Upper Extremity Disorders Part 1 Flashcards
(127 cards)
1
Q
with shoulder hx CC - consider in the context of its ___ and ____
A
chronicity
patient’s age
2
Q
CC with shoulder disorders is typically ___ or ___
A
pain or instability
3
Q
shoulder hx - < 30 years old MCC
A
-
traumatic injuries or joint instability
- Glenohumeral dislocations or AC joint separation
- Rotator cuff tears and impingement syndrome rarely occur
4
Q
shoulder hx - MCC for 30-50 years old
A
- rotator cuff tears or impingement syndrome
- Dislocations are much less common and should raise a suspicion of a concomitant rotator cuff tear
5
Q
shoulder hx - MCC >50 years old
A
- rotator cuff dysfunction / tear, impingement syndrome and degenerative arthritis
- Acute pain in elderly may indicate pathological fracture due to osteoporosis- common at proximal humerus
6
Q
difference between acute vs chronic sx in shoulder pain
A
- Acute sx (< 2-3 wks duration)
- Think injury - Fracture, dislocation, rotator cuff tear or biceps tendon rupture - Chronic sx
- May be due to injury, but typically associated with overuse or arthritis
7
Q
components of instability in shoulder pain hx
A
-
Direction of instability
- Can be anterior, posterior, inferior, or multidirectional -
Degree of Instability
- Partial (subluxation) with spontaneous reduction vs. complete (dislocation)
8
Q
MC direction of instability in shoulder history
A
anterior
9
Q
during PE for shoulder cc, patient should be in what position with what removed
A
standing
shirt removed
10
Q
inspection during shoulder PE
A
- Assess contours and height of both shoulders
- Inspect both anteriorly and posteriorly
- Noteworthy findings: deformity, swelling, ecchymosis
11
Q
palpation for shoulder PE
A
- Start at the sternoclavicular joint and move laterally
- Assess all joints and bony structures
- Assess the subacromial bursa
- Assess long head of the biceps tendon
- Noteworthy findings: point tenderness, deformity, swelling
12
Q
shoulder PE - All 6 directions of movement should be assessed. These include:
A
horizational flexion & extension
extension
flexion
adduction
abduction
13
Q
things to keep in mind for shoulder PE ROM
A
6 directions
- Active followed by passive ROM
- Note direction of limited ROM
- Assess fluidity and smoothness of movement
- Palpate for crepitus
- Consider functional disability
14
Q
deltoid muscle testing
A
- Abduct shoulder at 90° with the elbow flexed at 90° and the forearm parallel to the floor
- Ask patient to resist downward pressure to the elbow
15
Q
special test for Supraspinatus
A
“Empty can test”
- Abduct shoulder at 90° with 30° forward flexion and internal rotation with the elbow extended
- In the “thumbs down” position - Push down as the patient resists
- Weakness or pain is indicative of rotator cuff disease
16
Q
special test for Infraspinatus and Teres Minor
A
- Flex elbow to 90° with shoulder in neutral position
- Support the elbow and attempt to externally rotate asking patient to resist movement
- hornblower’s sign
17
Q
special test for Subscapularis
A
“Gerber Lift-off Test”
- Place the patient’s hand behind the small of the back, palm facing away from back
- Have the patient lift the hand off the back against resistance
18
Q
muscle testing for Serratus Anterior
A
- Stabilizes the scapula
- Flex the shoulder above 90°
- Then with one hand, depress the arm (posteriorly), while the other hand palpates the scapula
- The scapula should remain on the chest wall
- Winging indicates muscle weakness
19
Q
muscle testing for rhomboid
A
- Have the patient place both hands on their sides, along the side of the iliac crest. Then push the arm forward as the patient resists your passive movement
- The scapula should remain on chest wall
- Winging indicates muscle weakness
20
Q
what is Neer impingement
A
- With patient seated, depress the scapula with one hand and elevate the arm with the other
- This compresses the rotator cuff tendons between the greater tuberosity and the anterior acromion
- Discomfort represents rotator cuff tear or impingement syndrome
21
Q
what is the Hawkins-Kennedy Test
A
- Forward flex the shoulder to 90° and the elbow flexed to 90°
- Internally rotate the shoulder
- Pain indicates impingement of the supraspinatus tendon
22
Q
what is the crossover test
A
- Elevate the shoulder to 90°
- Adduct the arm across the body in the horizontal plane
- Discomfort over the AC joint suggest arthritis or AC joint pathology
23
Q
what is apprehension sign
A
- Place the arm in supine position
- Place the arm in 90° abduction with elbow flexed at 90°
- Apply maximal external rotation
- Patients with anterior instability report a sense of impending dislocation
