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Shoulder

Orthopedics

QuestionAnswer
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