Shoulder Flashcards
Present a review of orthopedic problems in the shoulder and their tx. Etiology, signs, Sx, and management (143 cards)
1
Q
What is the common symptom orthopedic problems?
A
Pain
2
Q
What are associated orthopedic problems?
A
numbness- swelling can be associated deformity loss of function lacerations psychological problems - whether or not they have pain is difficult to tell
3
Q
Pathways of clinical discussion
A
CC- why are they here Hx of CC physical findings suspected differentiated diagnosis objective testing specific diagnosis tx
4
Q
severity of pain
A
burn? aching pain? numbness? swelling ? redness? what makes it better or worse?
5
Q
Hx of CC
A
initiating circumstances time factors past hx of similar conditions past hx of tx previous illness that may be related family hx of similar problem
6
Q
Notes of Hx of CC
A
How was it treated before? Aspirin Any recent injuries? Family history with similar condition or pain? How did it start ? Is it short term or long term ? Has it hurt like this before ? Numbness before? Tx in the past ? Any illnesses? Cough or cold urinary problems Arthritis or gout in the family?
7
Q
which joint usually sublux (dislocate) anteriorly?
A
glenohumeral joint
8
Q
Apprehension test
A
subluxation upon test show shoulder instability (COMMON)
90 degrees abduction to see it if sub luxes
Subluxation of a joint means a condition where a joint is dislocated
9
Q
What is a normal degree of full abduction
A
180
look for loss of abduction
10
Q
Physical findings of shoulder
A
inspection (general appearance, symmetry, atrophy, color)
Symmetry between mirrored anatomical structure make for a direct non pathological comparison
11
Q
Degrees of shoulder ROM
A
Flexion - 160 Extension - 45 abduction - 180 adduction - 45 internal rotation - 90 external rotation - 100
12
Q
Objective testing
A
Radiograph -
Electrodiagnostic
Vascular
Provocative
13
Q
CAT Scan
A
bony details - fx of intraarticular
14
Q
MRI
A
if you don’t know if it is a fx or not and there may be infection
15
Q
Arthrograms
A
if you can’t do an MRI (patient has pacemaker) - inject to see soft tissue (CONTRAST)
16
Q
ultrasound
A
rotator cuff tears
17
Q
Pain in shoulder - nerve
A
can be radicular pain (nerve root)
or may be coming from the neck
18
Q
EMG
A
see how the nerve functions by EMG
whether or not nerve is functioning or is irritated
DO IT for Axillary n.
19
Q
Nerve conduction velocities
A
speed of the nerve signal
20
Q
What kind of electrodiagnostic testing is used for carpal tunnel syndrome?
A
EMG/NVC
21
Q
What is the non-invasive vascular testing?
A
sonogram
=sound
22
Q
When do you do an objective PROVACATIVE testing?
A
Not sure what is wrong e.g. rotator cuff tear vs neck problem
inject needle under SUBACROMIAL AREA = if pain relieved from site anesthesia, then rule out origin of pain from the neck because it is localized and directly from the shoulder
23
Q
Can nerve root and localized nerve functioning both contribute to pain?