- Discomfort without apprehension is nonspecific
24
Q
what is the sulcus sign
A
- Apply traction in an inferior direction with the arm relaxed at the patient’s side
- Inferior instability: inferior subluxation of the humeral head and a widening of the sulcus between the humerus and the acromion
25
what is the Jerk Test
1. Place the arm in 90° flexion and maximum internal rotation with the elbow flexed at 90°
1. Adduct the arm across the body in the horizontal plane while pushing the humerus in the posterior position
1. If there is **posterior instability, this will cause posterior subluxation or dislocation**
26
dx imaging for shoulder injury
**Radiographs** - 1st line
1. **AP view** - Can add on AP internal and external rotation views
2. **Scapular “Y” view** - Helpful for shoulder dislocation, proximal humerus fracture and scapular fracture
3. **Axillary view**
27
* Can be obtained with internal and external rotation
* Internal (lesser tubercle of humerus); External (greater tubercle)
which xray view
AP view
28
which xray view provides better view of scapula
Lateral or scapular Y-view
29
which xray view provides a view of the relationship of the humeral head and the glenoid
Axillary view
30
Group of muscles and their tendons that act to ____ the shoulder, holding the humerus into the fossa of the glenoid
stabilize
31
Rotator Cuff Consists of 4 Muscles:
* **Supraspinatus** - MC affected
* Infraspinatus
* Teres Minor
* Subscapularis
32
pathophys of rotator cuff disorders
1. overuse
2. edema
3. inflammation
4. fibrosis
5. microscopic tear
6. partial thickness tear
7. full thickness tear
33
An **inflammation** of the **subacromial bursa** and **rotator cuff** tendons
Results from **repetitive compression** of these structures under the coracoacromial arch
Impingement
34
presentation of impingement disorder
1. **Gradual onset** of shoulder pain
2. Anteriorly and laterally
3. Pain worse with **overhead activity**
- Can also worsen when reaching behind the back
4. **_Night pain_** and **difficulty sleeping** on affected side
5. Prolonged cases: weakness and SITS muscle atrophy
35
PE for impingement
1. Inspection
- Usually normal
- Atrophy if prolonged condition
2. Palpation
- Tenderness over the **greater tuberosity and subacromial bursa**
3. ROM
- **Pain with abduction** (90-120°) and when **lowering arm** back down
- Crepitus with movement
4. Special testing
- (+) **Neer** and **Hawkins-Kennedy**
36
diagnostics for impingement disorder
1. X-rays typically normal
- Y-view x-ray could demonstrate subacromial spur
2. MRI - better, however $$$
3. Diagnostic anesthetic injection
- Assess muscle strength with **Empty Can** test
- Inject 10 ml of 1% lidocaine into the subacromial space
- Repeat Empty Can
- If **strength assessment improves impingement is more likely than tear**
37
impingement disorder management
1. **_Mainstay: Rest & NSAIDs_**
2. _Home exercise program_
- 6-8 wks (exercises 3-4x daily)
- _Should not have an increase in pain_ - Muscle soreness and stretching sensation are normal
- Ice application after exercises
3. _Corticosteroid injection_ if no improvement after 4-6 wks
4. Referral indications
- _PT_ - no improvement after 3-4 wks of home exercise
- _Ortho_ - no improvement after 2-3 months of PT
--- Possible consideration of surgical subacromial decompression
38
Repetitive overhead motions increase the demand on the shoulder and the musculotendinous junctions
Rotator Cuff Tendonitis
39
RF Rotator Cuff Tendonitis
1. MC - Repetitive overhead activity
- Pitching
1. Increased BMI
1. DM
1. Hyperlipidemia
40
Rotator Cuff Tendonitis - Excessive abduction and external rotation results in compression of what muscles
supraspinatus and infraspinatus
41
early sx of rotator cuff tendonitis
**Stage I tendonitis**
1. Aching and soreness with repetitive activity (throwing)
- Anterior shoulder
2. Athletes
- Decreased pitching speed and accuracy
3. Pain with ADL’s
4. Improves with rest
42
late sx of rotator cuff tendonitis
Stage II tendonitis
1. Posterior shoulder pain with activity and at night
1. Loss of ROM - abduction and external rotation
1. Rest is no longer effective
43
PE of rotator cuff tendonitis
1. Inspection
- Most patients are normal
- Atrophy of supraspinatus/infraspinatus (long-standing dz)
2. Palpation
- **Tenderness** along affected muscles, subacromial space
3. ROM
- **Pain above 90° abduction**
- **Passive ROM > active ROM**
4. Special Testing
- (+) **Empty-can**
- (+) **Neer and Hawkins** if associated impingement
44
imaging for rotator cuff tendonitis
1. Shoulder X-ray - Internal and external AP views
2. MSK Ultrasound
3. MRI shoulder
45
pros and cons of rotator cuff tendonitis US? findings?
