Shoulder

Adhesive capsulitis

*AKA frozen shoulder* Baby it too much, pain in shoulder with like 5 degrees rotation in each direction, thats a problem. Never sought medical attention. Takes a long time to fix, years worth of tx with physical therapy. maybe injections but PHYSICAL THERAPY is mainstay -MRI scan to evaluate rotator cuff issue is they have that too

Speeds test

*Biceps tendinitis*, will be long head of biceps, -*Flex elbow against resistance*

Most common bone fracture is

*Clavicle*, distal radius is second, you will see that more because it affects the patient more

Apprehension test

*Confirm if they have instability in shoulder* Labrum-piece of tissue around glenoid where head fits in. Shoulder has capsule around it, but its kind of loose, so labrum holds the shoulder in the glenoid, so doesn't move during ROM. if we injure labrum then it can sublet or dislocate, this test will prove that. lie down, 90 degrees hand toward ceiling, hands behind shoulder and put pressure, feel for instability or pain

DDx, Tx, Diagnostics of impingement syndrome

*DDx*: AC DJD, Cervical radiculopathy, RC tear, possibly shoulder dislocation *Treatment*: Rest, ICE, cortisone injection, NSAIDS, PT, surgery, DON'T USE SLING (could lead to adhesive capsulitis) *Diagnostics*: Xray usually normal MRI or CT w/arthrogram

DDx, Tx, Diagnostics of rotator cuff tear

*DDx*: AC DJD, cervical radiculopathy, impingement, possibly shoulder dislocation *Tx*: Rest, ICE, cortisone injection, NSAIDS, PT surgery *Diagnostics*: Xray usually normal MRI w/ arthrogram gold standard

Do you treat proximal humeral ruptures or distal humeral ruptures?

*Distal*, less common, we have to surgically treat, its a big deal with supination aspect of arm movement. -We treat proximal humeral ruptures conservatively

ROM of shoulder

*Forward elevation*, all the way up *Abduction*, 120-130 degrees *Internal rotation*- reach up back, up to L1 at least, maybe more *External rotation* -35 degrees ish, elbow stabilized (Extension - 30-40 degrees and adduction-across midline?-these aren't as important)

Frozen shoulder history

*Idiopathic*: -No memorable inciting event -Concomitant medical issues -Diabetes -Thyroid dysfunction *Post-traumatic*: -Injury -Pulmonary, cardiac surgery -Surgery involving the axilla

sulcus sign

*Inferior shoulder laxity* -Pt sits on table, arm stabilized, elbow at 90, grab elbow and push inferiorly -Inspecting from behind, look for sulcus between acromion and humerus

Neuropraxia

*Injury to the nerves that last.* -Do eventually resolve. Could take a day to several weeks, follow until they get better. -Loss of nerve conduction despite intact nerve fibers -Usually resolves over time -From blunt force and stretching of the nerve from trauma -Serial neuro exams to confirm impingement

AVN of shoulder

*Interuption of blood supply to humeral head* -Causes bone to be resorbed and remodeled -Leads to bone collapse, DJD, and joint instability -Main reason is Steroids! next one is probably alcohol abuse

Bicipital groove

*Long head of biceps* *most frequent area to rupture biceps is here* less frequent is distal one.

Impingement syndrome is the

*Most common condition causing pain in the adult shoulder* -pain can be from bursitis or tendonitis -most of the time with this and RC tendinitis do conservative tx, then shoulder arthroscopy or RC repair -younger person will go to surgery with full thickness tear

When does ortho need to see a patient ASAP?

*Open fracture*: Most of the time, often tx in ER with ABX, irrigation and loose sutures. Consult ortho for instructions. *Risk of fatty embolus*- Long bone fx, esp femur *Gross malformation* *Neuro-vascular compromise*

Yergason's test

*Resistance from supination*, *Biceps tendinitis*

What is the main tendon injured with rotator cuff injuries?

*Supraspinatus* Because it goes right between acromion and humeral head, humeral head impact acromion, and then you can get rupture or other injury

Scapula fracture

-*HIGHLY impacted injury*, MVA -Its hard to fracture this, just like pelvis -Shoulder pain after trauma -worry about neuropathy of pretty much *all nerves in the arm* and radial pulse Dx by X-ray, ct scan if you need to better delineate, CT thorax to rule out associated injuries Tx is conservative, sling and decrease ROM but if more disruptive then you need surgery

Burners

-*Paresthesia that completely abates* -Full muscle strength, ROM, and pain free -Return to his or her activity -Trauma, axilla injury could cause this in arm, don't do anything about this, resolves by itself. within an hour or two

Vasculature of shoulder

-*Subscapular artery*, when clavicle fracture occurs we are worried about damage to this, esp with ecchymosis -*A/P circumflex*- proximal humeral fracture, need blood supply to naturally repair fractures -*Brachial artery*

