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