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P-2 Ortho 1 > 7 Shoulder Part 2 > Flashcards

7 Shoulder Part 2 Flashcards

(74 cards)

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1
Q

What is the labrum?

A

Cartilaginous lining of the glenoid

- “meniscus of the shoulder”

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2
Q

Purpose of the labrum?

A

Deepens the glenoid

- increasing stability

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3
Q

Grades of slap lesion?

A 
Snyder grades
I: fraying
II: avulsion
III: bucket-handle
IV: tear into biceps tendon
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4
Q

Clinical symptoms of SLAP lesion?

A

Painful popping or catching

Pain deep inside shoulder

Pain with overhead activities
- overhead type sports, volleyball, baseball

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5
Q

Test for SLAP?

A

Obrien test

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6
Q

Imaging for slap?

A

MR Arthrography - Gold standard

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7
Q

Management for slap lesion?

A

Conservitive

  • the usual
  • PT, Pain, Rest, ROM

Surgical

    • works better for young pts, old people dont move and they get stiff afterwords
  • scope, burr, sew and stuff
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8
Q

MC type of shoulder instability?

A

Anterior and multidirectional

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9
Q

Two classifications of shoulder instability patients?

A 
AMBRI
A - atraumatic
M - multidirectional
B - bilateral
R - rehabilitation
I - inferior capsular shift
I - rotator Interval closure (MDI pt)

TUBS patient
T - traumatic
U - unidirecdtional
B - bankhart tear
S - surgery (traumatic dislocation)
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10
Q

Anterior instability prognosis?

A

High recurrence rate

- maybe b/c its more common in younger patients

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11
Q

Defects found in patients who have previously dislocated their shoulder?

A

Hill-sachs defect
- impression fx in the posterolateral humeral head

Bony bankhart lesion
- anterior inferior glenoid rim injury

Greater tuberosity fracture
- esp in older patients

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12
Q

Unstable (dislocated) shoulders need?

A

Reduction
- lots of techniques

Radiographs

  • AP erect
  • Axillary (its trauma right?) *****
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13
Q

Common causes of posterior instability (dislocation) of shoulder?

A 
Seizure
Electrocution
Offensive linemen
- posterior directed force w arms extended
Posterior labral tear/capsular inj
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14
Q

Clinical presentation of posterior dislocation(instability)

A

Arm adducted and internally rotated

  • “locked” in internal rotation
  • unable to externally rotate

Prominent coracoid

Limited external ROM and forward flextion

Painful and “popping” sensation w activities such as bench pressing

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15
Q

PE tests for posterior instability?

A

Jerk test

  • Internal force on elbow with adducting
  • (+) is a painful “clunk”

Kim test
- (+) is a painful “click”

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16
Q

Studies or posterior instability?

A

Axillary radiograph
- diagnostic

If you dont get it and you miss this its catastrophic

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17
Q

Radiographic findings for posterior instability?

A

Revers hill-sachs deformity
- hatchet-shaped anterior humeral head impression fx

Reverse bankhard lesion
- posterior glenoid rim

Lesser tuberosity fx

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18
Q

Pt presentation for multi directional instability?

A 
Young pt
Hyperlaxity
Positive inferior sulcus sign
Atraumatic etiology
Pain w ADL

Common scenario
- successful closed reduction in ED but they dislocate on way to x-ray

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19
Q

Ligamentous laxity assessment?

A

Beighton’s scale

  • thumb to forearm
  • 5th finger beyond 90
  • elbow beyond 10
  • knee beyond 10
  • Forward flexion of trunk, legs straight, palms touching floor

1 pt for each (1 for R and 1 for L)

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20
Q

Tests for multidirectional laxity?

A 
Beightons scale
Apprehension test
A-P drawer (shoulder)
Load and shift (anterior/posterior)
** Sulcus sign **

Bankhart lesion on humerus

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21
Q

Adverse outcomes of shoulder instability?

A

Axillary nerve injury

  • deltoid dysfunciton
  • numbness over lateral arm (usually resolves)

Osteoarthritis

Recurrent instability greater in younger pts and those with multiple episodes

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22
Q

Who should get non-op tx for shoulder instability?

