Med sci final

Radial nerve injury after humeral shaft fx

1.8-24% of shaft fx will get a radial nerve injury. Can be primary (occurs at the time of injury) or secondary (occurs during closed or open management). Transverse fx of the middle 1/3 are most commonly associated with neuropraxia causes the most traction on the nerve). Spiral fx of the distal 1/3 (Holstein-Lewis fx) has a high risk of laceration or entrapment of the radial nerve (due to reduction). Spontaneous recovery happens for more than 70% of cases, even with secondary palsies. 90% will resolve in 3-4 months. EMG and nerve conduction studies can help determine degree of injury and monitor rate of regeneration. Will do immediate surgical management of fx with radial nerve palsy if it is an open fx, Holstein-Lewis fx, or secondary palsy developed after a closed reduction.

Milestones after 1 year

18 months: Independent walking, straight leg alignment 2 years: Speech (1/2 is understandable), clothing, throws ball 3 years: Dresses, balances on one foot, draws a circle 4 years: Draws X

Rotator cuff tear statistics

23% of 50-59 y/o and 51% of >80 y/o will be asymptomatic with no treatment (all your tests for RC tear can be negative and they can still have a tear). Articular surface tears are 2-3x more common than bursal surface tears. The anterior arm of the RC is the most at risk for tearing (what you stretch when doing a towel stretch, so don't do this after an RC repair!).

Prox humeral fx imaging

3 views (trauma series) of the shoulder (scapular AP, axillary, and Y/transscapular) should be used for radiographs. May also use the modified/Velpeau axillary view (shooting from top down, rather than bottom up; not quite as good as regular axillary but done if they can't abduct their arm). or AP with IR or ER. The axillary view is crucial for finding head defects and displacement of the tubs. The Y view can show a scap fx or displacement. A CT of the shoulder is necessary for almost all prox humerus fx to see how many parts of the fx there are. Esp important for articular fx (looking for impression and head split), glenoid fx, and assessing tuberosity displacement. The head is split with direct blow trauma from the side where the head smashes into the glenoid; very bad injury.

Coracoid process attachments

5 things: Conjoined tendon (short head of the biceps and the coracobrachialis), coracoacromial (CA) lig, pec minor (taken off with a Bristow/Latarjet procedure but doesn't cause problems for them to do so), coracohumeral lig (just a thickening), and coracoclavicular lig (consists of the conoid and trapezoid; the Conoid is more Central).

Outcomes and treatment for 1 part humeral fx

75% of pts can expect to have a good to excellent result, and only 10% will have a poor result. Pts with excellent results tend to start ROM exercises within 10-14 days after injury.

Perthes lesion

A Bankart variant that is a labral-ligamentous avulsion with an intact periosteum that is slipped medially, becoming redundant. The redundant periosteum becoms a pseudo joint.

ALPSA

A Bankart variant that stands for "anterior labral-ligamentous periosteal sleeve avulsion". The scapular periosteum remains attached to the labral ligamentous complex (unlike with a Bankart). The complex is displaced medially and inferiorly like a shirt sleeve.

AC joint anatomy

A diarthroidal, plane-type joint that is convex on the lateral end of the clavicle and concave on the acromion. A meniscus is usually present Rotates about 3 axes and has 30 deg of upward rotation (all these motions can be hard to control with a sling; may need to go slow in rehab). Vulnerable to separation. Has fibrocartilaginous articular surfaces. The superior capsule is the strongest. The AC lig reinforces the lax joint capsule by preventing AP motion. Anterior translation is also prevented by the inferior capsule, and posterior translation is also prevented by the labrum and supero/posterior capsule. Coracoclavicular ligs are the most important stabilizers, consisting of the conoid (45-50 mm from the end of the AC joint) and trapezoid (30 mm from the end of the AC joint). If both of these ligs are torn, it causes a grade 3 AC separation.

RC interval

A triangular space between the tendons of subscapularis and supraspinatus and the base of the coracoid process. Contains the coracohumeral (acts as the roof) and superior glenohumeral ligament (acts as the floor; if no SGHL, which is the case in 30% of the population, then the middle GHL is the floor), the biceps tendon, and anterior joint capsule. Controls inferior subluxation and is the leading edge of the subscap. Doesn't have neurovascular structures, so a scope can be put through here during arthroscopy. Integrity of the RC interval is tested by pulling down on the arm; if they have a sulcus sign (increased distance between the acromion and humeral head) that isn't improved with ER, the RC interval is incompetent.

Infection discitis

A type of infection that occurs in children 1-5 years of age. Will be irritable, sickly, less active/not walking, and have abdominal and back pain.

Tibia vara

AKA Blount's disease. Growth retardation of the medial aspect of the proximal tibial physis. Shouldn't still be varus at 2-3 y/o. May look like a SCFE. Infantile: Onset <3 y/o. Can be developmental (no inheritance) or familial (autosomal dominant). Unclear what causes it, but the leg is damaged for life. Often occurs in early walkers. Will brace with about 50% success. Juvenile: Onset 4-10 y/o. Adolescent: >10 y/o. Completely different from the others. They are growing perfectly normally, but then they get heavy really quickly. 3% of obese adolescents will develop this because their medial growth plate is destroyed (obesity puts a lot of vertical shear force through the joint and exceeds what a normal cartilaginous growth plate can handle). If nothing is done about it, they will get badly arhtritic knees (need to do osteotomy).

