsulitis = | Contraction of capsule (Frozen Shoulder )
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| Adhesive Capsulitis: Usually secondary to: | immobilization after injury
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| Clin dx of Adhesive Capsulitis: what is key? | ROM (usually lose external rotation first)
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| Adhesive Capsulitis: mgmt | PT, NSAIDs, injections; may need surgical lysis of adhesions
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| 3 Stages of Adhesive Capsulitis | Painful; Adhesive; Recovery
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| SLAP Lesions = | Superior Labral Anterior Posterior
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| SLAP Lesions S/S | Painful shoulder with clicks, pops with motion
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| SLAP Lesions: PE | Pos clunk test, crank test, OBriens, sometimes instability or biceps tendonitis; MRI
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| SLAP Lesions: tx | Conservative tx (NSAIDs, PT, rest); arthroscopy vs open repair
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| Tests for posterior shoulder instability | Pt supine, elbow flexed 90, arm abducted to 90; push postly, pos test = pt apprehension & laxity
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| Posterior shoulder dislocations cf to anterior: | Posterior will have limited external rotation cf to anterior dislocations
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| Clavicle Fractures: most common geography | middle third (followed by distal third); most common place at jnct btw middle & distal 1/3
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| Clavicle Fx: PE: | edema & pt tenderness over fx site; assess ROM of neck, shoulder; motor strength, sensation; SC dislocations
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| Clavicle fx: Tx | Sling; Figure of 8 (sig displacement, use of arms for ADLs); Periodic ROM; No contact sports for 6 wks
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| Clavicle Fx: When to Refer? | NV compromise; open fx; symptomatic non-union at 12 wk; Cosmesis; Distal third (? physeal injury, AC injury); Proximal third (SC joint dislocation)
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| Rotator cuff disorder: DDX: | Instability; SLAP; Bursitis; Referred pain ; Calcific tendonitis; Thoracic outlet syndrome; Adhesive capsulitis
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| Ant Shoulder Dislocation: may need surgical repair | Thermal capsular shift (subluxations); arthroscopy vs open repair
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| Biceps Rupture: Mgmt | Conservative: Proximal (most); MRI if dx uncertain; Tenodesis within 3-4 wks prn (Distal)
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| Adhesive Capsulitis: epidemiology | assoc w/ other illnesses (DM, thyroid, recent chemo/ rad); F >> M (increased estrogen receptors around shoulders)
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| Adhesive Capsulitis: Painful stage | (0-3 months); pain w/ movement; genl ache; mx spasm; inc noc/ rest pain
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| Adhesive Capsulitis: Adhesive stage | (3-6 months); Less pain; inc stiffness & restricted movement; less noc pain; pain at extreme ranges of movement
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| Adhesive Capsulitis: Recovery stage | (>6 months); dec pain; restrictn w/ slow, gradual inc ROM; recovery spontaneous, often incomplete
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| rotator cuff PE | RC: pain, less ROM w/overhead supraspinatus (empty can) weak to abd; Neers: pain w/forward flexion; Hawkins: pain on int rotation; + drop off test
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| most common causes of shoulder pain in absence of trauma = | RC tendonitis, bursitis, bicipital tendonitis
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| Shoulder pain DDx | rotator cuff, subacromial bursitis (pain/TTP), humerus fx, biceps tendonitis (groove TTP), GH OA, SLAP tear (no weakness)
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| Shoulder pain after repetitive activity, point tenderness at anterior humerus or AC joint. + drop arm test or apprehension test | Rotator cuff injury (SITS muscles)
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| ROM: Shoulder | Flexion: 0-170; Extension: 0-40; Abduction: 0-150; Adduction: 0-30; External rotation: 0-90; Internal Rotation: 0-80
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| Avulsion of the antero-inferior glenoid labrum = | Bankart lesion
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| Compression fx of posterior humeral head = | Hill-Sachs lesion
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| Shoulder dislocation: xray & reduction maneuvers (3): | Rowe (opposite ear over head), Stimson (prone), Hippocratic (traction)
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| Most common cause of shoulder pain | impingement
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| Single most sensitive and specific physical exam finding in rotator cuff tears | weakness with resisted external rotation and or abduction
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| Tests for anterior shoulder instability | Sulcus; apprehension & relocation (both passive)
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| AC Separation: MOA | Usually direct blow to shoulder
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| AC Separation: PE: | step deformity, TTP AC joint, (+) crossover sign
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| Anterior SC (sternoclavicular) joint dislocation: PE: | TTP SC joint, deformity
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| Posterior SC Dislocations: MOA | Usually fall on flexed and adducted shoulder
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| Posterior SC Dislocations: Concern | Can be life-threatening; immediate referral and CT
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| Posterior SC Dislocations: Mgmt | Closed reduction or surgical reduction
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| Anterior Shoulder Dislocation: Tx | once reduced, sling w/ mobilization in 2 wks
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| Rotator cuff disorder: age of most pt | usually > 40 y.o. unless traumatic
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| Rotator cuff disorder: PE: | ROM, RC strength, Hawkins/Neer, Jobe
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| Rotator cuff disorder: Tx (conservative) | NSAIDs, ice, avoid painful activity, PT, injections
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| Rotator cuff disorder: Tx (surgical) | arthroscopy vs open
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| Biceps Tendonitis: PE: | TTP Bicipital groove, Speeds, Yergasons
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| Biceps Rupture: age of pt | Usually > 50 yrs old
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| Clavicle Fractures: most common geography | middle third (followed by distal third); most common place at jnct btw middle & distal 1/3
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| Clavicle Fx: PE: | edema & pt tenderness over fx site; assess ROM of neck, shoulder; motor strength, sensation; SC dislocations
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| Clavicle fx: Tx | Sling; Figure of 8 (sig displacement, use of arms for ADLs); Periodic ROM; No contact sports for 6 wks
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| Biceps Rupture: Mgmt | Conservative: Proximal (most); MRI if dx uncertain; Tenodesis within 3-4 wks prn (Distal)
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| Adhesive Capsulitis: epidemiology | assoc w/ other illnesses (DM, thyroid, recent chemo/ rad); F >> M (increased estrogen receptors around shoulders)
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| Indications for rotator cuff repair | <60 yo, or 60-70 yo with favorable medical history and comorbidities
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| Shoulder dislocation that is the most common | anterior
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| Two fractures associated with the shoulder | Bankart, Hill-Sachs
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| Shoulder exam: active tests (3) | empty can, lift off, infraspinatous
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| Shoulder exam: passive tests (4) | Neer, Hawkins, sulcus, cross arm
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