A
Yes
24
Q
AC joint
A
acromion process and clavicle
Acromioclavicular joint/ superior acromioclavicular ligament
25
SC joint
Sternoclavicular joint / / anterior sternoclavicular ligament
clavicle and manubrium (not sternum)
26
Glenohumeral joint
glenoid cavity and head of the humerus
27
Scapulothoracic joint
suscapular fossa and medial border of the scapula to the thorax (ribs)
28
Coracovicular joint
corocoid process of the scapular to the clavicle
| oracoclavicular ligaments – trapazoid and coracoid ligaments
29
G-H joint problems
```
Instability
Impingement
rotator cuff
bicipital tendon
degenerative joint disease
adhesive capsulitis (arthritis)
```
30
Diagnosis of G-H instability
subluxation - usually anteriorly
head of the humerus can move from the glenoid fossa
hyaline cartilage not seen in the joint space when collapsed
31
G-H joint subluxation
superiorly
| inferiorly (acute dislocation)
32
How to view inferior G-H joint subluxation
lateral and Y view x-ray
| not just AP
33
CC of G-H instability
```
Pain
Painful ROM
Weakness in abduction
apprehension of instability
guarding
spontaneous dislocation
```
34
Pain ROM in G-H instability
deformity
35
Weakness of abduction in G-H instability
won't be able to move the arm if complete dislocation
can indicate nerve injury to the axillary n. which supplied the deltoid (abduction function) = decreased abduction of the arm if ax. n. traumatized
36
apprehension of instability (apprehension test)
stress test to stretch the joint and they will feel pain and think the shoulder will dislocate
37
Guarding
CLINICAL SIGN OF G-H INSTABILITY
-Patient won't abduct
think they will dislocate the arm
38
Spontaneous dislocation
Instability of the joint will cause spontaneous dislocations
shoulder will pop out of the place ; pt has to be sedated to have it put back into place
FOOSH injury
39
Hx or cause of G-H instability
TRAUMA
CONGENITAL
INFECTION
40
Trauma
acute - fall on arm; FOOSH
| chronic overuse - that wears out the supporting structure of the shoulder (shoulder tend to sublux)
41
Congenital (born with it)
Chronic laxity - lax shoulder
| deformity of joint
42
Congenital deformities of the G-H joint
Ehler’s Danlos syndrome – how the collagen fibers are laid down in the capsular structures
-weakened capsular structures
-lax everything: elbow hyperextended, thumb hyperextended, and knee caps dislocated
glenoid may be shallow
43
Infection
destroy articular spaces and destroy joint
better tx infections quickly
eliminate the possibility of this joint becoming post-infection
44
Physical findings of G-H instability
```
asymmetry
weakness
decreased functional ROM
palpatory hypermobility
TESTS!!!!!!
```
45
What are tests for G-H instability
APPREHENSION TEST
RELOCATION TEST- pop it back in
ANTERIOR DRAW TEST
46
Weakness of G-H joint
cause instability
joint sublux where the head of the humerus used to be
SULCUS SIGN - DEPRESSION AT AREA where humeral joint would normally be
-weakness particularly if shoulder is CHRONICALLY INSTABLE
47
Decreased functional ROM at G-H joint
won't have the ability to move the arm - feels like you would dislocate that arm
48
Objective testing for G-H instability
1. X-rays - AP, exillary Y -view r lateral view)
orthogonal XR should be initial objective testing
2. CT scan - Hill Sachs lesions
3. MRI - labral tear, bankart lesion
4. Arthrogram - when you can't do a MRI
49
Hill Sachs lesions
seen in CT
occur @ G-H joint
head of the humerus gets pushed on and dislocates by the head of the glenoid rim
creates a defect in the head where the head is being pushed
50
How do you see a Hill Sachs lesion?
CT
51
How do you see a bankart lesion?
MRI or arthrogram if can't do MRI on a patient with pacemaker or other devices
52
Bankart lesion
```
torn labrum which is cartilaginous
it creates a lesion
labrum is torn off
usually can do it with MRI
located in the BACK of the joint
```
53
How to Tx G-H instability?
Dont do SURGERY if Ehler's Danlos (upper brachial plexus injury) or collagen type II defect
54
Tx acute G-H dislocations
Need to be put back in place !!!!
| use safe technique - stimson's technique
55
Surgery for G-H instability
Trauma - ACUTE
bankart lesion (fix the labrum)
CHRONIC RECURRENT DISLOCATIONS
instable shoulder (subluxed) - not yet dislocated ; tighten up the capsule and repair the glens
56
What are chronic recurrent dislocations of G-H?
patient will continue to dislocate unless something is done surgically
CHRONIC DISLOCATIONS DO REQUIRE SURGERY
57
What is the safest way to put G-H joint back in place?