* Requires trained technician; operator dependent
* Inexpensive, convenient, and no radiation exposure
* Will show **thickening** (>5 to 6 mm), **hypoechogenicity, and heterogeneity**
46
indications for MRI shoulder in rotator cuff tendonitis? findings?
1. Indications
- Unclear presentation (clinical diagnosis is questionable)
- Inadequate response to conservative therapy
2. Will show **inflammation and edema**
47
management for rotator cuff tendonitis
1. _Stage I_
- **Rest** - no overhead weight training or throwing x **10 days**
- After 10 days of rest - intermittent throwing
- Physical therapy
2. _Stage II_
- **Rest and refer to PT** - Complete shoulder rest until after PT has been completed
3. _Referral indications_
- Failure of conservative therapy
48
Tear in one or more of the 4 rotator cuff muscles (SITS)
Rotator Cuff Tear
49
Which tendon is most common injured for rotator cuff tear
supraspinatus
50
Pathophysiology/Etiology of rotator cuff tear
often multifactorial
1. Age-related **degeneration**
1. Chronic **mechanical impingement**
1. **Altered blood supply** to tendons
51
presentation of rotator cuff tear
1. Chronic shoulder **pain**
- Ranging from mild-debilitating
- Worse with activity and at night
2. Associated **weakness, catching, and crepitus** when lifting the arm overhead
3. _Inability to fully perform ADL’s_
- Washing/styling hair
- Putting on shirt/jacket/bra
- Reaching for items in higher shelves/cabinets
4. Older pts may be asx
52
PE of rotator cuff tear
1. Inspection
- Atrophy of posterior shoulder - if chronic
2. Palpation
- **Tenderness** along greater tuberosity
3. ROM/Muscle strength
- **Limited, painful/weak AROM** - Abduction and external rotation; Internal rotation will be limited if the subscapularis tendon is involved
- **Full PROM**
- **+ Drop Arm**
4. Specialized Testing
- (+) **Empty can, Neer’s, Hawkins**
53
imaging for rotator cuff tear
1. **X-rays**
- Rules out other pathologies
- May show **acromial spur** or **sclerosis** of the humeral head
2. **US**
- Highly accurate in detecting **full-thickness** rotator cuff tears
3. **MRI**
- Helps determine **size, location, and characteristics** of rotator cuff pathology
- Less sensitive for partial-thickness tears (but still very sensitive overall - 91%)
4. **Arthrography**
- Less expensive than MRI; invasive procedure
- High sensitivity with full thickness tears; sensitivity decreases with partial tears
54
XR shows evidence of shallow space between acromion and humerus
indicative of what dx?
chronic rotator cuff tear
55
conservative approach for rotator cuff tear
1. Rest - avoid overhead activities
1. NSAIDs
1. PT - Minimum of 6 wks
1. Glucocorticoid injections
- Only in pts who are _not surgical candidates_
- Limited to 3-4
56
surgical indications for rotator cuff tear
1. Tear in patients < 55 y/o
1. Acute, full-thickness traumatic tear in healthy individual
1. Acute on chronic tear with loss of function
1. Failure of conservative therapy after 3-6 months
57
A painful loss of both AROM and PROM due to idiopathic inflammation of the joint capsule
Adhesive Capsulitis Aka “frozen shoulder”
58
adhesive capsulitis is MC seen in who?
