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Ortho Test 1-Shoulder girdle disorders/injuries*
Terms in this set (143)
Etiology of scapular fx?
Result of high energy trauma
Epidemiology of scapular fx?
1% of fractures (uncommon)
M/F 64% in males
Usually has associated injuries- ribs (53%), pneumothorax (47%), head/spine trauma (39%)
Often missed b/c of other body trauma
Clinical presentation of scapular fracture?
Pt holding arm close to side
Pain w/ movement
What will be seen on PE w/ scapular fx?
Tender to palpation
Dx of scapular fx?
x-ray- often not able to sit upright, obtain chest and shoulder films
CT- for poorly visualized fracture involving the joint itself (glenoid)
Tx of scapular fracture?
Non-operative w/ arm in sling
Early ROM as tolerated
Consider admission due to pulm contusion
Referral of scapular fx?
Displace fracture >2mm
Fractures of neck of scapula (>30° angulation)
Acromion fractures w/ impingement signs
Eiology of clavicular fx?
Indirect or direct trauma to clavicle
Epidemiology of clavicular fx?
Most common in children and young adults
2.6% of fractures
Incidence decreases in adulthood and increases again in elderly
What do medial fx's of clavicle usually occur from?
Anterior chest trauma
What are distal clavicle or acromion fx's due to?
Where do most fx's occur in the clavicle?
Medial 1/3- 5%
Middle 1/3- 80%
Lateral 1/3- 15%
Clinical presentation of clavicular fx?
Hx of injury
Outstretched arm or direct impact
What can be seen on PE of clavicular fx?
Decreased ROM of shoulder w/ pain over fx
Feel gliding of clavicle
What to make sure to examine w/ clavicular fx?
Neurovascular function distal to the fracture
Axillary, musculocutaneous, median, ulnar and radial nerves- sensation of UE's, muscle strength in UE's, reflexes (brachioradialis, biceps, triceps)
Evidence of decreased perfusion- skin color changes, diminished pulses
Dx of clavicular fx?
X-ray- AP view (10° cephalic tilt)
CT- medial clavicle fx's
Classifications of clavicular fx?
Know- medial end (15-A type), diaphysis (15-B), lateral end (15-C)
Tx of clavicular fx?
Most mid-shaft fx's are nonsurgical
Figure 8 brace
After 3-4 weeks start gentle shoulder exercises
NSAIDs for pain
When should clavicular fx's be reduced or not?
Middle third is almost never required- manipulation can cause neurovascular injury
Displaced lateral or medial third fx's require orthopedic referral
Open fractures- ORIF
Nonunion over 4 months
When should clavicular fx's undergo surgery?
Displaced fx of distal clavicle
Any medial clavicular fx
Comminuted or severely shortened overall clavicle length- >2cm if over 12 yrs
Skin over fx at risk
Displaced lateral 3rd fx's
Adverse outcomes of clavicular fx's?
Neurovascular copmlications (rare)
Malunion- visual or palpable lump
Degenerative arthritis if AC intra-articular involvement
Etiology of proximal humerus fx?
High energy trauma in adults
Epidemiology of proximal humerus fx?
Usually in children and osteoporotic pts
4-5% of all fx's
80-85% have no displacement or are minimally displaced
Clinical presentation of proximal humerus fx?
Hx of mechanism of injury
Find out pt's dominant hand it may change tx
PE tests/findings in proximal humerus fx?
Arm may be rotated
Neurovascular testing- if complaints of numbness (nerve injury), distal extremity is pale (vascular injury), skin inspection, DTR, cap refill, strength, sensation
Inspect for lacerations, contusions or signs of open fx
Dx of proximal humerus fx?
X-ray- Trauma series of shoulder
AP, axillary view, scapular Y
Tx of proximal humerus fx?
Minimal displacement- sling w/ exercise after 3 weeks and signs of healing
Early ROM to decrease frozen shoulder
PT w/ humeral fracture protocols
When do refer proximal humerus fx's to surgery?
Angulated >45° or >1cm displacement
Displacement of greater tuberosity >0.5 cm
Displaced 2-part fractures
All 3 and 4-part fractures
Any neurovascular involvement
Adverse outcomes of proximal humerus fx's?
Dislocation of shoulder- get axillary view to see alignment of humeral head and glenoid fossa
Etiology of humeral shaft fx's?
Result of direct blow to the arm- MVA, fall, impact sports
What do we worry about w/ humeral shaft fx's?
Radial nerve entrapment
Clinical presentation of humeral shaft fx's?