Drop arm test/sign

-*Tests supraspinatous* -Indicative of *rotator cuff tear*, doesn't tell if full thickness or partial. -After maneuvers and you think supraspinatus problem, you put back in abduction, hold arm up, then gradually let go, and see if they can hold it up. You might see shaking, full thickness tear would be a full drop, sometimes they can maintain, and bring arm down slowly, once they initiate that movement sometimes it will fall

Axilary nerve

-Allows us to shrug shoulders, lateral aspect of proximal humerus, -Injured with proximal humeral fractures When we see that fracture, we want to check NV status to make sure its working -Important post op to check they can do this

Clinical findings of a rotator cuff tear

-Anterio-lateral shoulder pain .. +/- radiates deltoid -Pain below elbow consider radiculopathy -Pain awakens at night -+/- Weakness -Painful decreased active / ROM Passive wnl -+/-Hawkins +/- Neers + Drop Arm Sign if massive tear -Weak with resisted abduction: Supraspinatous stress test -Resisted external rotation: infraspinatous -Positive Lift-off: subscapularis

Differential diagnosis for thoracic outlet syndrome

-CTS - paresthesia radial hand + phalens -Cervical radiculopathy - neuro findings in radicular pattern -Impingement - + impingement signs -Ulnar nerve entrapment- + Tinsel's sign at elbow & no symptoms above elbow

Thoracic outlet syndrome

-Compression of BP and/or subclavian vessels -*Younger females*, woke up with this, swelling, pain, feels cold, *typically because slept on arm wrong* -Ischemia, claudication, cold intolerance, swelling with venous congestion, occasional thromboembolic phenomena with distal arterial occlusion

Emergent treatment

-Immobilization: sling and shoulder immobilizer -Sling and swathe -Add pad may be placed in the axilla to minimize skin chafing -Adequate pain control

Fracture of clavicle

-Many are non-displaced if they break through skin or tenting skin and looks like its going to break through, then you can do surgery. -If not, do spring or figure of 8 brace, activity modifications. probably don't even need, just to treat pain

AVN treatment

-Non-weight bearing -Electrical stimulation of bone growth -Maybe physical therapy, -NSAIDS -Usually requires joint replacement once they can't live with it anymore

Hawkin's Impingement Test

-One of main problems of the shoulder *humeral head is impinging upon the acromion*, it hits the supraspinatus, gets irritated, bleeding occurs, get inflammatory response, and pain. -With repeated injury, its hitting acromion and clavicle, and you get bone spurs typically on acromion but also on distal clavicle. Bone spurs also dig into supraspinatus. -Elbow and shoulder at 90 degrees, get behind them, bend down, try to impinge and produce pain.

Rotator cuff tear

-Partial or full thickness tear -Repetitive or isolated event (usually no hx of trauma) -Described by the number of tendons involved, size tear, atrophy, and retraction of tendons

Glenoid labrum injury

-Provides stability of shoulder -Tear allows for dislocation and subluxation -Rotator cuff often involved -Weight Lifters: Overhead & bench pressing exercises Golfers: Hit ground with club -Pain forced external rotation at 90 degrees abduction -Pain forced horizontal abduction -DX: MRI or CT w/arthrogram Tx: PT, NSAIDS, Surgery

Impingement syndrome risk factors

-Repetitive overhead activities -Pain may also develop as the result of minor trauma or spontaneously with no apparent cause -Rotator cuff injuries

AVN

-aseptic *avascular necrosis* why did the bone lose bone supply? ASEPTIC (atraumatic) Alcohol, AIDS Steroids *most common*, Sickle, SLE Erlenmeyer flask (Gaucher's) Pancreatitis Trauma Idiopathic/infection Caisson's (the bends) Posttraumatic: fracture

AC injury photo

AC separation, clavicle is sitting way up, going to require surgery

Clinical findings of impingement syndrome

Anterio-lateral shoulder pain May radiate to deltoid Worse at night Muscle atrophy +/- Painful but usually ROM ok Tender greater tuberosity & subacromial bursa Crepitus +Hawkins + Neers Weakness 2nd pain inject 10 ml 1% Lido into subacromal bursa and retest

Apprehension sign

Anterior instability

Empty Can

Any weakness or pain? compare to CL side. *Tests supraspinatus*

External rotation

Arm at side, externally rotate against resistance, look for weakness.

How do you isolate subscapularis?