MC in women 40-60 y/o
59
RF for adhesive capsulitis
1. **DM I - MC**
1. Hypothyroidism
1. Dupuytren’s disease
1. Cervical disc disease
1. Parkinson’s
1. Cerebral hemorrhage
60
presentation of adhesive capsulitis
1. _“Freezing” phase_ - **Progressive loss of ROM and pain**
1. _“Thawing” phase_ - **Gradual improvement in ROM and discomfort**
- Lasting 6 months - 2 years
3. Exam
- Significant reduction (>50%) in **both AROM and PROM**
- Tenderness at the deltoid insertion - May be diffuse
61
imaging for adhesive capsulitis
1. **X-rays**
- Normal
- Utilized to r/o Ddx
2. **MRI**- _Indicated only if presentation is atypical_
- Imaging will reveal “**contracted capsule and loss of inferior pouch**”
62
management for adhesive capsulitis
1. NSAIDS
1. **Moist heat** compresses
1. Home **Stretching** Program
- 3-4 wks
- Ice application after stretching
1. Image guided **intra-articular steroid injection**
- Fluoroscopy or US
- Limited (3-6 total) over course of disease
1. **Physical Therapy**
- Transcutaneous Electrical Nerve Stimulation (TENS) Unit
1. **Surgical repair**
- Arthroscopic capsular release
- Indicated for failure of conservative therapy - _No improvement 3 mo of consistent rehab_
1. Patient education
- **Prognosis**: 1-2 year for full recovery
63
the humeral head partially slips out of the glenoid cavity
Subluxation
64
the humeral head becomes completely dislodged from the glenoid cavity
Dislocation
65
MOA of anterior shoulder dislocation
Blow to abducted, externally rotated and extended arm
Example: blocking basketball shot
66
presentation of anterior shoulder dislocation
1. Arm is slightly abducted and externally rotated
1. Prominent acromion (thin patients)
1. Loss of the normal rounded appearance of the shoulder
1. No ROM
67
MOA of posterior shoulder dislocation
* Blow to the anterior portion of the shoulder
* Axial loading of an adducted and internally rotated arm
* Violent muscle contractions following a seizure or electrocution
68
presentation of posterior shoulder dislocation
* Arm is **adducted and internally rotated** with an **inability to externally rotate**
* Shoulder prominence posteriorly with flattening anteriorly
* The coracoid process may be more prominent
69
MOA of inferior shoulder dislocation
Axial loading with the **arm fully abducted** or **forceful hyperabduction** of the arm
MC: overhead grasp of object to keep from falling
70
presentation of inferior shoulder dislocation
**Arm is held above the head**, pronated with the **inability to adduct**
71
Patients can typically voluntarily dislocate the shoulder
Poor prognosis for surgical treatment
what type of shoulder instability
Multidirectional Instability
72
Physical exam testing for assessing instability
* Apprehension test (anterior instability)
* Jerk Test (posterior instability)
* Sulcus sign (inferior instability)
73
4 complications from shoulder instability
1. axillary nerve damage
2. Hill-Sachs Lesion
3. Bankart Lesion
4. Greater tuberosity fx
74
1. numbness over the lateral arm and deltoid dysfunction
1. weakness of the teres minor and deltoid
type of shoulder instability complication?
Axillary nerve damage
1. sensory
2. motor
ALWAYS perform NV exam
75
**Depression fracture of the humeral head** created by the glenoid rim during dislocation
MC seen in **anterior** dislocations
which type of shoulder instability complication?
Hill-Sachs Lesion
76
* **Glenoid labrum is disrupted** during dislocation
* MC in patients < 30 y/o
* May result in a bone fragment avulsion
which type of shoulder instability complication?
Bankart Lesion
77
diagnostics for shoulder instability
* **X-ray** - AP, "Y" view, axillary view
* **CT** - only if plain films do not clearly define direction of dislocation
* **MRI** - Performed **after reduction** if soft tissue injury is likely
78
at what ages do Bankart lesions and rotator cuff MC occur?
* Bankart lesion - < 30 year old
* Rotator cuff - young (< 40) patient with traumatic dislocation
79
management for shoulder instability
1. anterior/inferior/posterior **dislocation reduction**
2. Reassess **NV status**
1. **post-reduction films** to verify successful reduction
1. Immobilize shoulder in **sling x 3 wks**
1. Refer to **PT** for strengthening
1. Refer to Ortho if concern for complications
80
techniques for anterior shoulder dislocation reduction
1. Stimson Technique (prone)
1. Longitudinal Traction
May use procedural sedation or intra-articular lidocaine injection
Informed consent required
81
technique for inferior shoulder dislocation reduction
axial traction
82
technique for posterior shoulder dislocation reduction
Traction-
countertraction
Informed consent required
83
* Caused by trauma to the AC joint resulting in ligamentous disruption
* MOA: Fall directly onto adducted shoulder
Acromioclavicular (AC) Injuries
84
AC injury classification system
I-VI
based upon severity of separation
85
* **Most common**
* AC joint ligaments are **partially disrupted** and the strong coracoclavicular (CC) ligaments are intact
* **No separation** of clavicle from acromion
AC injury classification?
