CMS II: Ortho - Shoulder

What are the THREE joints of the shoulder?

Glenohumeral

Acromioclavicular

Sternoclavicular

Where does the short head of the biceps bind to in the shoulder?

coracoid process of the scapula

What does SITS stand for?

Supraspinatus

Infraspinatus

Teres minor

Subscapularis

*4 muscles that compose the rotator cuff

The tendon of the long head of biceps runs ______ to the humeral head and is held in place by what ligament?

anterior; held by the transverse humeral ligament

REVIEW: Bones and Ligaments of the Shoulder.

B → Long head biceps

CC → coracoclavicular ligaments

A → acromion

C → coracoid process

CA → coracoacromial ligament

AC → acromioclavicular joint capsule

What degrees of ADDUCTION does the shoulder have?

45

What degrees of ABDUCTION does the shoulder have?

180

What FOUR muscles participate in shoulder ABDUCTION?

Supraspinatus (0-30)

Deltoid (30-100)

Trapezius + levator scapulae (100-180)

What degrees of FLEXION does the shoulder have?

180

What degrees of EXTENSION does the shoulder have?

45

What degrees of INTERNAL ROTATION does the shoulder have?

75

What degrees of EXTERNAL ROTATION does the shoulder have?

80

REVIEW: Shoulder XR (AP view)

REVIEW: Shoulder XR (AP view - II)

T → greater tuberosity

S → surgical neck of humerus

A → anatomical neck of humerus

G → glenoid fossa

C → coracoid process

AC → acromion process

REVIEW: Shoulder XR (AP view - III)

A → greater tubercle

B → acromion

C → clavicle

D → humeral head

E → glenoid process

F → medial/vertebral border of the scapula

G → coracoid process

H → inferior angle of scapula

J → axillary/lateral border of scapula

REVIEW: Shoulder XR (Axillary view)

A → coracoid process

B → glenohumeral joint

C → less tubercle

- externally rotated so will look more anterior

D → posterolateral humeral head

E → acromion

F → spine of the scapula

G → glenoid process

H → base of the coracoid

What special test can evaluate for impingement of structures passing under the coracoacromial ligament?

Neer's

What TWO special tests can be used to reinforce a (+) Neer's?

Hawkins

Kennedy impingement

What term can be used to describe arthritis of the shoulder due to destruction of joint cartilage?

glenohumeral arthritis

Where is GH arthritis most common?

posterior aspect of the shoulder

T/F. RA will typically present with multiple joint involvement - often bilaterally.

TRUE

Which shoulder XR view is more reliable?

axillary view

What SIX findings on diagnostic studies suggests an RTC deficiency?

Flattening of the humeral head

Joint space narrowing (<7mm)

Cartilage destruction

Erosion

Osteopenia

Superior migration of the humeral head

**rotator cuff syndrome

What can be used in the treatment of shoulder arthritis?

NSAIDs

Heat and/or ice

Stretching exercises

Glucosamine and/or chondroitin sulfate

Steroid injections

- can be detrimental for RTC deficiency (limited use)

If advanced → TSA or reverse TSA

What are TWO rotator cuff syndromes?

Shoulder impingement

Rotator cuff tear

What causes shoulder impingement (RTC tendinitis)?

occurs when the supraspinatus tendon is pulled under the coracoacromial arch

What are the FOUR components of the coracoacromial arch?

Coracoid process

Coracoacromial ligament

Acromion

AC joint capsule

Inflammation of the subacromial bursa and RTC tendons is most commonly seen in what population?

middle age patients

What FOUR symptoms can present with shoulder impingement?

Anterior + lateral shoulder pain

Worse with overhead activity + lowering arm

Night pain + difficulty sleeping on affected side

What THREE special tests if (+) suggest shoulder impingement?

Neer's

Hawkin's

Empty can test

What special test if (+) suggest supraspinatus tendon weakness/tear/irritation?

Empty can test

** (+) → pain

Shoulder impingement commonly presents with what type of arthritis?

RA

What can be used in the treatment of shoulder impingement?

NSAIDs

Rest

Stretching/Strengthening exercises

Subacromial steroid injections

What does atrophy of muscles on the top and posterior aspect of the shoulder suggest?

RTC tear

What population most commonly presents with full-thickness RTC tears?

>60 year olds

What THREE symptoms can present with a RTC tear?

Shoulder pain

- worse at night

"Catching" or "Grating" during overhead use

Decrease in ROM

- Abduction and lateral weakness

If the back of the shoulder appears SUNKEN, what does it suggest?

weakness of the infraspinatus muscles

What FIVE special tests if (+) can suggest RTC tear?

Neer's

Hawkin's

IR Lag sign

ER Lag sign

Drop arm test

- unable to hold arm up

What special test can be used to evaluate the integrity of the external rotators?

external rotator lag

**infraspinatus + TM

What special test can be used to evaluate the integrity of the internal rotator?

internal rotator lag (lift off test)

**supraspinatus

What muscle does the drop arm test evaluate?

supraspinatus

What diagnostic imaging study can CONFIRM the presence of a RTC tear?

MRI

What is recommended in the treatment of a RTC tear?

NSAIDs

PT

Steroid injections (limited)

Surgery if fail rehab or traumatic

What shoulder tendon is most typically affected by calcific tendonitis?

supraspinatus

What is the most common symptom of bicipital tendonitis?

pain in the anterolateral aspect of the shoulder

**common in young athletes

What special test if (+) suggests bicipital tendonitis?

Speed's test

- elevation against resistance

(+) = pain

If a young patient with a Hx of heavy lifting presents with a large mass in the shoulder with bruising and a (+) Popeye sign, what is the most likely diagnosis?

biceps rupture

- will feel a pop/snap following by pain

What biceps tendon is most commonly ruptured?

long head (96%)

What FOUR special tests can be used to evaluate the biceps tendons?