Severe pain and swelling
Palpation moves the shaft
Radial nerve entrapment (rare)
PE in humeral shaft fx's?
Asses neurologic funtion- ulnar, radial and median nerves
Assess radial pulse
What are signs of radial nerve entrapment?
Radial nerve palsy
Unable to extend the wrist or fingers
Can have loss of posterior hand sensation
Dx of humeral shaft fx's?
AP and lateral views
Obtain shoulder and elbow films too
Tx of humeral shaft fractures?
Usually tx'd non surgically
20° angulation is acceptable
Fx's <2cm displacement can be splinted for a few weeks and transitioned to fracture brace
Brace for additional 6 weeks
Sling distal arm
Encourage ROM of elbow, wrist and hand
When is surgery indicated (ORIF)?
If the radius and ulna are also fx'd
Displaced comminuted fx's
Nonunion >3 months of tx
Associated head injury/seizures
Adverse outcomes of humeral shaft fx's?
Radial nerve injury
Stiff shoulder and/or elbow
Splint irritating skin
What are examples of joint disorders?
Subacromial impingement syndrome
Adhesive capsulitis (frozen shoulder)
Acromioclavicular joint separation
Sternoclavicular joint injuries
Etiology of subacromial impingement syndrome?
Due to repetitive movements
Common in athletes w/ overhead activities
(the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion)
Epidemiology of subacromial impingement syndrome?
Mostly seen in middle age
Clinical presentation of subacromial impingement syndrome?
Anterolateral aspect of shoulder
Overhead movement increases pain
Pain at night, can't sleep on affected side.
Atrophy of muscles of chronic
PE tests/findings in subacromial impingement syndrome?
Palpation over lateral acromion and greater tuberosity
Worse pain w/ 90-120° of abduction of shoulder
Neer impingement sign
Hawkins impingement sign
Test supraspinatous strength (empty can test)
How to do Neer sign?
Lock elbow, internally rotate arm
Grab wrist and flex shoulder
Free hand on scapula to stabilize it
The greater tuberosity can compress against anterior acromion
How to do Hawkin's sign?
Reinforce Neer testing
Shoulder is flexed to 90°, elbow at 90° and ratchet arm internally
How to perform empty can test?
Arm is straight w/ thumb pointing down
Shoulder flexed at 90°
Arm is abducted to 30°
Apply downward pressure while pt resists
W/ empty can test, if the pt is initially week and then is strong after subacromial injection what do you suspect?
Most likely tendonitis or bursitis
Less likely to be a tendon tear of rotator cuff
What is sulcus sign?
Muscle atrophy of the posterior and superior aspect that usually indicates a rotator cuff tear
It is an orthopedic evaluation test for glenohumeral instability of the shoulder. With the arm straight and relaxed to the side of the patient, the elbow is grasped and traction is applied in an inferior direction. With excessive inferior translation, a depression occurs just below the acromion
Dx of subacromial impingement syndrome?
X-ray: AP and axillary views
Narrowing space between humeral head and inferior aspect of acromion on AP view
Tx of subacromial impingement syndrome?
NSAIDs and rest
Stretching program- posterior capsular stretching
Home PT- for 6 weeks
Formal PT if tx not helping w/in 3-4 weeks
Corticosteroid injection if continued discomfort or not improving after 6 weeks
When to refer subacromial impingement syndrome?
Substantial weakness of rotator cuff
Failure of 2-3 months of PT
Adverse outcomes of subacromial impingement syndrome?
NSAID dyspepsia/ulceration/hepatic issues
Tear of rotator cuff or biceps tendon
What is adhesive capsulitis (frozen shoulder)?
Idiopathic loss of both AROM and PROM
Different from post traumatic shoulder stiffness
Epidemiology of adhesive capsulitis (frozen shoulder)?
40-60 yr olds at highest risk
More frequent in women
What is the greatest risk factor of adhesive capsulitis (frozen shoulder)?
Type 1 DM
What are other conditions that adhesive capsulitis (frozen shoulder) is common in?
Cervical disk herniation
Cerebral hermorrhage and tumors
What are the different phases of adhesive capsulitis (frozen shoulder)?
Clinical presentation of adhesive capsulitis (frozen shoulder)? (three phases)
Freezing phase- pain w/ movement of shoulder, ROM starts to decrease
Frozen stage- pain diminishes but ROM continues to decrease
Thawing phase- slow return of ROM
Phases can take 6-24 months until resolution of condition
PE tests/findings of adhesive capsulitis (frozen shoulder)?
50% reduction in both AROM and PROM
Affected arm lacks external rotation due to contracture of coracohumeral ligaments, this is pathognomonic.
