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Musculoskeletal Exam 2 > Orthopedics - The Shoulder > Flashcards

Orthopedics - The Shoulder Flashcards

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1
Q

What is the most common symptoms in patients who present for orthopedic consultation?
What is this symptom in association with?

A
  • Pain

- Numbness, deformity, Loss of function, Lacerations, Psychological problems (most difficult).

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2
Q

For the universal pain assement tool what does the scale mean?

A
  • 0 (no pain) –>10 (worst pain possible)
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3
Q

What is the methodology for physical findings?

A
  • inspection ( general appearance, symmetry, atrophy, color)
  • Palpation
  • Range of motion
  • Stability ( one of the biggest issues with the glenohumeral joint)
  • Neurovascular status
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4
Q

What tests should be performed to test for range of motion?

A
  • Internal rotation
  • external rotation
  • extension
  • With arm flexed and at 90 degrees push the head of humerus forward to see if they sublux for pain or not.
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5
Q

What are the types of objective radiographic testing that can be performed?

A
  • Convential
  • CAT scans
  • MRI (won’t know if theres a fracture or not )
  • Bone Scans
  • Arthrograms
  • Ultrasound
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6
Q

What are objective tests for electrodiagnostic, vascular, provocative?

A
  • Elecrodiagnostic: EMG ( radicular pain) and Nerve conduction velocities
  • Vascular: noninvasive, invasive
  • Provocative: ex. inject ansethetic into joint and numb it and test patient to see if pain is still there)
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7
Q

What joints does the shoulder contain and what ligaments are contained in them?

A
  • Glenohumeral joint
  • Acromioclavicular joint (superior acromioclavicular ligament)
  • Sternoclavicular joint (Anterior sternoclavicular ligament)
  • Scapulothoracic joint
  • Coracovicular joint ( Coracoclavicular ligaments= trapezoid + Conoid)
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8
Q

What are the main orthopedic problems that can occur at the glenohumeral joint?

A
  • Instability
  • Impingment
  • Rotator cuff pathology
  • Bicipital Tendon
  • Degenerative joint disease
  • Adhesive capsulitis
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9
Q

What are the main problems seen at the sternoclavicular or acromioclavicular joints?

A
  • Separations
  • Infections
  • Degenerative joint disease
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10
Q

What are the main problems seen at the scapularthoracic joint?

A
  • Impingment

- Congenital deformities

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11
Q

What bone of the shoulder are most commonly fractured?

A
  • Clavicle
  • Humerus
  • Scapula
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12
Q

What are the most common causes of glenohumeral instability?

A
  • Subluxation
  • Acute dislocations
  • Chronic recurrent dislocations
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13
Q

To tell if an x-ray is an anterior-posterior view what additional view do you need?

A

A y-view

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14
Q

What are the chief complaint with a presentation of a Glenohumeral joint instability?

A
  • Pain
  • Painful ROM
  • Weakness
  • Prehension of instability
  • Guarding
  • Spontaneous Dislocation
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15
Q

What causative history leads to glenohumeral joint instability?

A
  1. Trauma ( Acute or chronic overuse)
  2. Congenital ( Chronic laxity or deformity of joint)
  3. Infection
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16
Q

What are the physical finding of instability of the glenohumeral joint?

A
  • Asymetry
  • Weakness
  • Decreased functional ROM
  • Palpatory hypermobility
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17
Q

What are the tests that can be done upon physical examination?

A 
Apprehension test ( checks anterior shoulder instability- shoulder abducted 90 degrees with elbow in flexion to 90 degrees and then shoulder is externally rotated)
Relocation test (Pushing it back in can be painful)
Anterior drawer test:
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18
Q

What is a sulcus sign?

A

It is a test of the glenohumeral joint. 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. The appearance of this sulcus is a positive sign.

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19
Q

What objective tests are available for glenohumeral instability?

A
  • X-rays (AP, Axillary Y-view)
  • CT scan (hill sachs lesions- compression in post aspect of head indicating an indention in the head that gets worse with progressive dislocations)
  • MRI ( Labral tear, Bankart lesion- anterior glenoid (labrium) tear allowing the head of the humerus to dislocate)
  • Arthrogram
  • EMG
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20
Q

What is the treatment of glenohumeral instability.

