Shoulder Complex - Diagnoses (Continued)

List the ligaments at the AC joint.

Coracoacromial, acromioclavicular, coracoclavicular (trapezoid & conoid)

What causes AC joint pathologies?

Traumatic sprains & dislocations OR osteoarthritic changes

A direct force to the AC joint drives the acromion _________ while the clavicle is driven ______ and the scapular and shoulder girdle are driven ___________

Downward, NOWHERE--it remains in anatomic position, inferiorly

Which ligaments/structures are damaged in a direct AC joint sprain?

Either AC and coracoclavicular sprain or clavicular fracture

Which ligaments/structures are damaged in an indirect AC joint sprain?

AC ligaments ONLY

How are the 6 types of AC joint injuries classified?

- degree of displacement of the distal clavicle

- involvement of the AC and coracoclavicular ligaments

- involvement of the fascia overlying the deltoid and trapezius

Grade ______ AC joint sprain is due to mild force to the point of the shoulder, producing a minor strain in the fibers of the AC ligaments

Grade I

In a grade I AC joint sprain, is the AC joint stable? Are the ligaments intact?

Yes

True or false: there is a palpable deformity w/ a grade I AC joint sprain

FALSE (but there may be minimal to moderate tenderness)

Grade ________ AC joint sprain is caused by a moderate force to the point of the shoulder --> RUPTURE to the AC ligament

Grade II

True or false: the coracoclavicular ligaments are intact in a grade II AC joint sprain

TRUE

Which type of AC joint sprain is the most painful?

Grade II

Grade _______ AC joint sprain involves a RUPTURE of the AC AND coracoclavicular ligaments due to a severe force applied to the point of the shoulder

Grade III

Which structures are also damaged in a grade III AC joint? (besides the ligaments)

Deltoid and trapezius muscles -- they are ruptured from the distal end of the clavicle

Grade _____ AC joint sprain results in tears of both the AC AND the coracoclavicular ligaments w/ POSTERIOR displacement of the distal clavicle

Grade IV

Grade ______ AC joint sprain results in tears of both the AC AND the coracoclavicular ligaments w/ SUPERIOR displacement of the distal clavicle

Grade V

What deformity is extremely present in a grade V AC joint sprain?

Step-up deformity

Grade _______ AC joint sprain involves tears of both the AC AND the coracoclavicular ligaments w/ clavicle displaced UNDERNEATH coracoid

Grade VI

What are some lifestyle factors that contribute to acute AC joint injury?

Repetitive or traumatic activity that overloads the AC joint

With an AC joint injury, a painful arc is present after __________ degrees of abduction

>170 degrees

What increases the likelihood of the AC joint developing osteoarthritis?

Prior traumatic injury (specifically, the fibrocartilaginous disc)

What age demographic typically presents with AC joint OA?

Clients >45

What is the test-item cluster for AC joint involvement?

Cross-body adduction, AC resisted extension, & O'Brien's Active Compression test

If all three tests for AC joint involvement are +, what are the likelihood ratios?

+LR 7.4

-LR 0.21

In an AC joint OA differential diagnosis, what do you need to examine first?

Cervical spine!! If this fails to reproduce the chief complaint the likelihood that symptoms are related to the shoulder increases

What are the 3 basic causes of peripheral nerve injuries commonly seen in the clinic?

Stretch, lacerations, compression

__________ is the LOWEST degree of nerve injury, where the nerve is intact but signaling ability is damaged

Neurapraxia

________ is the 2nd degree of nerve injury, where the AXON is damaged, but the surrounding CT remains intact

Axonotmesis

________ is the MOST severe degree of nerve injury, where the axon AND surrounding nervous tissue is severed w/ complete loss of nerve conduction

Neurotmesis

What are the causes of an axillary nerve injury?

Entrapped in quadrilateral space, shoulder dislocations, humeral neck fractures

What is the resulting motor loss of an axillary nerve injury?

Deltoid and teres minor (abduction and ER)

What is the resulting sensory alteration of an axillary nerve injury?

Deltoid tuberosity area

What is the functional loss of an axillary nerve injury?

Ability to position hand in space

What causes a suprascapular nerve injury?

Entrapped in the scapular foramen

A suprascapular nerve injury involves _______ (posterior/anterior) shoulder pain

Posterior

Motor loss: suprascapular nerve injury

Supraspinatus and infraspinatus (weak rotator cuff --> altered shoulder mechancis)

Sensory alteration: suprascapular nerve injury

Clavicle to spine of scapula

What is a clinical sign of a suprascapular nerve injury?

Supraspinatus & infraspinatus atrophy

What causes a musculocutaneous nerve injury?

Entrapped in coracobrachialis

Motor loss: musculocutaneous nerve injury

Biceps, coracobrachialis, brachialis

Sensory loss: musculocutaneous nerve injury

Lateral aspect of forearm

Functional loss: musculocutaneous nerve injury

Forearm flexion, weakened supination (esp. at 90 degrees flexion)

What causes long thoracic nerve lesions?