Pain at insertion of deltoid is common
Should is diffusely tender to palpation
Dx of adhesive capsulitis (frozen shoulder)?
X-ray: AP and axillary views to view osteophytes (bone spurs), loose bodies, tumors, Ca deposition
MRI- see contracted capsule and loss of inferior pouch of axillary recess
Tx of adhesive capsulitis (frozen shoulder)?
Corticosteroid injection- avoid multiple injections
Educate that recovery period could be 1-2 yrs
Resolves on own 80-85% of time
Ice after stretching to minimize inflammation
PT goal is to reduce pain and increase mobility
When to refer adhesive capsulitis (frozen shoulder)?
No substantial change w/ 3 months of rehab or failure of tx
What is the most common location of joint instability?
Different between dislocation and subluxation?
Dislocation- abnormal separation of joint
Subluxation- partial dislocation
What are two different modes of dislocation?
Where can instability be in a dislocated shoulder?
What is the most common direction of traumatic and atraumatic dislocation?
What is multidirectional instability (MDI)?
Aka atraumatic shoulder instability
Described as laxity of the shoulder's glenohumeral joint in multiple directions.
Clinical presentation of shoulder dislocation?
Pt states joint slipped out
Initial anterior subluxation is from substantial trauma- fall or forceful throwing motion
Subsequent dislocation may lead to instability w/ overhead activities
MDI- vague sxs related to activity. Some pts can voluntarily dislocate shoulder due to MDI
PE findings of shoulder dislocation?
Pain w/ movement
Anterior dislocation- arm held in neutral position, internal rotation may be difficult.
Posterior dislocation- arm often adducted and internally rotated, external rotation is impossible
Axillary nerve- needs to be assessed pre and post reduction- sensation over deltoid, deltoid contraction
What tests to perform w/ shoulder dislocation?
Apprehension test- assess recurrent anterior instability
Sulcus sign- assess inferior laxity
Jerk test- assess posterior laxity
Dx of shoulder dislocation?
Shows posterior dislocation (light bulb)
What are key x-ray findings w/ shoulder dislocation?
Both due to anterior sublux/dislocations
What is bankart lesion?
Injury to anterior and inferior aspect of glenoid labrum
Can create a loose space that the humeral head can slip into
What is hill-sachs lesion?
Depression fracture of posterior humeral head
What are some examples of things that cause posterior shoulder dislocation?
Uncommon, seen w/ seizures and electric shock
Occurs w/ adduction w/ internal rotation position
Tx of shoulder dislocation?
Reduction of sublux/dislocation
Reduce as close to time of injury as possible- gets more difficult w/ time
First time dislocation/reduction- immobilize in neutral position for 3-4 weeks. PT for cuff strengthening
Atraumatic dislocations- PT avoid activities that may cause dislocation
Adverse outcomes of shoulder dislocation?
80% of posterior dislocations are missed on initial eval
When to refer shoulder dislocation?
Closed reduction fails
Recurrent dislocations ≥2 despite 3 months or more of rehab
Epidemiology of acromioclavicular (AC) joint separation?
More common among physically active people
Commonly cause by a fall directly on tip of shoulder- fall off bicycle, rugby, MMA, Skiing etc
Classifications of acromioclavicular joint separation?
The separation increases in severity as the classification type increases in number
What is type 1 AC joint separation?
Coracoclavicular ligaments are intact and strong which prevents superior elevation of clavicle from acromion
No superior separation
What is type 2 AC joint separation?
AC ligaments torn
CC ligaments are intact
Widening of AC joint compared to contralateral side
Moveable anterior to posteriordirections
What is type 3 AC joint separation?
AC ligaments completely torn
CC ligaments are torn- wide CC joint
Superior displacement- ≥30%
Spring sign evident
What are type 4 and 5 AC joint separations?
AC ligaments completely torn
CC ligaments are torn
Superior and posterior displacement
Type 5 is more superiorly displaced than type 4
What is type 6 AC joint separation?
Super bad condition
Clinical presentation of AC joint separation?
Complain of pain over the AC joint
Pain w/ lifting the arm
Physical deformity in type 3-6
Pt holds arm in adduction
Any motion induces pain especially abduction
PE findings of AC joint separation?
Tender to palpation over the AC joint
May have palpable deformation w/ type 2
Definite deformation w/ type 3-6
Elevation of arm can reduced AC separation
Spring test or piano key sign
Dx of AC joint separation?
