Other Shoulder Conditions

Osteoarthritis of shoulder occurs less commonly than in WBing jts. Primary OA begins on

glenoid surface

proceeds to humeral head over many years

Secondary OA caused by:

instability

previous surgery

trauma

Patients with shoulder Osteoarthritis will have ↓ ROM due to shortening of jt capsule, as well as

atrophy of muscles 2ndary to disuse

Pain/discomfort (sore at 1st, better w/ motion. Worse w/ too much OR little motion)

Crepitus (joint crunch)

labrum degradation

What is the conservative tx for Rheumatoid Arthritis? (progressive & destructive joint disease)

Exercises to improve ROM & strength (back off heavy loading)

Activity modification- prevent shoulder impingement

NSAID’s

What is the surgical tx for Rheumatoid Arthritis (Progressive & destructive joint disease)?

TSA

Arthrodesis: Bony fusion of glenoid fossa, humerus & acromion

rheumatoid arthritis population

40-50s, worse at 60s

primarily females > males

Indications for Total Shoulder Arthroplasty

RA: 24-40%

Complex Fractures: 30%

OA: 20%

Tumors, avascular necrosis: 10%

Cemented TSA is more stable immediately s/p surgery than non-cemented → faster rehab progress, cemented TSA is typically indicated for pts w/

considerable bone loss

Does not allow for biological growth (long term), not good for younger candidates

Cement-less TSA fixation uses metal backed w/ a surface tx to facilitate biological ingrowth. This surgical technique is used for pts w/ adequate bone. Loosening may occur before ingrowth takes place.

More conservative rehab needed, slower progress

Subscap is taken down & repaired for visualization

Subscap precautions for 6 weeks:

avoidance of (passive) ER stretching ~30°

avoid resisted (active) IR

Indications for Hemiarthroplasty

Proximal humerus fracture: Intact glenoid

Mostly intact/functional RC is needed

Poor glenoid bone stock

Osteonecrosis

Hemiarthroplasty has better outcomes than TSA with

OA & RA

Indications for Reverse Total Shoulder, (advantages are you don’t need RC)

Large irreparable rotator cuff

Poorer Overhead motions compared to TSA

Overall good outcomes

s/p TSA involves immobilization for 1–2 wks in a sling. Early Rehab Goals s/p TSA include

↑ mobility/ROM 1-6 weeks

Immediately do AAROM in pain free range

Protect Subscapularis if repaired

Avoid excessive ER stretching >30°

Goals for >6 weeks s/p TSA

↑ ROM

↑ Strength

↑ Functional activities

Goals for >12 weeks s/p TSA

No limitations

Functional strength

Prognosis after TSA rehab is Fair/Good; restricted motion & some pain but still

significant ROM deficits at end of rehab, but functional

Flexion: ~140º

ER: 25-40º

IR: hand to gluteal region to lumbar spine

Worse Outcomes w/ RA

Clavicular Fractures prevalence

most prevalent in children (1 in every 20 fractures in children)

80% of clavicle fractures occur in the

medial ⅓ portion

clavicle fracture MOI

Fall on point of shoulder: Children falling off playground equipment

Blow to lateral aspect of shoulder

Direct blow to clavicle

Force to superior shoulder from above

FOOSH

Clavicular Fractures common clinical findings/observation

Edema, Eccyhmosis

Tender to touch, Crepitus

Lateral clavicle is usually depressed (due to weight of arm) & medial clavicle is usually elevated (due to tension of SCM)

Clavicular fractures possible complications

Pneumothorax (puncture pleural cavity)

Damage to ligaments (shoulder separation):

Coracoclavicular—conoid or trapezoid fibers

Acromioclavicular

Clavicle fracture rehab s/p Clavicular Healing includes Stretching, Strengthening, & Functional Activities. What is the prognosis for healing of a clavicle fracture?

heals in 6–8 weeks

Humeral Fractures make up 5-8% of all fractures in body, its most prevalent in

women &/or osteoporosis

Incidence ↑ w/ age (balance, proprioception, falls)

types of humeral fractures

Non-displaced or minimally displaced

Displaced Surgical Neck Fracture (rare) -> (surgery)

Fracture – Dislocation (rare)

Humeral fracture protocols typically involve limiting all ROM for

~6 weeks (some surgeons do less ~2 weeks)

Proximal Humeral Fractures account for 10% of all humeral fractures; Affected proximal locations include

Greater Tuberosity (RC attachment, can’t lift arm)

Lesser Tuberosity

Head

Shaft

Surgical neck is at distal end of greater & lesser tuberosities

Humeral Fractures MOI for proximal fractures

FOOSH

direct blow

Humeral Midshaft fractures account for 1-3% of all fractures in body, MOI for diaphysis fractures include

