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1022 THEORY > Week 4 Shoulder conditions and different diagnosis > Flashcards

Week 4 Shoulder conditions and different diagnosis Flashcards

1
Q

why are shoulders good to treat?

A
  • highly mobile joint
  • relies on active stability
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2
Q

red flags for shoulder conditions

A
  • infection
  • unreduced dislocation
  • tumour
  • acute cuff tear
  • neurological pathology or injury
  • cardiovascular or visceral impairment
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3
Q

symptoms/ signs and action of infection

A

symptoms/ signs:
- red, hot, swollen joint
- severe pain
- possible fever, fatigue, feeling unwell if sepsis 敗血症

action: refer to ED

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4
Q

symptoms/ signs and action of unreduced dislocation

A

symptoms/ signs:
- traumatic history
- abnormal shoulder shape
- reduced range of motion

action: refer to ED

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5
Q

symptoms/ signs and action of tumour

A

symptoms/ signs:
- soft tissue mass 軟組織腫塊
- swelling (unexplained by trauma)
- history of cancer
- night sweats
- UWL

action: refer to GP

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6
Q

symptoms/ signs and action of acute cuff tear

A

symptoms/ signs:
- traumatic history
- pain and shoulder weakness

action: In younger athletic patients consider orthopaedic referral if candidate for RC repair

對於年輕的運動患者，如果適合 RC 修復，請考慮骨科轉診。

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7
Q

symptoms/ signs and action of neurological pathology or injury

A

symptoms/ signs:
sudden motor or sensory loss

action: refer to GP/ ED

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8
Q

symptoms/ signs and action of cardiovascular or visceral impairment

A

symptoms/ signs:
eg: cardiac event (heart attack) referral of pain to left shoulder

action: refer to ED

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9
Q

special questions for shoulder injuries

A
  1. Has your shoulder ever ‘popped’ in and out, felt unstable for felt like it came out of the joint?
  2. Pain at rest?
  3. Neurological symptoms in the arm or hand e.g. tingling
    刺痛, shooting pain, numbness
  4. Severity, duration and impact on function – e.g. can they get dressed, sleep at night, do things around the house

refer to 1 - consider glenohumeral dislocation or sublaxation
refer to 2 - consider inflammatory conditions e.g. adhesive capsulitis
refer to 3 - consider cervical nerve root compression or peripheral nerve injury
refer to 4 - This can help guide treatment and management decisions

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10
Q

diagnosis of acromioclavicular joint injuries

A

stability is provided by: joint capsule, AC ligaments, coracoclavicular ligament

most common site of injury when the person falls onto the point of the shoulder, or outstretched arm

diagnosis:
- localised pain to AC joint site
- pain with horizontal flexion
- pain with elevated overhead
- possible step deformity 畸形 (X-ray can see)

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11
Q

rockwood classification of injury (acromioclavicular joint injuries)

A

type I
- sprain of the capsule
- localized pain (particularly horizontal flexion)
- 0-2 weeks recovery

type II
- complete tear of AC ligament and sprain of coracoclavicular ligaments
- well localized tenderness and palpable step deformity
- 3-6 weeks recovery

type III to VI
- complete tears of coracoclavicular ligaments
- marked step deformity
- type IV, V, VI much rarer than I, II and III

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12
Q

management of acromioclavicular joint injuries

A
  • ice and analgesics 止痛藥
  • immobilisation in a sling for pain relief (2-3 days for type I or up to 6 weeks in severe type III)
  • cervical spine ROM
  • isometric exercises and gentle mobilisation once pain permits
  • protective taping
  • type IV, V, VI and type III that failed conservative management require surgical management –> avoid contact sports for 8-12 weeks
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13
Q

sternoclavicular joint injuries

A
  • uncommon
  • from compression forces to the chest (MVA, sports)
  • sprain
    –> mild: ligaments intact and joint stable
    –> moderate: ligaments partially disrupted and joint subluxed
    –> severe: joint dislocation
  • anterior dislocation is more common than posterior
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14
Q