A
  • Acute dislocations
  • Subluxations
  • Chronic recurrent dislocations
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21
Q

When should you not perform surgery for glenohumeral instability?

A
  • Erlos danlos syndrome or collagen deficiency
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22
Q

In treatment of glenohumeral instability what is the stimson technique?

A
  • It is a treatment in which a weight is placed on the arm and as the muscles relax the bone will pop back into place (low risk)
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23
Q

For glenohumeral instability what is the traction-countertraction treatment?
What is the Hippocratic method?

A
  • attempts to pop back into place (closed reduction)

- Don’t do hippocratic method

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24
Q

What is the Kocher method of treatment for glenohumeral instability?

A

Externally rotate arm, catch head, and try to pop it back into place. But is contraindicated in elderly women and osteoporotic patients.

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25
After you return the joint back into place what do you have to do to the arm? - What is the correlation between age and recurrent dislocation?
- mobilize it with a sling and swath (stops from external rotation) - The younger you are the more likely that it will become dislocated again
26
What is injured in an anteroinferior glenohumeral dislocation?
- anteroinferior labrum and anteroinferior glenohumeral ligament
27
What is the percentage of re-dislocations in adolescents with an open growth plate at time of inital dislocation? - percentage of re-dislocations in 18-30 y? - greater than 40 y?
-100% - 55-95% <10%
28
What are the complications of Gleno-humeral dislocations?
- Recurrent dislocations, - Torn glenoid labrum - Hill-sachs lesions - Axillary nerve injury
29
What is a subacromial impingement?
- Compression of rotator cuff tendons between undersurface of acromion and greater tuberosity of humerus, essentially there is abnormal contact between the acromion and the greater tuberosity in mid-abduction
30
What chief complaint is there upon presentation of impingement?
- Painful abduction of shoulder - Painful lifting or working overhead - Difficulty throwing - Crepitance or catching
31
What type of history would lead to an impingement?
- overhead work - Exercise with muscle hypertrophy (Swimming can have hypertrophy of their rotator cuff [ essentially just a huge supraspinatus m.]) - Trauma to acromioclavicular joint - Congential deformity - Degenerative joint disease
32
What are the physical findings for impingement?
- Difficultly lifting arm above head - Crepitance with abduction - Impingement sign (passive forward flexion over 90 degrees causes pain) - Provocative test
33
What are some of the Objective testing for impingment?
- X-ray: DJD of AV joint, calcifications of tendon - chronic inpingment - Arthrogram: may be normal - MRI: Hypertrophy, congenital downsloping of acromion.
34
What is the Bigliana Classification?
- Type I flat acromion - Type II curved acromion - Type III hooked acromion ( is associated w/ impingement anteriorly; hooks down and leads into area of the rotator cuff.
35
What is the treatment for impingement?
- Medication (oral , injectable, iontophoresis- forcing cortisone into skin) - Modification of activity - PT - Surgery (acromioplasty- Open; incision and take part of acromion off, Mumford- Open take distal part of the clavicle off, Arthroscopic decompression- decompress the subacromial space)
36
What does surgery for impingement always involve?
Decompression of the rotator cuff
37
What are the two types of rotator cuff tears?
- Partial thickness tears | - Full thickness tears
38
What are the main chief complaints that present with a rotator cuff tear?
- Weakness (abduction) - Painful Abduction - Can not lift arm overhead - can not lay on arm - Can not throw - Can not work overhead - Pain at rest
39
What is the drop arm test? | If rotator cuff is completely torn how high can the patient rise the arm.
- Lifting patients arm above head (at full abduction) and releasing to see if patient can hold arm there. Tests for rotator cuff tear. - 14 degrees
40
What activities would result in a microtrauma tear in the rotator cuff? What type of activity would result in chronic impingement of the rotator cuff tear? What type of activity would result in trauma of the rotator cuff?
- Overhead work, repeated lifting - Downsloping of acromion - Fall, pulling exceeds tendon strength, lifting exceeds tendon strength
41
What are the physical findings of rotator cuff tears?