Entrapment at middle scalene OR traction injury, mastectomy, surgery

Motor loss: long thoracic nerve lesion

Serratus anterior

Sensory loss: long thoracic nerve lesion

None

Functional loss: long thoracic nerve lesion

Winging of the scapula and painful arc

Clinical test: long thoracic nerve lesion

Push against wall to assess for winging

How does injury to the brachial plexus occur?

Traumatic (contact sports, motor vehicle accidents) OR non-traumatic (obstetric injury, parsonage-turner syndrome)

Erb's point is otherwise known as a ________ plexus injury

Upper

Which nerve roots are involved in Erb's point?

C5, C6

What causes Erb's paralysis?

Traction injury (birth, fall, anesthesia)

How does Erb's point present?

Arm hangs by the side in medial rotation w/ forearm extended & pronated ("Waiter's tip")

Which muscles are involves in Erb's point?

Biceps, deltoid, brachialis, brachioradialis, supraspinatus, infraspinatus, supinator

_________ is a transient injury to the upper plexus which occurs following a direct blow, stretch, or compression injury

Burner or stinger

Global transient UE weakness and tingling, numbness, paresthesia in the invovled UE are common symptoms of ________

Burner or stinger

Which nerve roots are involved in a lower plexus injury?

C8, T1 (mainly)

What is another name for injury to the lower brachial plexus trunk?

Klumpke's paralysis

What are the causes of Klumpke's paralysis?

Severe abduction of the shoulder OR birth injury

How do patients present w/ Klumpke's paralysis?

Claw hand --> hyperextension @ the MCP & flexion at the IPs

Which muscles are involved in Klumpke's paralysis?

Intrinsic muscles of the hand (T1) AND ulnar flexors of the wrist and fingers (C8)

True or false: for avulsion and rupture injuries, there is NO potential for recovery unless surgical reconnection is made in a timely manner

TRUE

Where are the most common areas for shoulder complex fractures?

Surgical neck of humerus, mid-humerus, clavicle, scapula

What is the epidemiology of shoulder fractures?

Bimodal age

- young w/ high-impact mechanism or growth plate injury

- elderly w/ low-impact muchanism such as a FOOSH (w/ females 4:1 over males)

Why is it more commonly for elderly females to have a fracture?

Osteoporosis

____________ is injury to the growth plate of the prox humerus in skeletally immature clients

Little leaguer's shoulder

What causes little leaguer's shoulder?

Repetitive torsional and distractive stresses @ the growth plate

How will little leaguer's shoulder present on an x-ray?

Widened prox humerus growth plate

True or false: little leaguer's shoulder symptoms will include a gradual onset throughout the entire upper arm near the prox humerus that is activity dependent

True

What does a motion assessment reveal about little leaguers shoulder?

Loss of IR may reproduce symptoms

Which structures are secondarily affected by a surgical neck of the humerus fracture?

Rotator cuff function

Which nerve can be compromised w/ a surgical neck fracture?

Axillary nerve

Which muscles do you have to be careful with when treating a fracture of the greater tuberosity?

Rotator cuff (stretching w/ IR & contraction w/ ER)

What is Neers 3-phase program for management of proximal humerus fractures?

1. Passive exercises 2-6 weeks (ex: table bow, Codman's)

2. Active exercises w/ GENTLE stretching 6-12 weeks

3. Resistive exercises 12+ weeks

What are the typical patterns (shapes) of a humeral shaft fracture?

Tranverse, oblique, or comminuted

Compound fractures frequently have associated _______ damage

Nerve

With spiral fractures of the humeral shaft, the ________ nerve may be involved

Radial

What does the nonsurgical treatment of a humeral shaft fracture look like?

- Within 3-4 weeks: AAROM (started sooner due to no direct muscular attachment points)

- 6 weeks: AROM

- Progress to stretching and resisted exercises as tolerated

What is the general timeline for humeral fractures?

6-12 months

75-80% of clavicle fracture occur in the ________ segment

Middle 1/3

Group ______ clavicle fracture: middle third

Group I

Group ______ clavicle fracture: distal third

Group II

Group ______ clavicle fracture: medial third

Group III

True or false: operative management is the treatment of choice for clavicular fractures

True (due to risk of non-union and the poorer cosmetic appearance)

Which other injuries may be associated w/ a scapular fracture due to high-energy trauma, direct forces, and a FOOSH injury?

Rib, pulmonary injury, skull fractures, humeral fracture, CNS deficits, major vascular injury

How long does a person w/ a scapular fracture need to be in a sling?

First 6 weeks

What are 2 operative indications for a scapular fracture?

1. Significantly displaced

2. Floating shoulder (fractures of BOTH the clavicle and glenoid neck of scapula)