A

Atraumatic or voluntary (AMBRI)

But make sure you educate them that this shit is bad for them

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23
Q

Acute shoulder dislocations?

A

Must be reduced immediately

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24
Q

Management of shoulder instability?

A

1st time - treat conservatively

NSAIDS/Tylenol/ASA
Shoulder immobilizer
Activity mod
PT

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25
Best way to immobilize shoulder for multi directional instability?
External rotation sling | - takes the stress off the bankhart lesion
26
Shoulder instability, when to refer?
Failure to reduce by closed manipulation 2+ dislocations despite 3 mo trial of rehab Sx are intolerable and dont respond to rehab
27
This injury is commonly called shoulder separation
AC injury | - caused by direct trauma
28
Classification of AC injuries?
Rockwood classification - clavicle dislocation Type I: normal - stretched ligaments Type II: <100% dislocated - 1 ligament disrupted Type III: 100% dislocated - all 3 ligaments disrupted Type IV: posterior - dislocated posteriorly Type V: > 100% dislocated Type VI: anterior - clavicle gets under biceps and coraco-brachialis
29
Rockwood classification: surgical vs non surgical
Non-operative repair - type I, II, III Surgical repair - type IV, V, VI
30
Strain vs sprain
Strains = Tendons - it has a T Sprain = ligaments
31
Which ligaments are torn in type I AC injury
None - they are partially disrupted but intact
32
Which ligaments are torn in type II AC injury
AC ligaments are torn CC ligaments are intact - partial separation of clavicle to acromion
33
Which ligaments are torn in type III AC injury
AC and CC ligaments are completely disrupted - complete separation of clavicle from acromion
34
Which ligaments are torn in type IV AC injury
Clavicle is displaced and embedded in trapezius muscle
35
Which ligaments are torn in type V AC injury
AC, CC are disrupted Deltoid and trapezius insertion are disrupted >100% elevation of distal clavicle
36
Which ligaments are torn in type VI AC injury
AC, CC are disrupted Deltoid and trapezius insertion are disrupted Anteriorly displaced into subacromial or subcoracoid space
37
Clinical presentation of AC injury?
Pain - over AC joint - with lifting arm - overhead motions Type III + obvious and cosmetic deformity
38
PE for AC injury?
Pain w cross arm adduction Relief with lidocaine injection (diagnostic) - therapeutic if you add corticosteroid
39
Chronic AC injury (weight lifters)
X rays shows Distal clavicle osteolysis - degeneration of the distal clavicle w associated osteopenia and/or cystic changes Pic on side 65
40
AC injury management
Acute: - shoulder immobilizer, slign etc - ICE - rest - pain meds Conservative - NSAIDS/tylenol/ASA - activity mod - injections (w or w/o steroids) for ac joint arthritis Surgery for - types IV, V, VI - young manual labor w/ type III
41
Surgical management for AC injury?
Distal clavicle resection (mumford procedure) - false joint installed - bone spurs removed Can also try a tight rope (he said it doesnt work well)
42
What is adhesive capsulitis?
Dramatically decreased ROM following injury or over use | - often self resolves in 18-24 mo
43
What causes adhesive capsulitis?
Its idiopathic | - autoimmune, traumatic, inflammatory??
44
Risk factors for adhesive capsulitis?
Female Age 50-60 Diabetic Also seen with - HYPOthyroid - dupuytren disease - cervical disk herniation - Parkinson’s - cerebral hemorrhage - tumor
45
Adhesive capsulitis in Diabetics?
Often - refractory to tx - bilateral
46
PE for adhesive capsulitis?
Motion = painful (esp at extremes) TTP at deltoid insertion Diffuse global TTP
47
Criteria for adhesive capsulitis?
Codman’s criteria - comes on slow - pain at deltoid insertion - inability to sleep on side - painful/incomplete shoulder elevation - external rotation restriction (spasmotic and adherent types) - atrophy of spinatii - little local TTP - x-rays neg - pain = very bad - able to continue ADL
48
Imaging for adhesive capsulitis?