- Weakened and painful abduction - Muscle spasms - drop test - Gerber's lift off (subs cap)- putting the arm behind the back and telling patient to lift the arm off of their back - Empty can (supraspinatus) - Asks patient to pretend they are emptying a can of coke and seeing how much pain they are in.
42
What are two etiologies of rotator cuff injures?
- Vascular insufficiency in "critical zone" | - Micro trauma due to chronic impingment.
43
What are the objective testing for the rotator cuff tear that involves X-rays?
- Spurs and Degenerative joint disease - Narrowing - Resorption MRI Arthrogram - extravasation of contrast
44
What does a superior sublux of the humerous indicator?
- Rotator cuff prob
45
What would be the treatment of rotator cuff tears?
- rest - Abduction sling - Physical therapy - modification of activity - meds - surgery ( needs if it is completely torn)
46
What are the two diagnostic classifications for a biceps tendon rupture? What is the chief complaint of a biceps tendon tear?
- Proximal and distal | - Pain, weakness (supination), deformity
47
What history can lead to a bicep tendon tear?
- Lifting and supination - Impingment (ruptures proximally do to impingement) - Overuse - Iatrogenic ( ex. Cortisone injection in the bicerps tendon- which is why you never do it)
48
What are the physical findings of the bicep tendon tear?
- Tenderness (biciptial groove) - Popeye muscle - Yergusons test ( shake hands with patient and provide resistance against supination)
49
What is the objective testing of the biceps tear?
- MRI | - Ultrasound
50
What is the treatment of the biceps tendon tear?
- Skillful neglect (older people) | - Surgery
51
What are the disgnostic stages of acromioclavicular joint seperation?
- First: Sprain - Second: Partial tearing - Third degree: complete rupture and AC ligaments are completely gone - Higher degrees have bones moving further away from position
52
What is the chief presenting complaint of an AC separation?
- Pain at rest and with ROM - Crepitance - Palpable deformity
53
What history leads to AC separations?
- Trauma - fall onto shoulder or fall onto elbow | - Infection (rare)
54
What are the physical findings of an AC joint separation?
- Pain directly over A-C joint - Palpable deformity - Painful ROM (can raise joint 90 degrees afterwhich clavicle begins to move - Warmth over area
55
What are the objective tests for AC separation?
- X-ray ( with or without weights) - CT scan - MRI
56
What are the methods of treatment for an AC joint separation?
- Skillful neglect - Sling - AC strap (helps pull the clavicle down - Surgery
57
What is the diagnostic criteria for a snapping scapula?
AKA "Scapulo-Thoracic Impingment" - Chief complaint: catching when raises arm - History: usually congenital - Physical Findings - Objective test: CT scan, X-rays - Treatment: PT, injections, avoid surgery
58
What is the diagnostic criteria for adhesive capsulitis?
- Chief complaint: can't raise arm - History: slow progressive loss of motion - Physical: no active or passive ROM - Seen in: Older people who don't use arm enough - Testing: MRI - Treatment: Gradual physical therapy, meds, aggressive manipulation
59
What is the chief complaint when presenting with degenerative joint disease?
- Pain - - Loss of Motion ( racketing) - Warmth - Crepitance - Loss of Strength
60
What is the history of patients who present with degenerative joint disease? Why is osteoarthritis not a diagnosis?
- Gradual progression of disability - Serologic history - History of systemic disease - History of trauma - History of prior infection - Because osteoarthritis only occur in weight bearing joints such as knee or hip- not shoulder
61
What are the physical findings of degenerative joint disease?
- Warmth - Decreased ROM - Pain (with rest or activity) - Crepitance - Deformity - Systemic Findings
62
What are the objective tests for degenerative joint disease?
- X-ray - CT - MRI - Bone scan ( not done anymore) - LAB
63
What are the treatments for degenerative joint disease?
- Non-operative: Meds, PT, modification of activity | - Operative: decompression, replacement
64
What is thoracic outlet syndrome?
- Compression of subclavian artery and laterla cord of the brachial plexus between the scalene muscles and the first rib.
65
What is the chief complaint of patients who present with thoracic outlet syndrome?
- Arm and shoulder pain - Numbness of 4th and 5th fingers - coldness of hand with abduction
66
What is the history for patients presenting with thoracic outlet syndrome?
- Progressive development of symptoms - May be congenital ( anomalous first rib) - May develop post trauma (fracture clavicle with malunion)
67
What are the physical findings of thoracic outlet syndrome?