Type I - sprain
86
* _AC ligaments are torn_ but the **CC ligaments are intact**
* Partial separation of the clavicle from the acromion
AC injury classification?
type II
87
* **_Both_ AC and CC ligaments are completely disrupted**
* Complete separation of clavicle from acromion
which type of AC injury classification?
type III
88
Rare
Classified based upon degree and direction of separation
which types of AC injury classifications?
Type IV - VI
89
* **Pain** in AC joint on **abduction**
* Supports arm in an adducted position
* Deformities (Grade III-VI)
* **Tenderness** over AC joint
* Assess NV status
presentation of which dx?
Acromioclavicular (AC) Injuries
90
AC injury imaging and findings of the types?
1. **Radiographs**
- AP shoulder
- **Zanca** view: AP with 10-15 degree cephalic tilt
1. Type I - normal
1. Types II-VI - separation noted
91
Grade I-II AC injury management
1. **Ice** compresses
1. **NSAIDs**
1. **Sling** with rest x 2-3 days
1. **ROM exercises** and gradual return to activity as pain allows
- Start within 7-10 days
- Expectation of full return within 2-4 wks
92
Grade III AC injury management
1. **Conservative** as in I and II
1. Refer for **surgical consideration _if injury affects career_** - *Young manual laborer, athlete*
1. **Acceptable deformity** is likely without surgical intervention
93
grae IV - VI AC injury management
1. **Refer to ortho surgical repair** - Emergent if NV compromise
1. Deformity and weakness will be likely without intervention
94
* Ligament trauma to the joint connecting the sternum and the clavicle
* Ranging from microscopic tears (sprain) to complete disruption of ligaments (dislocation/subluxation)
what type of injury?
Sternoclavicular Injuries
95
anterolateral force applied to the shoulder with a rolling movement (sports)
which type of MOI sternoclavicular injury
anterior
96
* crushing forces to the chest
* May be associated with _mediastinal injuries_
* Consider airway assessment
which type of MOI sternoclavicular injury?
posterior
97
**Mild-moderate pain, tenderness and swelling** with no change in joint structure
which type of sternoclavicular injury presentation
sprain
98
* _Severe pain, swelling, ecchymosis, decreased ROM_
* The medial clavicle is **prominent** compared to sternum
which type of sternoclavicular injury presentation?
anterior dislocation
99
* _Severe pain, swelling, ecchymosis, decreased ROM_
* The medial clavicle is **less visible/palpable**
* **Hoarseness, dysphagia, dyspnea, UE paresthesias**
which type of sternoclavicular injury presentation?
posterior dislocation
100
diagnostics for sternoclavicular injuries
1. X-ray is **not sensitive** for detecting SC dislocation
1. CT chest - Consider IV contrast to R/O mediastinal injury
101
management for sprained sternoclavicular
1. Rest, sling, ice, NSAIDS
1. Gradual return to activities (same as AC Grade I)
102
management for anterior sternoclavicular dislocation
1. Reduction
- After procedural sedation (informed consent)
- Place rolled towel between scapula and table/bed and apply posterior traction to the affected arm - _may not remain in place d/t instability of joint_
- Place in sling/swathe or **figure 8** clavicle harness
2. Ice and analgesics
103
management for posterior sternoclavicular dislocation
1. Immediate ortho consult for **open vs closed reduction**
1. Consult trauma/general/vascular/thoracic surgeon for associated injury case based
104
clavicle fx is classified by ?
**location** of fracture
Proximal (medial) ⅓, middle ⅓, distal (lateral) ⅓
105
MC clavicle fx location
1. **diaphysis**
2. medial end
3. lateral end
106
1. Pain, swelling, deformity
1. **Skin tenting**
1. Tenderness along fracture site
1. Decreased ROM
- _Grinding sensation_ noted over fracture site with attempted ROM
presentation of which dx?
clavicle fx
107
imaging for clavicle fx?
imaging if initial not confirmatory?
What imaging if medial fx suspected?