Stimson's technique
| joint dislocation
58
Stimson's technique
weight on the arm
the muscles will relax and the weight will put the bone and put into the place
give med for the pain
FIRST LINE TX
59
What is the tract-countertraction method for putting back G-H joint back into place?
pull it back into place
sheet through the axillary complex
place heat
PROBLEM CAN OCCUR : AXILLARY N CAN BE DMAGED IN THE PROCESS OF PULLING
the method may not be effective in putting it back into place - usually doesn't go bakcin to place
60
What is an acceptable method of putting back G-H joint ?
series of movements: externally rotate and internally rotate to pop it back into place
RELOCATE THE JOINT
61
WHEN TO NOT PERFORM KOCHER'S METHOD?
an elderly woman who is osteoporotic because you can fx the humerus
62
What to do after you relocate the G-H back into place?
immobilize the joint
| if first time dislocation, there is a 100% chance that redislocation is common
63
Redislocation of G-H joint
Older you are age 40 and up the more common it is
Young people who has anterior dislocation frequently - redislocation can occur again = requires a swathe (sling) to further immobilize the joint
64
Why use sling and swathe for G-H joint?
prevent redislocation
immobilize the joint after putting it back into place
strap keeps the patient from EXTERNALLY rotate the arm
if it is a rotator cuff injury, USE ABDUCTION PILLOW !!!!!!!!!!
65
What is an associated pathology of the G-H joint instability?
traumatic anteroinferior glenohumeral dislocation most commonly injures the anterioinferior labrum and anteriorinferior glenohumeral ligament
TORN LABRUM
BANKART LESION
66
what is the redislocation rate for anterior dislocation?
100 % in adolescents with open growth plate
| 55-95% in 18-30 in air force academy study
67
Adolescents
redislocate after an anterior dislocation 100% of the time
68
Tendon tear
surgery is required
| labrum is anchored by a screw
69
Complications of G-H dislocations!!!!
Redislocation
Torn glenoid labrum
Hill sachs lesion
anxillary n damage
70
How to surgically tx hills sachs lesion?
UNIQUE
cover the lesion wi with tissue
metal screws will be placed in
the lesion occur at the articular surface of the humerus
71
Which muscle is usually injured with shoulder dislocation?
Deltoid m.
72
Subacromial impingement (G-H)
impinge rotator cuff tendons between undersurface of acromion and greater tuberosity of the humerus = INFLAMMATION
of the bursa and the tendons
MORE COMON THAN DISLOCATED SHOULDER
73
common CC impingement
Painful lifting or working overhead
74
Other complaints due to impingement
1. painful abduction of the shoulder - raying arm up
2. difficulty throwing
3. crepitance or catching
75
What is crepitance?
means grinding e.g. patient who ACHONDROMALACIA will show crepitance on rotator cuff
76
A patient who is a car mechanic or an electrician are likely to have painful abduction because of this...
impingement
77
What is a physical finding for impingement?
palpating the edge of the rotator cuff and resting ROM = pain !
78
Why are swimmer unique when they present with impingement?
they don't have bone impingement
They have a hypertrophy of the subscapularis m.
They will come in with pain in the muscle
They have impingement in the BURSAL contents
79
What is the abnormal contact between acromion and greater tuberosity in mid-abduction?
1. bursa can hyperthrophy
2. Trauma of AC joint can create bone spurs
compromises the subacromial space and movement of the joint
Compromises the amount of space the rotator cuff can move through
80
Hx of impingement
```
Over head work
Muscle hypertrophy
Trama to AC joint
Congenital deformity !!
Degenerative joint disease !!!! - impingement
CAUSE COMPRESSION
```
81
Physical findings of impingement
1. Difficulty lifting arm above head
2. Crepitance with abduction - grinding underneath acromial process
3. impingement sign
3. provacative test- whether or not it's a nerve root injury or from the shoulder itself
82
What is the impingement sign (physical finding)?
Passive forward flexion over 90 degree causes pain (physician flexes arm forward)
83
What is the hawkin's test?
it is used in subacromial impingement
| it is when you feel a grinding or crepitance when raising the arm forward
84
Objective testing for impingement
XR
Arthrogram
MRI
85
What is XR used for in impingement
Degenerative joint disease of the AC joint
| Calcifications of tendon of the rotator cuff (WHITE TENDON) = CHRONIC !!!!