Direct blow to humeral shaft: transverse fracture

FOOSH: spiral/comminuted fracture

Common Findings with a Humeral Fracture

Ecchymosis (w/in 24-48 hrs of injury; can spread down to elbow due to gravity)

Shoulder pain

Loss of shoulder motion due to pain

pts present w/ involved UE adducted & supported by opposite hand to protect it

For treatment of Proximal Humerus Fractures, most are

minimally displaced & do not require surgery: A sling is worn; not casted

Closed reduction humeral fracture treatment by

manipulation or traction (reduce fracture) then sling immobilization for 3-4 wks

If Closed Reduction for Humeral Fracture fails, surgeon uses

Percutaneous Pinning

Then 4 wks of immobilization using a sling → development of a stiff shoulder

ORIF for Humeral Fracture if is displaced

>1cm

What Humeral Fracture treatment involves shaft & humeral head replacement?

Hemiarthroplasty (humeral head too damaged to be repaired)

Humerus Fracture Complications: Malunion includes

incomplete union or union that occurred in poor alignment

Humerus Fracture Complications include RC damage based on affected bony structures

Greater tubercle of humeral head: infra/supraspinatus, teres minor

Surgical neck: subscapularis attachment to lesser tubercle

Humerus Fracture Complications include nerve injury, what are the affected structures for a proximal or diaphysis humeral fracture?

Proximal Humerus: Brachial plexus; Axillary nerve most common

Diaphysis (midshaft): Radial Nerve (travels in groove) (Sensory & motor deficits distally)

Humerus Fracture Complications: Arterial Injury can occur w/ a proximal humerus or midshaft fracture affecting the

Proximal: Anterior & Posterior Humeral Circumflex artery (supplies humeral head, can cause AVN)

Diaphysis: Brachial artery (medical emergency, diminished pulses)

Prognosis for proximal & midshaft humeral fracture healing?

Proximal Humerus Fracture: ~6 wks to heal

Diaphysis Fracture: 6–10 wks to heal

Most do not require surgery

Rehabilitation s/p Healing of Proximal humeral fx w/ closed reduction is to focus on prevent loss of ROM, can do

pain-free AROM after 2-4 wks of immobilization

Minimize stiffness, Maximize function

Restrictions are based upon method of immobilization (sling only, pinning, ORIF)

Once healing has occurred (~4-8 wks) can begin: A/PROM

Joint mobilization, Resisted exercise

Suprascapular Nerve Palsy- Sites of entrapment

Suprascapular notch: under hypertrophied transverse scapular ligament

Spinoglenoid notch: by hypertrophied spinoglenoid ligament

Spine of scapula & medial tendinous margin of infraspinatus & supraspinatus

Possible causes suprascapular Nerve Palsy include

Compression, Traction, Friction

Repetitive microtrauma

Direct injury

Brachial plexus disorder

Ganglion cysts

Lipomas

Transverse scapular ligament calcification

suprascapular nerve palsy signs/sxs

can’t lift arm: (+) drop arm

limited active ER: (+) ER lag, (+) resisted ER

atrophy of infraspinatus

WEAK & painLESS

(may look like RC tear)

Suprascapular Nerve Palsy clinical presentation

Deep, diffuse, dull aching pain over posterior lateral aspects of shoulder

Supraspinatus &/or infraspinatus muscle atrophy

Weakness of ER & abduction

(+) External Rotation Lag Sign, Drop Arm Sign

Empty Can: (+) for weakness

Suprascapular Nerve Palsy tx

NMES

wait & see (may need relocation of tendons of RC), need nerve to reinnervate

Axillary Nerve passes thru quadrangular space to innervate

deltoid & teres minor

if an Axillary Nerve Palsy occurs more distally then the

posterior deltoid (maybe lateral) & teres minor would be affected but not the anterior deltoid

Axillary Nerve Palsy MOI & sxs

Usually associated w/ trauma

Loss of sensation around deltoid tuberosity

Atrophy of deltoid

Weakness in all shoulder motions: May substitute w/ RC

Long Thoracic Nerve Palsy MOI

traction injury, viral (all these are suspected, but unknown)

Long Thoracic Nerve Palsy signs

Scapular flip sign

Scapular Winging: Anterior elevation; on a wall push‐ups, Medial Towards spine

Usually a result of poor scapulohumeral mechanics mechanics, generally no pain

Spinal Accessory Nerve Palsy MOI

Medical/Surgical Intervention (head & neck cancer tx)

Viral

Spinal Accessory Nerve Palsy signs/sxs

Trapezius Atrophy

Winging Scapula: Lateral elevation; shoulder ER against resistance, Lateral away from spine

No shoulder pain

Usually a result of poor scapulohumeral mechanics mechanics