diagnosis of sternoclavicular joint injuries

A
  • mainly observation and palpation
  • tenderness of SC joint after trauma
  • complete dislocation may lead to difficulty swallowing
  • CT scan may help
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15
Q

management for sternoclavicular joint injuries

A
  • ice + sling for 2-3 days
  • high likelihood of pain and subsequent arthritis 疼痛和隨後的關節炎的可能性很高
  • mild sprain: resolve within 7-10 days
  • moderate sprain: take 3-6 weeks (anywhere up to 12 weeks)
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16
Q

pathophysiology of adhesive capsulitis (frozen shoulder)

A
  • idiopathic
  • inflammatory thickening of joint capsule
  • increased vascularity and neural tissues - maybe a source of pain
  • reduces capsular volume – decreased ROM
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17
Q

4 stages of adhesive capsulitis (frozen shoulder)

A

stage 1 - pre-adhesion: no adhesions, full ROM, night pain
stage 2 - acute adhesive capsulitis: forming adhesions, mild loss of ROM, pain +, hypertrophy of synovium 滑膜肥大
stage 3 - maturation: fibrosis begins, reduction in ROM, less pain
stage 4 - chronic: dense fibrotic adhesions, loss of ROM, minimal pain

(1,2: many pain, less adhesion, have ROM
3,4: less pain, more adhesion, loss of ROM)

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18
Q

risk factors of frozen shoulder

A
  • 40-65 years old
  • female > male
  • can be after trauma
  • diabetes
  • thyroid disease
  • history of cervical spine, shoulder or breast surgery
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19
Q

management of frozen shoulder

A

stage 1-2: pain management
- corticosteroids
- gentle exercise when acute pain settles
- joint mobilisation, stretching - prevent effects of immobilisation

stage 3-4: improve ROM
- education
- exercise to improve ROM when acute pain settles
- joint mobilisation, stretching

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20
Q

diagnosis of biceps tendinopathy

A
  • overuse
  • instability or altered glenohumeral motor patterning/ function
  • pain reproduced on stretching of biceps or resisted shoulder/ elbow flexion
  • local pain on palpation biceps tendon
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21
Q

management of biceps tendinopathy

A

load management
progressive loading
address glenohumeral and scapula mechanics and function

22
Q

biceps rupture

A
  • relatively rare
  • obvious deformity - 'Popeye sign'
  • can be little pain and biceps strength is almost fully maintained
  • surgical management
23
Q

umbrella term - subacromial pain syndrome

Info

A
  • Rotator cuff disorders
  • Rotator cuff tendinopathy
  • Subacromial impingement syndrome
  • Rotator cuff impingement/syndrome
  • Shoulder impingement
  • Rotator Cuff Related Pain Syndrome
24
Q