- numbness of 4th and 5th fingers - loss of pulse with abduction (adson's maneuver) - Pain
68
What is adison's maneuver?
It is a test for thoracic outlet syndrome, doctor extends and rotates patients head while monitoring patients pulse. Positive if numbness or diminished pulse
69
What are the objective tests for thoracic outlet syndrome?
- EMG | - Vascular studies: invasive and non-invasive
70
What is the treatment of thoracic outlet syndrome?
- Physical therapy - MEDS - Surgical (final option)
71
What is the percentages of fractures at different parts of the clavicle?
- 80% middle third (usually in the bayonet opposition. - 15% lateral - 5% medial
72
What is the mechanism of injury for a clavicular fracture? What are some causes of pathologic fractures? What are the main features of distal clavicle fractures? What type of treatments are used for mid clavicle fractures?
- Fall or other direct trauma to shoulder - Infections or tumors (malignant and benign) - usually require orthopedic management, may require surgery, may result in post traumatic a/c arthritis - Treatment goal is to restore length, use of clavicl strap, or sugical indications (can fix significant displacement, comminution, or spiked fragments)
73
What are features of a proximal clavicle fracture? | What are complications of a fractured clavicle?
- usually require orthopedist management, or difficult to get anatomic result - Nonunion, pneumothorax, subclavian artery injury
74
What can occur the comminuted and the greater the inferior sublux is?
Lung puncture
75
What areas of the scapula are common?
- Commonly involve body, neck (if greater than 2mm than must be put back into place, acromion, glenoid ( if displaced and intra-articular need surgical management )
76
What is the mechanism of injury?
- Direct trauma (body, acromion) | - Fall on to outstretched arm (neck, glenoid)
77
What are the most common areas of the proximal humerus that can be fractured? What did Codman recognize?
- Head - Surgical neck - Anatomic neck - Proximal shaft - That proximal humeral fractures in adults occured along the lines of old physeal scars ( greater and lesser tuberosities, humeral head, and humeral diaphysis) so should can break into 4 major pieces
78
How common are proximal humerus fractures? What sex is more likely to get it? What are a majority of these fractures?
- 4-5% of all fractures, more common than hip - Woman (typical is an elderly patient who falls) - Nondisplaced fractures
79
What is the Neer classification system and what are the parts?
- It is a classification system of the proximal humeral fractures - One part (impacted), Two part (greater tuberosity fracture), Three part (head separates from shaft at surgical neck and greater tuberosity), Four part (head, greater and lesser tuberosity)
80
What is the mechanism of injury for a proximal humerus fracture? What are two functional deficiencies? What is also caused by a 4 part avascular necrosis?
- FOOSH - Abduction and strength - Avascular necrosis
81
What is the treatment for a one part proximal humerus fracture?
- Nonsurgical management: -->1-3 weeks immobilize in sling --> Pendulum exercises and ROM between 3-8 weeks -->Elbow ROM --> Codman exercises
82
What is the treatment for a 2 part proximal humerus fracture?
- For a surgical neck most can be reduced closed, and impacted. If unstable percutaneously pin, May require ORIF if unstable or have interposed tissue, use intramedullary rods, pins, plates, wire suture - Greater tuberosity: require ORIF if greater than 5mm displacement because of resulting posterio-superior impingement on acromion. Need screw, wire, suture. - Lesser Tuberosity: Rare, suture fixation, can also remove bone fragment and fix subscapularis tendon to fracture site
83
What is the treatment for a 3 part fracture of the proximal humerus?
- Unstable - Greater tuberositiy or less tuberosity alternatively intact - ORIG with wires or sutures - Locked plates in osteoporotic bone
84
What is the treatment for a 4 part fracture of the proximal humerus?
- Generally poor results with ORIF - High incidence of AVN - Preferred treatment is prosthesis with secure fixation of tuberosities to allow early motion.
85
What are the main chief complaints that present with a rotator cuff tear?
- Weakness (abduction) - Painful Abduction - Can not lift arm overhead - can not lay on arm - Can not throw - Can not work overhead - Pain at rest
86
What is the drop arm test? | If rotator cuff is completely torn how high can the patient rise the arm.
- Lifting patients arm above head (at full abduction) and releasing to see if patient can hold arm there. Tests for rotator cuff tear. - 14 degrees
87
