Shoulder Disorders

downward, tip, sprain, pain, tender, AC, crossbody

Acromioclavicular (AC) Joint Injuries: Mechanism and S/S

Mechanism of Injury

-Direct __________ blow to the ___ of the shoulder (hit, fall)

-______, subluxation/dislocation/separation

S/S

-____ to top of shoulder

-_______, swollen __ joint, possible step off

-Decreased ROM

-Positive ___________ test

Grade I

What grade is this AC joint injury?

-Partial tear of the AC ligament

-Contusion/sprain

Grade II

What grade is this AC joint injury?

-Torn AC ligament

-Subluxation or partial displacement, will see widening of the joint space

Grade III

What grade is this AC joint injury?

-Torn AC/coracoclavicular ligament and capsule

-Complete dislocation

Grade IV

What grade is this AC joint injury?

-Clavicle displaced posterior and buttonholed through trapezius fascia

Grade V

What grade is this AC joint injury?

-Severe displacement of the clavicle with clavicle superior to acromion

Grade VI

What grade is this AC joint injury?

-Distal end of clavicle is locked inferior to the coracoid

x-ray, I-III, sling, ROM, IV-VI, reconstruction

AC Joint Injuries: Diagnosis and Treatment

-Diagnosis

• Clinical

• _-___ → normal AC joint width is 1-3 mm

-Treatment: Non-Surgical (Grade _-___)

• _____ (2-4 weeks)

• Ice

• NSAIDs

• Early ___ exercises as tolerated

-Treatment: Surgical (Grade __-__ and sometimes III)

• Refer to ortho

• ORIF with ______________ of coracoclavicular ligament

pain, arthritis, NSAIDs, resection

AC Joint Arthritis

-Chronic _____ at the AC joint. One of the first joints to be affected by arthritis

-The pt may report pain with movement across the body or up by the head

-Diagnosis

• X-ray evidence of __________ → joint space narrowing and osteophytes

-Treatment

• ________, injections, and surgical ________ if conservative treatment failed

abduction, external rotation, abduction, internal rotation

Rotator Cuff Muscles

-Muscles that insert on the greater tuberosity:

• Supraspinatus (MC injured) → __________ and external rotation

• Infraspinatus → __________ __________ and abduction

• Teres Minor → external rotation and __________

-Muscles that insert on the lesser tuberosity:

• Subscapularis → _______ __________ and assisting in abduction and adduction

overhead, impingement, pain, overhead, Neer’s, night, pain, no, weakness

Rotator Cuff Tendinosis and Subacromial Bursitis

-Mechanism of injury:

• Repetitive ___________ activity, acute trauma/injury, ____________ syndrome

-S/S:

• Shoulder _____ especially with ___________ activity

• Possible + Painful arc sign, _______’_, and Hawkins

• Occasional _______ time pain

• Limited AROM d/t _____ (PROM > AROM) → __ muscle atrophy, no or very limited __________

-Treatment:

• Rest, ice, NSAIDs

• PT, steroid injections

entrapment, acromion, subacromial, repetitive, lateral, abduction, Neer’s, Hawkins

Impingement Syndrome: Background and S/S

-______________ of the RTC muscles/bursa by the ___________

-_____________ impingement is the most common

-Mechanism of Injury:

• ___________ use (overhead work), trauma, arthritis, and curved acromion

-S/S:

• ________ shoulder pain that is worse with _________ and internal rotation

• Positive _____’_ and ___________ signs

MRI, NSAIDs, 6-12

Impingement Syndrome: Diagnosis and Treatment

-Diagnosis:

• Clinical

• ___ to r/o RTC tear if highly suspicious or not improving with treatment

-Treatment:

• Rest, ice, ________

• PT, steroid injection

• Surgery should be considered if the patient has not improved after _-__ weeks

fall, repetitive, impingement, partial, weakness, full

RTC Tears: Background

-Mechanism of Injury

• Acute injury → _____ or forceful pull on the arm

• Chronic injury → _________ use and irritation or chronic __________

-Types

• ______ thickness tear → can progress to full thickness tear. The pt will have pain with little to no __________

• ____ thickness tear → increased pain and weakness

overhead, night, weakness, abduct, externally, atrophy

RTC Tears: S/S

-Moderate to severe pain especially when attempting _________ activity

-_____ pain

-Moderate shoulder muscle ____________ → inability to _____ arm, unable to __________ rotate arm against resistance, and drop arm test positive