86
What is arthrogram used for in impingement?
to see soft tissue
| usually normal
87
What does MRI show in impingement?
MUSCLE hypertrophy
| congenital downsloping of the acromion
88
What are the congenital acromion downslopping types?
```
BIGLIANA CLASSIFICATION
Type I - flat acromion
Type II - curved acromion
Type III - hooked acromion (pointed down) ****MOST common
HOW TO SEE IT? CT
```
89
Tx of impingement
1. Meds
2. Modification of activity - don't raise arm over the head
3. PT
4. Surgery
90
Tx impingement with meds
Oral - ibuprofen
injection - cortisone - prevent inflammation
inotophoresis
91
What is inotophoresis?
Take cortisone cream and put it on the skin and use electric current through the subcutaneous tissue
Get rid of the inflammation
92
Surgery options for impingement
acromioplasty - acromion is removed
Mumford - clavicle and acromion process
Arthroscopic decompression - take off part of acromion off
93
What is mumford procedure?
Take off a part of the clavical to the coracoclavicular ligament (open up the joint) and acromion process
Also take out Subacromial bursa which causes inflammation
94
What is athroscopic decompression?
take part of the acromion process off
95
Dx of Rotator Cuff Tear
Partial thickness tears = incomplete tear = repetitive microtrauma
Full thickness tears - tear the tendon = either full on trauma
96
How does rotator cuff tears occur?
SITS = 4 muscles of the rotator cuff
impingement it enough that it can tear
1. Can be caused by Wear and tear OR
2. VASCULAR cause weakening and rupture
97
What is the common demographic for rotator cuff tears?
50 years
| Usually Occur in the elder man
98
Watershed area of the supraspinatus - vascular injury to ROTCUFF
Undernearth the acromion bursa - has very little blood supply
99
The critical area of rotator cuff injury is?
the tendons that fuse and attach to the greater tuberosity
100
Early vs late complete tears
late tear shows resolved tendons at the ends
101
CC of Rotator cuff tear
```
weakness in abduction
painful abduction
can't lift arm overhead
can't lay on arm
can't throw
can't work overhead
pain at rest
```
102
How to test for rotator cuff tear?
DROP ARM TEST- can't abduct arm (weakness and painful)
103
Hx of rotator cuff injury
microtrauma - over use
Chronic impingement -> can cause micro trauma (partial tears)
Trauma
104
What are the mechanisms of injury rotator cuff tears?
Microtrauma - overhead work, repeated lifting
chronic impingement - acromion downsloping
Trauma - fall, pulling and lifting (stretch tendon)
105
2 cause theories for rotator cuff
vascular insufficency in critical zone (supraspinatus)
| micro trauma from chronic impingement
106
Physical findings of R-C tear
```
weakened and painful abduction
muscle spasms !!!!
DROP arm test
gerber's lift off
empty can
```
107
What is the GERBER'S LIFT OFF?
test R-C tear
test subscapularis m.
HAND AT OR BELOW THE SCAPULA = ATTEMPT TO LIFT HAND
108
Empty can tests which important m. in R-C injury?
supraspinatus
| a common m. injury in R-C tear
109
Objective finding of R-C tear
X-ray
MRI
Arthrogram
110
XR will show the following in R-C tear
bony spurs (will form from tendon) and DJD
narrowing !
resorption
will show as a subluxed humerus (superiorly) = no tissue to prevent sublux
111
MRI will show an important R-C finding
```
tears
bony spurs
DJD
narrowing
resorption
```
112
Arthrogram - RC tear
contrast that spreads outside the bursa to see area
113
Tx of RC tears
```
Rest
Abduction sling
physical therapy
modification of activity
meds
surgery
```
114
Tx of Incomplete RC tear
Simple traction
115
In surgery, a massive RC tear will show what
no muscles on top of the head of the humerus
116
Surgery method for RC tear impingment
Arthroscopic method to remove subacromial bursa and also partial acromionectomy
- can't also place in screw to put RC tendon back into place on humerus
117
Bracing RC after surgery
Shoulder abduction brace
118
Dx of Biceps tendon
Proximal
Distal
weakness in SUPINATION
119
CC of BC Tendon Tear
Pain - rubber band
Weakness - supination
deformity - pop eye = on the anterior forearm, a bulge will be seen
120
Hx of BCT tear
Lifting and supination
impingement
overuse - microtrauma
Iatrogenic- cortisone injection into the tendon (NEVER DO THIS!!!!)
