Shoulder 2

Question 1

In younger patients, high energy trauma results in

Answer 1

Humerus fractures!

While in elderly, MCC is a simple fall

Question 2

How do humerus fractures present

Answer 2

Severe pain
Limited ROM
Swelling
Ecchymosis

Question 3

How do you classify a humerus fracture

Answer 3

Neers classification for the proximal humerus; based on location, fracture parts, and displacement

Question 4

What are the types of humerus fractures

Answer 4

Two, Three, or Four part
Transverse
Oblique
Spiral (like a candy cane)

Question 5

A posterior fracture preserves

Answer 5

Extension! B/c it does not affect the radial nerve?

Question 6

What is Subacromial Impingement Syndrome

Answer 6

most frequent cause of shoulder pain!

Decreased subacromial space

Question 7

What is the MOI of a subacromial impingement

Answer 7

Repetitive microtrauma to supraspinatus tendon, subacromial bursa, and long head of biceps

Question 8

What can cause increased compression in SAIS

Answer 8

increased inflammation affecting volume in subacromial space

Question 9

Tendon degeneration can be caused by

Answer 9

Inflammation
Repetitive microtrauma
Reduction in stress intolerance

Question 10

What are the types of acromion morphology

Answer 10

I: Flat
II: Curved
III: Hooked

Question 11

Hooked acromion results in

Answer 11

Increased subacromial pressure and decreased space
More contact with rotator cuff tendons
Increased risk of SAIS= increased risk of rotator cuff tear

Question 12

What is a primary impingement

Answer 12

Driven by degenerative changes
MC in 35+ y/o
Associates osteophytes and calcified deposits
This is true or classic impingement

Question 13

What is secondary impingement

Answer 13

Due to repetitive overhead movement (Abduct and ER)
MC <35 y/o, overhead athlete
Faulty scapular posture (hunched forward)

Question 14

What contributes to faulty scapular posture

Answer 14

Forward head, Increased thoracic kyphosis

Question 15

Faulty scapular posture leads to

Answer 15

adaptive muscle imbalance
tight pec minor= anterior tilting and protraction= decreased subacromial space= impingement= inflammation and degeneration of subacromial structures

Question 16

SAIS presents with

Answer 16

Gradual onset antero/lateral shoulder pain, worse w/ overhead activity
Night pain and difficulty sleeping on affected side
TTP over greater tuberosity, subacromial bursa, and long head of biceps tendon

Question 17

Impingement tests are

Answer 17

Neers (No pain from 45-60 and >170)

Modified Hawkins-Kennedy

Question 18

Strength testing for SAIS includes

Answer 18

Empty can test (supraspinatus)
ER against resistance (infraspinatus)
Lift off (subscap)- internally rotate behind back and push against provider’s hand

Question 19

Muscles of the rotator cuff are

Answer 19

Supreaspinatus: Abduction
Infraspinatus: ER
Teres minor: ER
Subscapularis: IR

Question 20

What radiographs can you get with SAIS suspicion

Answer 20

X-ray: always if traumatic, to r/o Fx, eval for calcifications, bone spurs, and acromial morphology

Question 21

How do you treat SAIS

Answer 21

NSAIDs
avoid offending activities
PT and home therapy to correct posture

Question 22

If there is no improvement in 6 weeks of SAIS w/ initial therapy

Answer 22

Consider subacromial injection and continued therapy

Surgery (subacromial decompression) if failed conservative care, or if you have a calcification or bone spur!

Question 23

What causes rotator cuff tear

Answer 23

MC: Overuse (age related degeneration, chronic mechanical impingement)
Traumatic
Full thickness is NOT common <40

Question 24

Rotator cuff tears typically originate

Answer 24

in Supraspinatus tendon, and may progress

Question 25

How do rotator cuff tears typically present

Answer 25

Recurrent shoulder pain for months, or specific injury triggering Sx Subacromial pain, Pain localized to deltoid tuberosity Night pain and difficulty sleeping on affected side Weakness, catching, grating when lifting arm overhead

Question 26

On rotator cuff PE you may find

Answer 26

TTP over subacromial space Decreased ROM (shoulder shrug w/ abduction) + drop arm test Pain/weakness w/ isolation of involved RC muscles

Question 27

What imaging should you get for rotator cuff injuries

Answer 27

XR: all traumatic injuries to r/o Fx, eval for calcifications and bone spurs GOLD is MRI*: if chronic or concern for partial tear add arthroscopy. If full thickness, don't need arthrogram

Question 28

What is non-surgical Tx of rotator cuff

Answer 28

NSAIDs, PT, avoid overhead activities if <5-% tear | Steroid injection to decrease inflammation of subacromial bursitis, and short term pain relief

Question 29

Why should pts not get more than 3 subacromial injections per year

Answer 29

can lead to weakened tendon, and accelerate propagation of the tear

Question 30

When would you preform surgery to fix a rotator cuff

Answer 30

Significant Sx and failed rehab >3-6 months | Acute traumatic cuff tear (surgery w/in 6 weeks of injury!)

Question 31

What is adhesive capsulitis

Answer 31

Idiopathic loss of active and passive motion MC affects patients 40-60 Due to inflammation in GH capsule

Question 32

Adhesive capsulitis is related to these comorbidities

Answer 32

MC* DM type 1 | Also, hypothyroid, cervical herniation (what level???????), Parkinsons, and Dupuytren contracture

Question 33

Adhesive capsulitis leads to

Answer 33

gradual loss of ROM that pt is not aware of | mechanical restriction- ER (MC*), abduction, and flexion

Question 34

When evaluating adhesive capsulitis, you may find

Answer 34

``` Reduced ROM (50% or more) in ER (mostly), flexion and abduction Pain dull and achy at rest, sharp at end ROM of GH joint Diffuse shoulder ttp ```

Question 35

XR can be used for what in adhesive capsulitis

Answer 35

R/o other pathology

Question 36

MRI can be used for what in adhesive capsulitis

Answer 36

contracted capsule and loss of inferior pouch on arthrography

Question 37

What are the phases of adhesive capsulitis

Answer 37

Freezing: pain and progressive loss of motion Thawing: decreased discomfort associated w/ slow but steady improvement in ROM -can take 6 months-2 years for resolution aka end of thawing phase

Question 38

How do you treat adhesive capsulitis

Answer 38

Intra-articular steroid injection PT (aggressive ROM) Consider for pain control prior to PT visits If no improvement in 9-12 months, consider surgery