-Muscle ________ of shoulder

ice, steroid, humeroacromial, elevation, glenoid, surgery

RTC Tears: Treatment

-1st line → rest, ___, NSAIDs, PT

-2nd line → ______ injections

-X-ray → show reduced _____________ space; superior humeral ________ in comparison to the ______ possible

-Ortho referral → may need _______ if the pt fails conservative treatment within 6 months or they have a complete tear

active, passive, >, DM, injury

Adhesive Capsulitis (Frozen Shoulder): Background

-Global limitation of _____ and _________ shoulder ROM

-Epidemiology:

• 5th-6th decades

• F _ M

• __ and other systemic illness are at an increased risk

-Etiology:

• Idiopathic

• Secondary to shoulder ________

2-9, pain, stiffness, adhesive, 4-12, loss, improving, return

Adhesive Capsulitis: Staging

-1st Stage/Painful Phase (_-_ months)

• Diffuse, severe, and disabling shoulder ____ and increasing ___________

-2nd Stage/Intermediate (_________) Phase (_-__ months)

• Stiffness and severe ____ of shoulder ROM

• Pain gradually ___________

-3rd Stage/Recovery Phase (lasts up to 2 years)

• Gradual _______ of ROM (often incomplete recovery)

• Pain resolves

NSAIDs, PT, surgery

Adhesive Capsulitis: Treatment

-Acetaminophen/________

-Home exercises and __

-Steroid injections

-________ → if conservative measures fail (after 12 months)

overuse, anterior, biceps, proximal, distal

Biceps Tendinitis: MOI and S/S

-Mechanism of Injury:

• Frequent pulling, lifting, reaching, throwing

• __________ injury

-S/S:

• __________ shoulder pain that is aggravated by lifting, pulling, and overhead activity

• Radiation over ______

• TTP over ________ (bicipital groove) or _______ tendon

Speed’s, MRI, rupture, thickening, rest, steroid

Biceps Tendinitis: Diagnosis and Treatment

-Special tests (proximal tendon):

• ______’_ and Yergason’s tests

-Diagnosis:

• Clinical

• US or ___ if concerned about ______ or RTC injury. Will show _________ and tenosynovitis of the tendon

-Treatment:

• 1st line = ____, ice, NSAIDs, PT

• ______ injections are also an option, but they aren’t done very often

degeneration, contracted, pop, swelling, Popeye, squeeze

Bicep Tendon Rupture

-Mechanism of Injury

• Chronic irritation/_____________

• Sudden load to ___________ bicep → catching heavy object, shoveling

-S/S

• “___”, pain, ecchymosis, __________

• Proximal tendon = _________ deformity, which is only present in the rupture of the long heads

• Distal tendon = rarely any deformity, bicep ________ and hook tests

MRI, rest, ortho, asap

Bicep Tendon Rupture: Diagnosis and Treatment

-Diagnosis:

• Clinical

• US or ___, especially if the patient is considering surgery

-Treatment:

• Ice, compression, ____

• Proximal tendon = non-urgent _____ referral

• Distal tendon = ortho referral ____

compression, upper, brachial plexus, injury

Thoracic Outlet Syndrome

-_____________ of neurovascular structures supplying the _____ extremity

• _______ ________ is the most common

• Subclavian artery and vein are the least common

-Pathogenesis:

• Developmental abnormalities → anomalous or cervical rib, muscular anomalies

• _______ → hyperextension/flexion of the neck

• Predisposing physical activities

weakness, raising, neurogenic, ultrasound, PT, anticoagulation, surgery

Thoracic Outlet Syndrome: Symptoms, Diagnosis, and Treatment

-S/S

• Pain, numbness, ___________

• Swelling

• Provoked by _________ arm above head for 60 seconds

-Diagnosis

• Perform thorough neuro/vasc exam

• Electrodiagnostic eval → __________ (brachial plexus)

• Vascular studies → duplex ______________

• CXR → bony abnormalities

-Treatment

• Neurogenic → __ and NSAIDs, surgery if fail non-operative treatment

• Venous → _____________/thrombolysis; occasionally surgery

• Arterial → _______ is the most common treatment

abducted, posterior, abducted, resists, axillary

Anterior Shoulder Dislocation

-Most common dislocation

-Mechanism of Injury:

• Blow to _________, externally rotated, and extended arm

• Blow to __________ humerus or fall on outstretched arm (less common)

-S/S:

• __________ and externally rotated arm (elbow pointing out)

• _______ all movement

• Prominent acromion → “squared off” shoulder (positive Sulcus sign)

• Evaluate _______ nerve and vasculature

X-ray, subcoracoid, subglenoid, Hill-Sach’s, Bankart

Anterior Shoulder Dislocation: Diagnosis

-_-___ (axillary and scapular Y view)

• Humeral head in ___________ (most common)

• Subclavicular or ___________ position

-Associated fractures

• ____-_____'_ Deformity → cortical depression in the humeral head (groove fracture)

• Bony _______ Lesion → bony vs soft tissue, disrupted glenoid labrum with or without bony avulsion

• Greater tuberosity fracture

-MRI if concerned about soft tissue injury

Hill Sach’s Deformity

What deformity is shown in this xray?

Bony Bankart Lesion

What lesion is shown in this xray?

reduction, post, Milch, traction, sling, swathe, ROM, Bankart

Anterior Shoulder Dislocation: Treatment

-Immediate ___________ with ____ reduction x-ray

-Reduction techniques:

• Scapular manipulation, external rotation, _____ technique, Stimson Technique (least traumatic), and _______ countertraction

-Immobilized with a _____ and _______ 2-4 weeks

-Start ___ exercises at 2 weeks

-________ lesions typically require surgery

anterior, adducted, seizure, electric, posterior, flattening, unable, x-ray

Posterior Shoulder Dislocation (Rare)

-Mechanism of Injury

• Blow to ________ shoulder

• Axial load of an ___________ and internally rotated arm

• Violent muscle contractions → ________ or _______ shock

-S/S

• Prominence of ________ shoulder with anterior _________

• Prominent coracoid

• Adducted and internally rotated arm

• ________ to externally rotate

-Diagnosis → _-___

• Light bulb sign

reduction, adducted, internally

Posterior Shoulder Dislocation: Treatment

-__________ and immobilization

• Axial traction on ___________ arm with elbow flexed, apply traction and __________ rotate

-X-rays before and after reduction, recheck neurovascular status too

irreducible, greater, Bankart, instability

Shoulder Dislocations: Indications for Surgery

-___________ dislocations

-Displaced ________ tuberosity fractures

-_________ fractures that create glenohumeral instability

-Recurrent __________ or activity limitations

anatomical, greater, older, >, falls, dislocations

Proximal Humerus Fractures: Background

-Anatomy:

• __________ neck, surgical neck, _________ tuberosity, and lesser tuberosity

-Epidemiology:

• _______ adults ( > 60)

• F _ M

-Mechanism of Injury:

• ____ (most common)

• Direct blow

• Violent muscle contractions

• ______________

pain, ecchymosis, adducted, axillary, Neer

Proximal Humerus Fracture: S/S and Diagnosis

-S/S:

• ____, swelling, __________

• Arm _________ against body

• _______ artery and nerve may be injured, so be sure to check the pt’s neurovascular status distal to the injury

-Diagnosis:

• Xray (AP, axillary, scapular Y views) → ______ classification

displaced, immobilization, repeat, 6-12, anatomic, displaced, nerve, open

Proximal Humerus Fractures: Treatment and Surgical Referral

-Treatment: Non-__________ or minimally displaced

• ____________ (sling), ice, pain meds, and PT

• _____ x-rays to monitor for displacement

• Healing time is _-__ weeks

-Surgical Referral:

• Fractures of ________ neck (risk of avascular necrosis d/t circumflex artery)

• __________ or comminuted fractures

• _____/vascular injury

• ______ fracture

• Fracture-dislocations

males, females, severe, radial, weakness

Midshaft Humerus Fractures: Background

-Epidemiology:

• ______ in 3rd decade → high velocity trauma

• ________ in 7th decade → low velocity falls

-S/S:

• _______ arm pain, swelling, ecchymosis

• _______ nerve most commonly injured → may see wrist, finger, and thumb extension ___________ and wrist drop

-Diagnosis:

• X-ray

ortho, splint, functional, cast, ORIF, 10-14

Midshaft Humerus Fractures: Treatment

-Refer to ______

-Non-operative options:

• Initial → sugar tong _____ or sling and swathe

• Transverse → _________ brace

• Nonsurgical displaced oblique or spiral → hanging ____ or functional brace

-Operative:

• ____ for open fracture, vascular, or brachial plexus injuries with pain and weakness

-Healing time = __-__ weeks