121
How does a doctor cause BCT tear?
from cortisone injection to the biceps tendon
| RUPTURE THE TENDON
122
Physical finding of BCT tear
Tenderness over tehe bicipital groove
popeye muscle
yerguson's test
123
Yerguson's test
Hold patients hand and feel bicipital groove as you supinate the arm
124
Objective finding of BCT Tear
MRI - see the muscle tear
| Ultrasound
125
Tx of BCT tear
skillful neglect- will heal but the deformity will remain; leave it alone and monitor it
surgery
126
Grades of AC joint separations
1 Sprain the AC ligament
2 Tear the cap - AC ligament
3 complete tear of AC, and trapezoid and cuboid? ligament
127
Classifications of AC separations
Type I = sprain like grade 1
Type II torn AC lig and acromion moves downward
Type III - torn of all the ligaments and acromion moves inferior
Type IV the clavicle move inferior when ligaments are torn
Type V Clavicle moved superior when ligaments are torn
Type VI clavicle moves inferior to the biceps tendon
128
CC of AC separation
Pain at rest and with ROM
Crepitance - grinding
palpable deformity
129
AC joint separation = THINK....
HOCKEY!!!!
130
Hx of AC separations
Trauma - common - FALL or HOCKEY
| Infection - RARE
131
AC separation from trauma can show this
Elevated joint
but at grade 3 separation
inflammation will there
132
Physical finding of AC joint separation
1. pain directly over AC joint = after 90 degrees AC joint rotates = ILICIT pain
2. palpable deformity
3. warmth
4. painful ROM
133
AC joint function
rotation
| plane = gliding joint
134
What is unique about taking a XR of the AC joint?
compare load-bearing vs. non-load bearing
| when pt. is given weights
135
Objective testing of AC separation
1. XR - common
2. CT
3. MRI
136
Tx of AC separation
1. Skillful NEGLECT for grade 2 and below
2. sling
3. AC strap
4. surgery if severe subluxations and dislocations
137
What tx method for AC separation not popular?
AC strap
138
Snapping scapula
CC - catching THE ARM when raises arm
Hx - congenital
Physical findings - PROMINENCE ON THE RIBS AS YOU ROTATE THE SCAPULA
Objective test - CT, XR
Tx - injections underneath the scapula! AVOID SURGERY
scapulo-thoracic impingment
139
Adhesive capsulitis AKA .... FROZEN SHOULDER SYNDROME
```
Frozen shoulder syndrome
Scarring down of the articular capsule
CC: cant raise arm
Hx : slow progression of loss of motion
Physical : passive and active ROM is lost
Testing : MRI to see capsule
Tx : meds, PT, manipulation
```
140
Etiology of frozen shoulder syndrome
Due to trauma
or Disuse (OLD PEOPLE)
Inflammaton of the shoulder capsule
Complication fx or dislocation of the humerus
141
Adhesive capsulitis AKA .... FROZEN SHOULDER SYNDROME
```
Frozen shoulder syndrome
Scarring down of the articular capsule
CC: cant raise arm
Hx : slow progression of loss of motion
Physical : passive and active ROM is lost
Testing : MRI to see capsule
Tx : meds, PT, manipulation
```
142
Adhesive capsulitis AKA .... FROZEN SHOULDER SYNDROME
```
Frozen shoulder syndrome
Scarring down of the articular capsule
CC: cant raise arm
Hx : slow progression of loss of motion
Physical : passive and active ROM is lost
Testing : MRI to see capsule
Tx : meds, PT, manipulation
```
143
Etiology of frozen shoulder syndrome
Due to trauma
or Disuse (OLD PEOPLE)
Inflammaton of the shoulder capsule
Complication fx or dislocation of the humerus
