Other Shoulder Pathologies

Incidence of Proximal Humeral Fractures

often older (>70) after a fall (fragility fractures)

incidence higher in females

complications and comorbidities of proximal humeral fractures

osteopenia/porosis

balance issues

greater tuberosity/RC involvement

potential vascular involvement

concern of axillary nerve involvement

4 main fragments of proximal humerus fractures

articular surface

greater tuberosity

lesser tuberosity

proximal humeral shaft

anatomical neck fractures

intracapsular

rare

poor prognosis because the blood supply to the head of the humerus is usually completely disrupted (necrosis) - A/P humeral circumflex arteries

how to treat anatomical neck fractures?

young - ORIF

old - prosthetic replacement

physical exam findings with proximal humeral fractures

p! in anterolateral shoulder

severe ROM limitations

joint mobility

potential + RC involvement

may have neuro involvement - sensation, distal UE strength

what treatment is often recommended for proximal humeral fractures?

non-operative

what surgical treatments are available for proximal humeral fractures?

ORIF

total shoulder arthroplasty

primary GH OA

older >60

shoulder pain

progressive stiffness in ER/elevation

functional limitations in OH position

associated with degenerative cuff tears

secondary GH OA

posttraumatic - instability, RC tears, AVN, previous fracture

key findings in primary GH OA

older >60

shoulder pain

more common in women

gradual

morning or inactivity stiffness

max pain outer aspects of upper arm close to deltoid but can radiate into elbow

progressive stiffness in ER/elevation

limitations in OH positions

associated with degenerative cuff tears

when is non-operative treatment considered for GH OA?

mild deficits and pain

non-op tx for GHOA

education

NSAIDs

ROM/strength progression per tolerance and irritability level

when to consider surgical tx for GHOA?

lack of progression

severe sx or functional limitations

when is reverse TSA indicated?

GHOA and poor cuff function

AC joint injury MOI

most often trauma - fall/significant impact to anterolateral shoulder

atraumatic

type 1 AC joint injury

sprained AC ligaments

normal coracoclavicular (CC) ligaments

type 2 AC joint injury

disruption of the AC ligaments

sprained CC ligaments

type 1 and type 2 AC joint injury similarity

both maintain integrity of CC ligaments

type 3 AC joint injury

disruption of AC and CC ligaments

type 4 AC joint injury

posterior displacement into or through the traps

what do type 3 and 4 AC joint injuries have in common

both disrupt AC and CC ligaments

type 5 AC joint injury

rupture of the delotrapezial fascia

type 6 AC joint injury

inf displacement of distal clavicle under the conjoined tendon

what makes type 6 AC joint injury unique?

only one with inf translation of clavicle in relation to acromion - can compromise neurovascular injury

physical exam findings AC joint injury

limited/painful ROM in elevation and horizontal adduction

pain with palpation and mobility testing of AC joint

+ o'brien's and painful ACJ palpation

scarf test (cross arm adduction test) - passive and pain at ACJ is +

non-op tx for AC joint injury

types 1-3

short immobilization

traumatic

education

gradual ROM progression

scapular, RC, deltoid strength

surgery for AC joint injury

higher grade (4-6) acute injuries, persistent p!, cosmetic reasons

surgeon specific protocols

clavicular fractures MOI

trauma

young/active or older due to falls

mid-shaft clavicular fracture

most common

lateral to SCM, but medial to CC ligaments

distal clavicular fracture

at and lateral to CC ligaments

management of clavicular fractures

Traditionally managed conservatively with satisfactory functional outcomes but potential for shoulder ROM limitations and non-union

what is little league shoulder?

proximal humeral epiphyseal plate injury

what increases the risk of little league shoulder?

increased cumulative exposure - such as increased pitch count, year round playing, etc.

MOI of little league shoulder

shear or stress injury of growth plate prior to closing caused from repetitive mechanical loading of skeletally immature shoulder

what age is likely to get little league shoulder?

young (11-16) throwing athletes

exam findings for little league shoulder

prior elbow/shoulder injury

recent growth spurt

progressive general shoulder p! with throwing that improves with rest

decreased velocity

TTP lateral proximal humerus *****

shoulder weakness + pain

A/P radiographs with ER

grade 1 little league shoulder

widening of epiphyseal plate in the lateral area only

grade 2 little league shoulder

widening in all areas of the epiphyseal plate and metaphyseal demineralization

grade 3 little league shoulder

slipped epiphysis

tx for little league shoulder

rest/discontinuation of OH activity for 3-6 months

address: shoulder, hip/core ROM and strength, gradual return when strength/ROM achieved

massive rotator cuff tears leads to

pseudoparalysis

pseudoparesis

pseudoparalysis

only able to demonstrate shrug no active forward elevation but full passive elevation

pseudoparalysis on imaging

anterosuperior migration of humeral head

pseudoparalysis + injections

pain improves but NO motion gain - if motion increases then pseudoparesis

pseudoparesis

<90 active forward elevation w/ full passive elevation

pseudoparesis on imaging

little to no anterosuperior escape

pseudoparesis + injection

pain may improve

examination of massive RC tears

inspection - atrophy of post/sup cuff, scapular mm

RC tests

neuro screen (C5, axillary n., suprascapular n.)

pain my be limiting (injection trial)

conservative management for massive RC tear

anterior deltoid strength

PROM

NSAIDs, subacromial injections

function and motion improves but risk of OA progression, fatty infiltration and tear progression

proximal biceps rupture - tenosynovitis

LHB in synovium

glides in highly constrained intertubercular groove during abd and rotation --> tenosynovitis

what can progressive tenosynovitis lead to?

Degenerative cascade - tendinosis --> delamination --> prerupture --> eventual rupture

clinical manifestation of proximal bicepts rupture

popeye deformity

treatment for proximal biceps rupture

restore motion

supination strength

RC tears + proximal biceps rupture

rupture indicates inflammation of rotator interval

generally in older population

some degree of supra, subscap tendon tearing