1. Clavicle **x-ray**
- AP
- **10 degree AP cephalic view** if AP is non-confirmatory
2. **CT chest w/ contrast** if _medial fx suspected_
- Look for associated mediastinal injury
108
management for uncomplicated clavicle fx
1. **Figure 8 strap, sling, ice, analgesics**
- Strap/sling x 3-4 wks (age 12 and under), 6-8 wks for adults
2. gentle ROM exercises after 2-3 wks (as pain allows)
109
findings that indicate for Ortho consult for **closed/open clavicle reduction with internal fixation**: (5)
1. Medial fracture
1. Tenting of the skin
1. 100% displacement
1. Displaced distal ⅓ fractures
1. Severe comminution
110
* A common inflammatory process of the long head of the biceps tendon
* overuse (repetitive lifting)
* Commonly coexists with other conditions
Biceps Tendinopathy
111
95% of patients with biceps tendinopathy have what other condition?
impingement syndrome
112
1. Pain reported in the **anterior shoulder** radiating to the elbow
1. Worsened by activity - **Lifting, pulling, or repetitive overhead activities**
1. **Night pain** is common
1. Sx relieved with rest and ice
2. Tenderness along the bicipital groove
3. Pain with both active and passive ROM
4. **(+) Yergason’s Test**
dx?
Biceps Tendinopathy
113
dx and management for biceps tendinopathy
1. Dx is clinical, no use of imaging
1. Rest/Modification of activities; Ice; NSAIDs
1. Glucocorticoid injection if after failure of conservative therapy - Medication cocktail injected at subacromial space or bicep tendon sheath
1. PT if sx don’t improve with conservative management
114
caution with injections for biceps tendinopathy as there is a risk for ?
tendon rupture
115
MC location of Biceps Tendon Rupture?
who is it MC seen in?
* **proximal end** of the long head
* **older adults** with chronic shoulder pain or **impingement**
* May occur in weight lifters or throwing sport athletes
116
1. **Sudden onset** of pain in the upper arm
1. Audible “**snap**” may be felt and heard
1. Ecchymosis noted initially
1. **Bulge** / “popeye deformity” - Accentuated with flexion of elbow against resistance
1. Tenderness in the bicipital groove
dx?
bicep tendon rupture
117
diagnostics for bicep tendon rupture
1. **X-ray** - shoulder
- May be used to rule out other ddx (i.e. fracture)
2. **MRI** - Rule out rotator cuff tear
118
management for bicep tendon rupture
1. **Conservative** for most patients
2. _**Surgical repair** indications_:
- Unacceptable deformity
- Young athletes or laborers (< 40 y/o)
119
Generally a result of a **direct blow** to the arm such as MVA or falling on an outstretched arm
humeral fx
120
* humeral fx are classfied based on ____?
* name each
**location**
1. **Proximal** - Greater tuberosity, lesser tuberosity, humeral head, anatomical neck, surgical neck, proximal shaft
1. **Shaft**
1. **Distal** - Supracondylar (MC in children); Epicondylar
121
* presentation of humeral fx
* difference if Proximal fx vs Shaft fx
1. Pain, swelling, ecchymosis - Look for evidence of open fracture
1. Tenderness to gentle palpation over fracture site
1. **Limited ROM** of the shoulder (proximal/shaft fx)
1. Assess **NV status**
- **Proximal fx** - Axillary nerve/artery
- **Shaft** - Radial nerve (shaft/distal fx)
122
imaging for humeral fx
X-ray
* Shoulder (proximal fx)
* Humerus (shaft fx)
123
management for proximal humeral fx with minimal displacement
1. Sling - Full time x 3 wk then part time as pain allows
1. exercise program / refer to PT after 3 wks
1. Open Reduction and Internal Fixation (ORIF) as indicated
1. prosthetic replacement as indicated
124
indications for open reduction and internal fixation (ORIF) for humeral fx
1. **Displacement** of **> 1 cm** or **> 45° angulation**
1. **Displacement of greater tuberosity > 0.5 cm** - Affects rotator cuff muscles
125
Prosthetic replacement indicated for ____ due to risk of blood supply disruption of the humeral head
4-part fractures
126
management for humeral shaft fx with angulation < 20°?
* **U-shaped coaptation splint** for 2wks followed by a humeral fracture brace for 6 wks
* Encourage ROM of the fingers, wrist and elbow
127
surgical indications for humeral fx
1. Open fracture
1. NV compromise
1. Pathologic fractures
1. Ipsilateral forearm fractures