Radiographs - osteopenic appearance of bone MRI/MRA - contracted capsule and loss of inferior pouch (froze shoulder)
49
Adhesive capsulitis tx?
Conservative - pain meds (no narcs) - moist heat - stretching - ICE - steroid - electrical nerve stimulation (TENS) - manipulation under anesthesia Surgical - arthroscopic capsular releasee
50
Prognosis of tx for adhesive capsulitis?
Non-surg = 80-85% | - takes 1-2 yrs to get better though
51
When to refer adhesive capsulitis?
Substantial improvement not achieved in 3 months Surgery if failure of nonsurgical tx
52
Where do clavicles usually fracture?
Middle 1/3 (80%)
53
Clinical symptoms of clavicle fracture?
Substantial injury - fall onto shoulder - being hit there Shoulder motion/strength limited 2/2 pain Bony deformity Shoulder droop
54
Clavicle fx PE?
Obvious deformity TTP, Crepitus over site, also w raising arm Tented skin of fx - rarely penetrates
55
Though rare, if you suspect medial end of clavicle fx or dislocation you need?
CT, it wont show on x-ray
56
Clavicle fx tx?
Arm sling Figure of 8 clavicle strap (rare) X 3-4 weeks (children <12) X 6-8 weeks for adults
57
Clavicle fx, who gets surgery?
- Severely shortened middle 1/3 - open fx - neurovascular inj - ipsilateral rib fx (flail chest) - communited, highly displaced
58
When to refer clavicle fx?
Nonunion after 4 months Widely displaced lateral Midshaft w segmental fx
59
You suspect proximal humerus fracture, what x-rays do you order?
True AP Axillary lateral view or scapular Y Velpeau (cant get axillary) Cant rely on AP alone, they cannot document associated shoulder dislocation
60
What is a key element of proximal humerus fx tx?
Early ROM - disabling stiffness is very common - esp in elderly Watch for overly aggressive exercise though -> nonunion
61
Tx for proximal humerus fx?
Simple - sling, PT Surgery - fixation - Two part w greater tuberosity separated >0.5cm - operative repair - Displaced 2 part -> humeral neck - Displaced 3 and 4 part fx Surgery - Prosthetic replacement - displaced 4 part fx that disrupt blood supply to humeral head
62
Common causes of humeral shaft fx?
Direct blow to arm - MVA - FOOSH - Sports
63
Humeral shaft tx and prognosis?
Most are treated non-op | - rate of union nearly 100%
64
You gently palpate humeral shaft fx and feel motion at fx site wtf?
Common finding with these
65
Big concern for humeral shaft fx?
Radial nerve injury - will not be able to extend wrist or fingers - loss of sensation over back of hand
66
X rays for humeral shaft fx?
``` AP Lateral (transthoracic) - dont rotate shoulder ``` Or Modified axillary Velpeau view
67
Tx for humeral shaft fx?
``` Minimal shortening (2cm) - U-shaped coaptation splint x 2 weeks ```
68
Concern w humeral shaft fractures
Radial nerve inj - weakness of wrist/fingers - numbness in 1st dorsal web space Usually resolves w/in 6 mo - EMG if radial nerve function doesnt return after 6 weeks
69
Humeral shaft fx, who to refer?
- vascular inj - nerve inj - open fx - segmental fx - floating elbow (radius and ulna also fx) - nonunion after 3 mo - head injury/seizure d/o, multiple injuries - pathologic fx - skin breakdown over brace
70
Common etologies of glenohumeral arthritis ?
Age over 50 (osteoarthritis) RA Post traumatic arthritis rotator cuff tear that wen untreated x long time
71
S/s of GH osteoarthritis?
Diffuse or deep seated pain Glenohumeral arthritis - posterior aspect of shoulder AC arthritis - top of shoulder Aggravated by activity (esp overhead) Trouble sleeping
72
PE for GH osteoarthritis?
Usually unilateral (unless its RA) Atrophy of muscles TTP over front and back Bone on bone crepitus is common w rotation or flexion Decreased ROM
73
Uncommon finding w GH osteoarthritis?
Swelling | - when present its difficult to detect
74
Surgeries for GH osteoarthritis?
Advanced (for low impact pts) - total shoulder replacement - hemiarthroplasty Young, manual labors (high impact) - arthrodesis (they break prosthetics)

P-2 Ortho 1 (7 decks)

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