What activities would result in a microtrauma tear in the rotator cuff? What type of activity would result in chronic impingement of the rotator cuff tear? What type of activity would result in trauma of the rotator cuff?
- Overhead work, repeated lifting - Downsloping of acromion - Fall, pulling exceeds tendon strength, lifting exceeds tendon strength
88
What are the physical findings of rotator cuff tears?
- Weakened and painful abduction - Muscle spasms - drop test - Gerber's lift off (subs cap)- putting the arm behind the back and telling patient to lift the arm off of their back - Empty can (supraspinatus) - Asks patient to pretend they are emptying a can of coke and seeing how much pain they are in.
89
What are two etiologies of rotator cuff injures?
- Vascular insufficiency in "critical zone" | - Micro trauma due to chronic impingment.
90
What are the objective testing for the rotator cuff tear that involves X-rays?
- Spurs and Degenerative joint disease - Narrowing - Resorption MRI Arthrogram - extravasation of contrast
91
What does a superior sublux of the humerous indicator?
- Rotator cuff prob
92
What would be the treatment of rotator cuff tears?
- rest - Abduction sling - Physical therapy - modification of activity - meds - surgery ( needs if it is completely torn)
93
What are the two diagnostic classifications for a biceps tendon rupture? What is the chief complaint of a biceps tendon tear?
- Proximal and distal | - Pain, weakness (supination), deformity
94
What history can lead to a bicep tendon tear?
- Lifting and supination - Impingment (ruptures proximally do to impingement) - Overuse - Iatrogenic ( ex. Cortisone injection in the bicerps tendon- which is why you never do it)
95
What are the physical findings of the bicep tendon tear?
- Tenderness (biciptial groove) - Popeye muscle - Yergusons test ( shake hands with patient and provide resistance against supination)
96
What is the objective testing of the biceps tear?
- MRI | - Ultrasound
97
What is the treatment of the biceps tendon tear?
- Skillful neglect (older people) | - Surgery
98
What are the disgnostic stages of acromioclavicular joint seperation?
- First: Sprain - Second: Partial tearing - Third degree: complete rupture and AC ligaments are completely gone - Higher degrees have bones moving further away from position
99
What is the chief presenting complaint of an AC separation?
- Pain at rest and with ROM - Crepitance - Palpable deformity
100
What history leads to AC separations?
- Trauma - fall onto shoulder or fall onto elbow | - Infection (rare)
101
What are the physical findings of an AC joint separation?
- Pain directly over A-C joint - Palpable deformity - Painful ROM (can raise joint 90 degrees afterwhich clavicle begins to move - Warmth over area
102
What are the objective tests for AC separation?
- X-ray ( with or without weights) - CT scan - MRI
103
What are the methods of treatment for an AC joint separation?
- Skillful neglect - Sling - AC strap (helps pull the clavicle down - Surgery
104
What is the diagnostic criteria for a snapping scapula?
AKA "Scapulo-Thoracic Impingment" - Chief complaint: catching when raises arm - History: usually congenital - Physical Findings - Objective test: CT scan, X-rays - Treatment: PT, injections, avoid surgery
105
What is the diagnostic criteria for adhesive capsulitis?
- Chief complaint: can't raise arm - History: slow progressive loss of motion - Physical: no active or passive ROM - Seen in: Older people who don't use arm enough - Testing: MRI - Treatment: Gradual physical therapy, meds, aggressive manipulation
106
What is the chief complaint when presenting with degenerative joint disease?
- Pain - - Loss of Motion ( racketing) - Warmth - Crepitance - Loss of Strength
107
What is the history of patients who present with degenerative joint disease? Why is osteoarthritis not a diagnosis?
- Gradual progression of disability - Serologic history - History of systemic disease - History of trauma - History of prior infection - Because osteoarthritis only occur in weight bearing joints such as knee or hip- not shoulder
108
What are the physical findings of degenerative joint disease?
- Warmth - Decreased ROM - Pain (with rest or activity) - Crepitance - Deformity - Systemic Findings
109
What are the objective tests for degenerative joint disease?
- X-ray - CT - MRI - Bone scan ( not done anymore) - LAB
110
What are the treatments for degenerative joint disease?
- Non-operative: Meds, PT, modification of activity | - Operative: decompression, replacement
111
What is thoracic outlet syndrome?
- Compression of subclavian artery and laterla cord of the brachial plexus between the scalene muscles and the first rib.
112
What is the chief complaint of patients who present with thoracic outlet syndrome?