Speed's

Yergason's

Ludington's

Lippman's

What TWO procedures are involved treatment of PROXIMAL biceps tendon rupture?

tenodesis

subacromial decompression

What occurs in a tenodesis?

consists of cutting the normal attachment of the biceps tendon on the shoulder socket and reattaching the tendon to the arm bone (humerus)

What is involved treatment of DISTAL biceps tendon rupture in young/athletic patients?

anatomical reattachment

Where on the shoulder does dislocation most commonly occur?

glenohumeral joint

What type of dislocations are most commonly seen in the shoulder?

anterior and multidirectional

If an individual dislocates their shoulder following ABDUCTION + ER, what type of dislocation is present?

anterior

**inferior + medial

If an individual dislocates their shoulder following ADDUCTION + IR, what type of dislocation is present?

posterior

**superior + lateral

What nerve most commonly injured with a shoulder dislocation?

axillary nerve injury

What TWO special tests if (+) suggest a shoulder dislocation?

Apprehension test

Sulcus sign

What special test evaluates the INFERIOR instability of the GH joint?

Sulcus sign

What special test evaluates the MULTIDIRECTIONAL instability of the GH joint?

Rowe's test

What TWO special tests evaluate the anterior/posterior capsular mechanism?

Anterior drawer test

Posterior drawer test

What TWO special tests evaluate for anterior/posterior labrum/capsule instability?

Anterior apprehension test

Posterior apprehension test

What is a Hill-Sachs lesion?

compression fracture of posterior humeral head due to ANTERIOR dislocation

What is a Bankart lesion?

glenoid labrum tear in the anterior joint that occurs due to an ANTERIOR dislocation most commonly

In order to evaluate for a POSTERIOR shoulder dislocation, what XR view must be obtained?

axillary

- if unable → trans-scapular lateral view

What TWO S/S suggest an axillary nerve injury?

deltoid weakness

C5 numbness

What TWO XR findings on AP view suggests a POSTERIOR shoulder dislocation?

light bulb sign (IR of humerus)

rim sign (>6mm joint widening)

What XR findings on axillary view suggests a POSTERIOR shoulder dislocation?

humeral head will move towards the acromion and away from the ribs

What is the treatment for a shoulder dislocation?

reduction (either Stimson or longitudinal)

PT (after 1-3 weeks of neutral arm position)

A patient with an ANTERIOR dislocation should be immobilized when?

when it is their 1st dislocation

What is the most common method for surgically stabilizing a shoulder prone to ANTERIOR dislocation?

Bankart repair

What surgical approach tightens the joint capsule to increase stability?

capsular shift

If a patient presents with pain over their AC joint and distal clavicle following fall onto tip of shoulder, what diagnosis is most likely?

AC separation

- will have pain with movement in ALL direction

What are THREE most common types of AC separation?

I → partial disruption of AC ligaments; CC ligaments intact

- no separation

II → AC ligaments are torn; CC ligaments intact

- partial separation of clavicle from acromion

III → AC + CC ligaments are torn

- complete separation

**IV-VI = not common

REVIEW: AC joint separation XR.

What TWO special tests can be used to evaluate for AC joint pathologies?

Crossover/Adduction test

O'Brien's test

What is the treatment for Type 1-3* AC separation?

Wear sling

Ice

Analgesics

Activity as tolerated

What is the treatment for Type 4-6 AC separation?

surgical repair

**3 might also need surgical repair

What is the most common risk factor for a frozen shoulder (adhesive capsulitis)?

DM

If DM patient presents with loss of shoulder ER with painful motion, what diagnosis should be considered?

adhesive capsulitis

What is the treatment for adhesive capsulitis?

NSAIDs

Moist heat

PT/Home exercise program

- with stretching

Intra-articular steroid injection

If refractory → surgery

What is a SLAP injury?

superior labrum anterior-to-posterior lesions/tears

T/F. SLAP is often a diagnosis of exclusion.

TRUE - can be confirmed at the time of surgery

What THREE special tests can evaluate for shoulder labral tears?

O'brien

Clunk

Anterior slide

What is the GOLD STANDARD for diagnosing SLAP?

MRA (arthrogram)

What is the treatment for SLAP?

NSAIDs

PT

Surgery

An elderly individual who falls on an outstretched hand m/c present with what type of fracture?

shoulder

Where is a clavicle fracture most common?

middle 1/3

What on PE can suggest a clavicle fracture?

bump or tent deformity

shoulder droop

What TWO XR views can confirm a clavicle fracture?

AP view

10 degrees cephalic tilt

What is the most common treatment for a clavicle fracture?

non-surgical

- immobilization

- NSAIDs

What nerve is most commonly injured with a humeral shaft fracture? What S/S suggest injury?

radial

- will be unable to extend wrist/fingers

- lose sensation on the dorsum of the hand

Wrist drop is most often seen in what type of nerve injury?

radial (Saturday night/Crutch palsy)

T/F. Most humeral shaft fractures are treated non-surgically.

TRUE

If needed, what are THREE surgical options for a humeral shaft fracture?

IM rod

ORIF

External fixation

What is a common complication of a humeral shaft fracture?

malunion

What is the most common proximal humeral fracture ?

2-part Fx at the surgical neck

What is involved in a 3-part proximal humeral fracture?

Humeral head

Shaft

One of the tuberosities

When is surgery indicated for a proximal humeral fracture?

>1cm displacement or >45 angulation

What nerve is most commonly injured in a proximal humeral fracture?

axillary