Arm at side, hands in middle on tummy, push away from body against resistance. -Back lift off is same but on back and pushing away from back against resistance (aka lift off test)

Dx of adhesive capsulitis

Arthrogram: decreased filling of glen-humeral capsule

Muscles that control forward elevation (aka flexion)

Assisted by AC and sternoclavicular joint -Anterior deltoid -Pectoralis major -Coracobrachialis -Biceps brachii (short head)

Popeye sign

Biceps tendon rupture, was doing something and heard a loud pop

Pain diagram of shoulder

Can help limit whats going on

Fatty embolus

Can present same way as PE

when to operate

Displaced 2 part surgical neck fx Displaced 3-4 part Greater tuberosity fx w/ greater than 5 mm displacement

Thoracic outlet syndrome nonsurgical treatment

Elevation ice, change ergonomics Behavior modification: sleep patterns, working patterns, and driving patterns to avoid compression

Tx of arthritis of shoulder

Goals: Pain reduction and restoration of mobility and function -NSAIDS, Physical therapy, joint replacement -Other nonoperative treatments: physical therapy, injectable corticosteroids, and viscosupplementation

A/P drawer test

Hands on shoulder, move back and forth, see if any instability.

Humerus fracture

High impact, often associated with dislocation. -Can see in older female with osteoporosis (or fall in older patient) -Get AP, lateral, and axillary X-rays -type of fracture determines tx, for non-displaced you immobilize for 6 weeks and sling, physical therapy early.

Adson's test

Hold patients arm in slight abduction while palpating the radial pulse -Ask the patient to extend the neck and rotate toward the affected side -Positive = the patient reports paresthesias or if the pulse fades away

Plain field X-rays of shoulder

Humeral head, surgical neck, tuberosities, glenoid, ribs, scapular spine

2 types of Adhesive Capsulitis

Idiopathic and post-traumatic -Both result in restricted passive and active ROM -Pain that usually subsides over time

Cutoff for surgery

If tear is over 50% of total area, you be getting surgery.

Special tests revolve around?

Impingement/stability

ROM

In conjunction with the other side Active vs passive

Muscles of External rotation

Infraspinatus Teres minor Posterior deltoid

Typical routine may be

Inspection Palpation ROM Strength Stability Special tests

Suprascapular nerve injury

Johnson has never seen, rare

Don't forget

Joint above/below, contralateral sides Neurological Vascular Referred pain

Ligaments of shoulder

Know: AC ligament Coraco-acromial ligament

Muscles that control extension

Latissimus dorsi Teres major Posterior deltoid Triceps brachii (long head)

Scapular winging is caused by injury to what?

Long thoracic nerve injury

Tx of adhesive capsulitis

NSAIDS, aggressive PT, manipulation under sedation

Brachial plexus

Not focusing a lot -in axilla region, part of shoulder, can get damage to nerves with high impact injuries, turn into radial ulnar and median nerves

Internal rotation

Note which spinous process they can reach to

Neer impingement test

Other impingement test, arm at side and forward elevation against resistance, at some point you get impingement -Greater tuberosity on acromion

Arthritis of the shoulder

Pain, decreased ROM -lots of different kinds focus on primary and avascular necrosis -Glenohumeral joint degeneration is a disabling condition -ADL's severely compromised -Can have crepitus, popping, instability

Be aware of how radial, ulnar, median nerves transverse down the arm

Pectoral nerve goes down chest wall that can be injured

Muscles of Abduction

Pectoralis major Coracobrachialis Latissimus dorsi Theres major Subscapularis

Strength

Provide resistance to see if any subtle difference in muscle strength or tone *esp for rotator cuff

History

Questions include: Onset Mechanism of injury Quality of sx Persistence of sx Previous injuries Tx to date ADL's Work activities Precipitating factors Alleviating factors Mechanical sx Training routines

Muscles that control abduction

Requires glenohumeral and scapular engagement *Supraspinatus* Middle deltoid Serratus anterior

Referred pain to lateral aspect of arm is what?

Rotator cuff tear, where deltoid inserts

Proximal humeral fracture sx

Severe pain Swelling Deformity Movement at fracture site Axillary and radial nerve injuries: --Unable to shrug shoulders --Unable to extend wrist or fingers --Loss of sensation of dorm of hand Sometimes ecchymosis is distal, gravity can make it accumulate in elbow

Even if theres just a puncture hole from a fracture...

Still considered open fracture, needs to go to ER and have to do irrigation and debridement in operating room

Stability exam: 3 tests

Sulcus sign Apprehension test The anterior/posterior drawer test

Spectrum of rotator cuff injuries

Tendonitis Impingement Tear Shoulder Dislocation

Major problems of the shoulder

Tendonitis, Tear, Impingement, Arthritis, Brachial plexus injuries, Radiculopathy, Fractures

AC injuries

The AC joint anchors the clavicle to the acromion of the scapula -*Tendonitis* (DJD) -*AC separation*-impact injury (while arm is adducted) can separate that ligament completely or just a little. bikers a lot, flip over their bike, athletics, M>F -*Fracture*

Inspection

They have to undress Skin for atrophy, lesions, erythema, ecchymosis, swelling, abrasions, cuts,

Long thoracic nerve injury

Winging of scapula

Most common dislocation of shoulder is

anterior dislocation

Generalized laxity

be aware of this.

AC separations come in...?

come in 6 types First 3 types aren't that bad, last 3 are more disruptive and require surgery

AC joint test

crossover of arm, reproduce pain there