X-ray: w/ and w/o weights
AP of both shoulders
Type 1- normal x-rays
Type 2-6: indicate separation of AC joint elevation
Tx of type 1 and 2 AC joint separation?
Sling until pain subsides
Ice for first 48 hrs
Return to activity as pain allows- usually w/in 4 weeks
Tx of type 3 AC joint separation?
Surgical or non surgical tx
If person is not very physically active you may treat nonsurgical
Young manual labor, or similar type of pt may require surgery
Tx of type 4-6 AC joint separation?
Require referral and surgical repair
Adverse outcomes of AC joint separation?
Stiffness due to prolonged sling use
KT tape- skin breakdown
AC arthritis regardless of tx type
What occurs in a sternoclavicular joint injury?
Tears of the soft tissue of the joint
Capsule tears lead to subluxation or dislocation- ant or post dislocation
Is anterior or posterior sternoclavicular injury more common?
Anterior dislocations are most common, complications are rare- lump in chest, arthritis
Posterior dislocation is less common- 25% of posterior dislocations have complications
What are some complications of posterior sternoclavicular joint injury?
subclavian artery or vein occlusion
Clinical presentation of sternoclavicular injury?
Anterior- Hx of trauma to upper chest or shoulder, tenderness over proximal clavicle, prominence of proximal clavicle
Posterior- hx of trauma to chest wall, hoarseness, dysphagia, respiratory distress
Tx of sternoclavicular joint injury?
Anterior- nonsurgical, sling it, hard to maintain reduction
Posterior- reduce early
2-3 of sling immobilization
DO NOT elevate arm for at least 3 weeks
ROM exercises at 3 weeks
Refer if medial clavicular fractures
What are examples of tendonopathies?
Rotator cuff tears
Rotator cuff tendonitis
Rupture of the long head of biceps tendon
What is the purpose of the rotator cuff?
Stabilize, rotate, and lift humerus
What are the four muscles that make up the rotator cuff?
Supraspinatus- lifts and stabilizes humerus, assists in abduction
Infraspinatus- main external rotator, helps extend arm
Teres minor- smalles muscle of cuff, assists in ER
Subscapularis- stabilize shoulder, internal rotator and adductor
What do rotator cuff tears (RCT) occur from?
Acute trauma or chronic issues
Age related degeneration
Chronic mechanical impingement
Which of the four muscles of the rotator cuff suffers the most tears?
Supraspinatus w/ progression anteriorly and/or posteriorly
T/F- full thickenss tears rarely happen in the rotator cuff in people >40 years
False. Rare in pts <40 yrs
25% of people over 60 yrs have an RCT
Clinical presentation of rotator cuff tears (RCT)?
Most are asymptomatic or mild sxs and nondisabling
Complaint of shoulder pain for several months
Most can contribute to injury or incident
Pain when sleeping and unable to sleep and affected side are characteristic for rotator cuffs
Weakness, catching or grating feel in shoulder esp when raising arm overhead
Atrophy of infraspinatus= sunken shoulder blade
PE findings/tests of rotator cuff tears (RCT)?
AROM- may be limited
W/ large tears, pt can't abduct affected arm
Shrug of shoulder in attempt to abduct
Pt may struggle keeping arm abducted at 90°
Jobe/empty can and full can tests
Drop arm test
ER- pt resists pressure, + if pain
Lift off test
Painful arc test- slowly abduct laterally w/ palms forward
What muscle is tested w/ jobe/empty can and full can tests?
How to perform jobe/empty can and full can tests?
Pt position- 90° abduction, forward flex, internal rotation
Pt resists downward pressure
Pain and/or weakness suggests supraspinatus impingement or tear
Full can test-
Isolates supraspinatus and helps confirm empty can test fidings
What is the drop arm test?
Help pt abduct shoulder and ask them to slowly lower it
Positive test is when arm drops
How to do lift off test?
Pt arm is internally rotated w/ back of hand in small of back
Pt is asked to lift their hand off the back against resistance
Pain/weakness is positive
Dx of rotator cuff tears (RCT)?
X-ray: osteophytes on acromial border, cephalization of the humerus in the joint
Tx of rotator cuff tears (RCT)?
Corticosteroid injections- can propagate tear b/c it weakens tendon
Refer to ortho for surgery
The longer you wait, the greater the chance of muscle atrophy and adipose deposition
Adverse outcomes of rotator cuff tears (RCT)?
Loss of motion
Chronic pain w/ weakness
What are two types of shoulder injuries from overhead throwing?
Rotator cuff tendonitis
Etiology of rotator cuff tendonitis?