- Arm and shoulder pain - Numbness of 4th and 5th fingers - coldness of hand with abduction
113
What is the history for patients presenting with thoracic outlet syndrome?
- Progressive development of symptoms - May be congenital ( anomalous first rib) - May develop post trauma (fracture clavicle with malunion)
114
What are the physical findings of thoracic outlet syndrome?
- numbness of 4th and 5th fingers - loss of pulse with abduction (adson's maneuver) - Pain
115
What is adison's maneuver?
It is a test for thoracic outlet syndrome, doctor extends and rotates patients head while monitoring patients pulse. Positive if numbness or diminished pulse
116
What are the objective tests for thoracic outlet syndrome?
- EMG | - Vascular studies: invasive and non-invasive
117
What is the treatment of thoracic outlet syndrome?
- Physical therapy - MEDS - Surgical (final option)
118
What is the percentages of fractures at different parts of the clavicle?
- 80% middle third (usually in the bayonet opposition. - 15% lateral - 5% medial
119
What is the mechanism of injury for a clavicular fracture? What are some causes of pathologic fractures? What are the main features of distal clavicle fractures? What type of treatments are used for mid clavicle fractures?
- Fall or other direct trauma to shoulder - Infections or tumors (malignant and benign) - usually require orthopedic management, may require surgery, may result in post traumatic a/c arthritis - Treatment goal is to restore length, use of clavicl strap, or sugical indications (can fix significant displacement, comminution, or spiked fragments)
120
What are features of a proximal clavicle fracture? | What are complications of a fractured clavicle?
- usually require orthopedist management, or difficult to get anatomic result - Nonunion, pneumothorax, subclavian artery injury
121
What can occur the comminuted and the greater the inferior sublux is?
Lung puncture
122
What areas of the scapula are common?
- Commonly involve body, neck (if greater than 2mm than must be put back into place, acromion, glenoid ( if displaced and intra-articular need surgical management )
123
What is the mechanism of injury?
- Direct trauma (body, acromion) | - Fall on to outstretched arm (neck, glenoid)
124
What are the most common areas of the proximal humerus that can be fractured? What did Codman recognize?
- Head - Surgical neck - Anatomic neck - Proximal shaft - That proximal humeral fractures in adults occured along the lines of old physeal scars ( greater and lesser tuberosities, humeral head, and humeral diaphysis) so should can break into 4 major pieces
125
How common are proximal humerus fractures? What sex is more likely to get it? What are a majority of these fractures?
- 4-5% of all fractures, more common than hip - Woman (typical is an elderly patient who falls) - Nondisplaced fractures
126
What is the Neer classification system and what are the parts?
- It is a classification system of the proximal humeral fractures - One part (impacted), Two part (greater tuberosity fracture), Three part (head separates from shaft at surgical neck and greater tuberosity), Four part (head, greater and lesser tuberosity)
127
What is the mechanism of injury for a proximal humerus fracture? What are two functional deficiencies? What is also caused by a 4 part avascular necrosis?
- FOOSH - Abduction and strength - Avascular necrosis
128
What is the treatment for a one part proximal humerus fracture?
- Nonsurgical management: -->1-3 weeks immobilize in sling --> Pendulum exercises and ROM between 3-8 weeks -->Elbow ROM --> Codman exercises
129
What is the treatment for a 2 part proximal humerus fracture?
- For a surgical neck most can be reduced closed, and impacted. If unstable percutaneously pin, May require ORIF if unstable or have interposed tissue, use intramedullary rods, pins, plates, wire suture - Greater tuberosity: require ORIF if greater than 5mm displacement because of resulting posterio-superior impingement on acromion. Need screw, wire, suture. - Lesser Tuberosity: Rare, suture fixation, can also remove bone fragment and fix subscapularis tendon to fracture site
130
What is the treatment for a 3 part fracture of the proximal humerus?
- Unstable - Greater tuberositiy or less tuberosity alternatively intact - ORIG with wires or sutures - Locked plates in osteoporotic bone
131
What is the treatment for a 4 part fracture of the proximal humerus?
- Generally poor results with ORIF - High incidence of AVN - Preferred treatment is prosthesis with secure fixation of tuberosities to allow early motion.

Musculoskeletal Exam 2 (8 decks)

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