signs and symptoms of subacromial pain syndrome

A
  • most common type of shoulder pain (70%)
  • exacerbated 加剧 with repetitive/ overhead activities
  • reduced elevation ROM
  • pain around the lateral deltoid/ deltoid insertion
  • painful arc
  • weakness and pain with ER and abduction strength testing
25
special tests for the shoulder in subacromial pain syndrome
- **Hawkins-Kennedy** - **Neer's** - **Empty can** - Jobe's - ER resistance - Painful arc
26
Self-Reported Questionnaires – Validated Outcome Measures of subacromial pain syndrome ## Footnote Info
* American Shoulder and Elbow Surgeons Shoulder Score * Rotator Cuff Quality of Life Index * Shoulder Pain and Disability Index * Upper Extremity Functional Index * Western Ontario Rotator Cuff (WORC)
27
**MRI or Diagnostic Ultrasound recommended if: (diagnostic imaging of subacromial pain syndrome)**
* Traumatic injury * Clinical suspicion 懷疑 of full Thickness Rotator Cuff Tear * Conservative management has failed
28
**diagnosis of full thickness rotator cuff tear (specific in subacromial pain syndrome)**
- **older adults** or **trauma in younger athletes** - **>50% of age 70-80 people may present cuff tears** - full thickness tears **increase with age** diagnosis: - `decreased strength of ER/ IR` - decreased `elevation ROM and painful arc`
29
yellow flags of subacromial pain syndrome
- patient expectation - expectations of recovery with physio treatment - employment status - lack of social support .
30
conservative management of subacromial pain syndrome and rotator cuff tear
- **exercise** therapy (shoulder `strength` and endurance exercises) - **education** (`pain education`, anatomy and function of the shoulder) - **manual therapy** (`stretching`, `passive mobilisation of GH joint` and `massage`)
31
definition of instability, subluxation and dislocation
instability: the `humeral head` moves **within the confines (area)** 在範圍內 of the `shoulder socket` subluxation: humeral mead **moves part way out** of the shoulder socket dislocation: humeral mead moves **completely out** of the shoulder socket
32
**anterior glenohumeral dislocation**
- **often traumatic**, common in: - `young athletes (men) -- sporting injury` - `older people (women 61-70 yo) -- fall` - **most common direction** - 95% cases - **arm forced into excessive abduction and external rotation** - tackling player, trauma with arm in 'stop sign' position, fall - humeral head - anterior and inferiorly displaced - can result in damage to: anterior capsule/ glenohumeral ligaments, bankart lesion, bony bankart lesion, hill-sachs lesion, tearing of posterior/ superior labrum, vascular or nerve injury
33
bankart-lesion vs hill-sachs lesion
Bankart Lesion - compression fracture of the **anteroinferior glenoid margin** Hills Sachs Lesion - compression fracture of **posterior humeral head**
34
**symptoms/ signs of GH dislocations**
- **popping noise** or **sensation of giving way** - **numbness over lateral shoulder if damage to axillary nerve** - **prominent humeral head** - **deltoid is depressed** - **loss of normal contour** 輪廓 - acromion protrudes 突顯 with hollow below - humeral head palpated under the coracoid process
35
why x-ray is required for GH dislocations
- to eliminate bony damage 以消除骨骼損傷 1. glenoid (i.e. bankart lesion) 2. posterior humeral head (i.e. hill-sachs' lesion) 3. **avulsion** 撕脫 **fracture greater tuberosity** - preferable prior to relocation but not always practical 但並不總是可行 - must be done post-reduction
36
GH dislocations reduction 位錯減少
- **ASAP** - **difficult** due to -> `muscle contraction due to pain` -> `displacement of humeral head into the joint capsule` .
37
symptoms/ signs, reduction of posterior GH dislocation
- **less common** - **direct trauma** or **fall on outstretched hand with IR and adduction** symptoms/ signs: - arm held in IR/ adduction (*unable to E*R) - **loss of anterior contours** 前部輪廓喪失 reduction: forward traction of humerus
38
first time traumatic dislocations have
high rate of shoulder dislocation reoccurrence, especially in younger athletes
39
convervative managment of GH joint dislocations
- non operative rehabilitation is common - **immobilised in sling for 2 weeks**: --> IR VS ER immobilisation --> ER maybe more effective no difference --> traditional sling may worsen Bankart lesion - **rehabilitation (6 months)**: - **isometric scapular and RC strengthening** - **improve neuromuscular control (proprioception)** - **RTS 2-3 months (3-4 months with Bankart lesion)** - reconditioning and progressive strengthening of RC and scapular muscles (trapezius and serratus anterior)