Overhead activites that require force and involve all for muscles (SITS)
Repetitive stress of cuff to seat the humeral head in glenoid under force leading to inflammation
Excessive wear and force can lead to deformation of the cuff and capsule
This can lead to impingement and swelling and cuff tear
What can rotator cuff tendonitis lead to?
SLAP lesion (superior labrum anterior to posterior)
What is a SLAP lesion?
Labrum tear. Caused by biceps (long head) being stretched and pulled to extremes
What is biceps tendinopathy (tendonitis)?
Inflammation or irritation of the long head of biceps
Long head of biceps lays in bicipital groove
Clinical presentation of biceps tendinopathy (tendonitis)?
Pain in anterior shoulder
Hx of throwing over the shoulder activities
PE of biceps tendinopathy (tendonitis)
Pain to palpation of biceps tendon
Tendon slip in and out of bicipital groove
Weakness due to pain, full ROM
Dx of biceps tendinopathy (tendonitis)?
MRI- inflammatory changes to long head of bicipital tendon
Tx of biceps tendinopathy (tendonitis)?
Ice initially (48 hrs) and after activities, heat if it helps
Corticosteroid into tendon sheath for biceps tendonitis
Subacromial or intraarticular shoulder injection
Surgery- biceps tenotomy
What is calcific tendonitis?
Calcium depositing in the tendons of rotator cuff due to stress on tendon
PE is similar to impingement syndrome
Tx- NSAIDs, injections, PT, time
Epidemiology of biceps tendon rupture?
Most likely in older adults
Most w/ hx of rotator cuff issues
Uncommon in young athletes unless pt is athlete, wt lifter, swimmer etc.
Clinical presentation of long head of biceps rupture?
Sudden pain in anterior shoulder
Possible audible pop
Bulge in arm
PE findings of rupture of long head of biceps?
Palpate bicipital groove may feel empty or void. Palpate at 10° may cause pain
Dx of rupture of long head of biceps?
X-ray: rule out fx
Hx of shoulder issues and pain
MRI: rule out cuff pathology
Tx of rupture of long head of biceps?
Most don't need surgery or have loss of function
Exercise program to regain full elbow strength
What are examples of nerve plexus disorders?
Brachial plexus syndrome
Thoracic outlet syndrome
What is brachial plexus syndrome?
Broad array of neurologic dysfunction from momentary paresthesia to flailing upper limbs
Burners and stingers- transient stretch injuries to upper trunk of brachial plexus (C5-C6 nerve roots)
Clinical presentation of brachial plexus syndrome?
Hx of contact sports or trauma
Complaints of sharp, burning, shoulder pain that radiates down arm following a nerve root
Weakness in arm
PE findings of brachial plexus syndrome?
Neurologic exam- sensation to light touch, muscles strength, DTRs
Head, neck, clavicles, shoulder and humerus eval- ROM, strength, deformity
What do you suspect if any sign of bilateral burners, or radicular complaints into legs?
Spinal cord injury until proven otherwise
Dx of brachial plexus syndrome?
X-ray: C-spine and shoulders, if abnormal, get MRI
Tx of brachial plexus syndrome?
Stretching and strengthening
Surgical tx of c-spine pathology, fx, or nerve impingements
All sxs must be resolved, FROM regained before allowing to return to athletics
What is thoracic outlet syndrome (TOC)?
Compression of brachial plexus and subclavian artery and or vein due to narrow space between first rib and clavicle
Epidemiology of thoracic outlet syndrome?
Common in 20-50 yo women
Etiology of thoracic outlet syndrome?
Abnormally long C7 TPs
Fibrosis of scalenes or fibromuscular band in thoracic outlet
Clinical presentation of thoracic outlet syndrome?
Sxs mimic distal nerve entrapment- more commonly mimics ulnar nerve paresthesia
Aching neck w/ radiation into should, arm, forearm and fingers
Vascular issues- swelling, discoloration, diminished pulse
PE of thoracic outlet syndrome?
Palpation of supraclavicular fossa- check for masses
Auscultate for bruits
Neurofunction- axillary, medial, median, radial and ulnar
Tests done for thoracic outlet syndrome?
Elevated arm stress test (roos)
Combo of tests:
Adson's + roos
Adson's + wrights
Dx of thoracic outlet syndrome?
x-ray: anatomic abnormalities such as cervical rib or C7 TPs (transverse processes)
MRI if shoulder or C-spine issues
Tx of thoracic outlet syndrome?
3-6 months of home exercise
Avoid straps that increase pressure over shoulder
NSAIDs, TENS unit, muscle relaxants
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