40
how does recurrent dislocation occur
capsule ligament and labour are more lax than they were. It heals but are not tight or strong as before
41
shoulder instability classification ## Footnote mechanism of injury, direction and severity
mechanism of injury: `1. traumatic ` - often from an **initial acute injury producing a dislocation** - **fall, a direct hit, or force applied to the outstretched arm** `2. atraumatic ` - **less common** - **develops slowly without any history of previous injury** (repetitive overhead work, such as throwers, swimmers) direction: anterior, posterior, inferior and multi-directional severity: dislocation vs sublaxation
42
risk factors of shoulder instability
- **age** - **severity of initial trauma** 初始創傷的嚴重程度 - **presence bankart lesion/ hill-sachs lesion** - **limited or no immobilization 固定 of the shoulder after first dislocation**
43
clinical features of anterior instability of GH joint
* **`Recurrent dislocation`** or subluxation * shoulder is going to **‘`pop out’ or ‘doesn’t feel right’`** * episodes 發作 of **`‘dead arm’ syndrome`** * **`Shoulder pain`** (may also have rotator cuff tendinopathy) * **`Catching sensation`** * **active and passive ROM** (generalised ligamentous laxity 全身韌帶鬆弛 and the amount of ER) * **special clinical tests** (apprehension test, relocation test)
44
special tests for anterior GH joint instability
- apprehension test - relocation test - inferior instability
45
posterior GH instability
* **`Most commonly atraumatic`** 無創傷性 * able to voluntarily posteriorly subluxate * **`+ve posterior drawer`** * **`treated with strengthening of` the `posterior stabiliser muscles`** (surgery if fails)
46
multidirectional instability (MDI)
- difficult to diagnose interview: - **often no traumatic event** 通常沒有創傷事件 - **generalised hypermobility** - **multiple times of subluxation** 多次半脫位 - low irritability - **potential history of overhead sport participation** objective tests: test battery: - anterior apprehension and posterior apprehension test - hyperabduction test (>105 degrees)
47
physiotherapy management of instability
1. **scapular stability and mobility** (could include biomechanical analysis) 2. **rotator cuff strength, endurance, symmetry** (0 degrees abd to elevation) 3. **upper limb** strength, endurance, symmetry 4. **thoracic mobility, posture, strength** 5. **proprioceptive and functional retraining** (consider sport or positions of instability)
48
what is SLAP lesions ## Footnote superior labrum anterior to posterior
- **tears around** the point where **LH of biceps tendon attaches to superior labrum** - **`relatively poor healing`** - unstable vs stable
49
mechanism of SLAP lesions
- **forceful LH biceps contraction** - traumatic events: --> inferior traction (**lifting a heavy object**) - overuse/ chronic use --> **overhead activities** (throwing) --> natural degeneration of laburm - **aging** the history gives a lead as to the diagnosis may hear a '**clunk**'
50
what type of SLAP lesions is the most common ## Footnote there are 10 types of SLAP lesions
type II: detechment of **superior labrum** and **tendon of LH biceps** from the glenoid rim 邊緣
51
symptoms, physical examination and special clinical tests of SLAP lesion
symptoms: - **poorly localised shoulder pain** - **noises** physical examination: - **palaption** - bicipital groove active compression (LHBT) - movements: **resisted elbow flexion** - observation - **muscle wasting** special clinical tests: **anterior slide test** (positive if pain or click is elicited in anterior shoulder) **O'brien test** (positive if pain increases) **crank test** (positive if occurs pain, catching or grinding in the shoulder 肩部磨傷) `MRI is standard for diagnosis`
52
common fractures of shoulder
1. **clavicle** - **middle 1/3** clavicle # - clavicle #: * Fall on point of shoulder 摔倒在肩部 or direct blow * Localised pain and bony deformity * Requires X-ray * 4-6 weeks immobilised 2. **greater tuberosity** - maybe associated with anterior GH dislocation or RC tear - if non/ minimal displacement can be managed conservatively - immbolise sling for 6 weeks - allow PROM exericse from 2-3 weeks with x-ray monitoring 3. **SNOH#** - Fall on outstretched hand 跌倒時用手撐地時導致的一系列傷害，有可能傷到肩膀、手肘、前臂、手腕等 * Direct trauma * Minimally displaced fractures treated conservatively 輕微移位骨折保守治療 * Comminuted-surgical Management: * 4-6/52 sling, isometric strengthening, ROM, cuff strengthening

1022 THEORY (11 decks)

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