Capsulorraphy

AKA Neer capsular shift. Done for multi-directional instability; will close the RC interval and remove/pleat the redundant capsule. Uses two rows of anchors. Will be protected in an abduction brace for 6 weeks. The axillary nerve is at risk (will likely come back if injured; if anything it will just be bruised). The subscap is peeled off, so it needs to be protected afterwards. Should be healed at 12 weeks. If done arthroscopically, can use a suture punch, suture anchors (3 or more at 2:30, 4:00, and 5:30), or biodegradable tacks at 90 degrees (however these leave bad humors and then cysts when they dissolve).

Adhesive capsulitis

AKA frozen shoulder. A clinical entity, not a diagnosis. The RC interval is too tight because there is a coracohumeral lig contracture. Has three stages, each lasting 3-6 months. Predisposing factors are immobilization, 40-70 y/o (young men are the least likely to get it), DM, trauma, cervical disc problem, thyroid disorders, intrathoracic dysfunction, and post MI. Phase 1: Initiation/inflammation phase where the shoulder is hot/painful. Treatment is NSAIDs or injection. During this phase PTs can make the condition worse (unless it's gentle pool therapy). If with the pt's arm at their side ER/IR produces pain and they can't get to 20 deg ER, they are in this phase. Phase 2: Frozen phase where they have less pain and are losing more motion. If with their arm at their side ER/IR doesn't hurt, they are in this cold phase and PTs can help. Phase 3: Slow improvement

Cerebral palsy

AKA static encephalopathy. A motor disability (palsy) caused by a static, non-progressive lesion in the brain (cerebral) prior to 2 years of age. Prenatally caused by infections, alcohol, drugs, or malformations. Perinatally it can be caused by immaturity (born prematurely), infarction of the middle cerebral artery, hypoxia, placental problems, sepsis, etc. Very few get CP from birthing process anymore. Postnatally it can be caused by meningitis, trauma, suffocation, or child abuse (e.g. shaken baby). Its prevalence has remained static for the past 40 years. The lesion won't progress, but the child will change because of maturation which can change their presentation. Newborns will have hypotonia and at 1 year will have abnormal muscle tone (most will have a mixture of abnormal tones). Motor development is slowed. Can get scoliosis (treated with fusion to prevent respiratory failure and death) hip dislocation (spastic muscles with tight hips; has to be dealt with surgically, will be crippled).

Pec major anatomy

Action: IR, flex/ext (depending on head), add, horizontal add, accessory respiratory muscle Nerve: Clavicular head by the medial pectoral nerve (C8-T1; this means the clavicular head can be used to stabilize the shoulder when muscles innervated by C5-C7 are no longer working) and sternal head by both medial and lateral pectoral nerves (C5-C7). Tendon: 5 cm wide and 1 - 2.5 cm long. Artery: Anterior humeral circumflex

Prox humeral fx associated problems/injuries

After prox humerus fx, disabilities are often underestimated; can get loss of motion, loss of reduction (happens when they are moved too early), AVN, or heterotopic bone (with head injury can cause heterotopic bone in the shoulder with an associated injury there; unclear why). Prox humeral fx are associated with RC tear, nerve damage (e.g. axillary nerve, brachial plexus), vascular damage (e.g. axillary artery, less common and happens if the humeral head slips under the coracoid; usually not life threatening), and scapula (common, tends to be non-op unless the humeral head is behind the scapula due to fx/dislocation) or clavicle fx.

Adhesive capsulitis after prox humerus fx

Almost universal but minimized with early motion. Treated with controlled PT and manipulation under anesthesia. At the 8 week mark they will give them a steroid shot, and then a week after that they will see you for therapy and you can do anything you want with them. Occasionally will do an arthroscopic release (with brittle diabetics who had a large trauma; you don't want to manip these people).

Subscap rupture treatment

Always operative because of how important this muscle is. Will reattach the subscap and the capsule using 3 suture anchors minimum and will do a pec major transfer (weakens the pec and may hurt the musculocutaneous nerve). Can't do resisted IR nor passive ext/abd beyond 20 deg for 12 weeks.

Shoulder arthrogram

Always used in conjunction with CT or MRI. Helpful for identifying labrum tears, capsular injury, Bankart/Bankart variants, SLAP, HAGL, GLOM, GLAD, pts <40 with dislocations, and loose bodies. An MRI arthrogram is used if the injury is chronic; if acute it isn't used because the dye will go everywhere. The dye can help in looking for something like an RC tear (used for suspicion of SLAP in throwers). Can help differentiate high grade partial from small, non retracted full thickness tears. If unsure of ligamentous injury, they will use dye. If the dye doesn't leak, there is scar tissue; if it does, there is a tear. A CT arthrogram is used if the pt is unable to have an MRI or if they are post-op. Can better define the pathology. Downside is that it's invasive and painful and has ionizing radiation.

Hill Sachs lesion

An osteochondral defect in the superior aspect of the posterolateral margin of the humeral head. Happens when the humeral head dislocates anteriorly, then comes back and hits the anterior glenoid, causing a crush fracture that will never fill in (can't have a Hill Sachs without a dislocation). The more on the articular surface it is, the more likely the humerus will dislocate again (causes anterior instability). The critical length is 2 cm and the critical depth is 5 mm (will need surgery). Will do a remplissage, which is where the fill in the crater with RC or MGHL tissue. If >25% of the humeral head is affected, it is an engaging lesion. Occurs with 30% of initial dislocations and with 75% of recurrent dislocations (according to Coggins lecture). A reverse Hill Sachs lesion is an impaction fracture of anteromedial aspect of the humeral head following posterior dislocation.

Outcomes and treatment for 2 part humeral fx

An unstable fx, so they will need a plate, K-wires, or tension bands.

Types of abnormal gait

Antalgic: Painful gait. Will have a reduced stance phase and reduced pressure through the affected LE. Spastic gaits: Scissoring (spastic adductors), hemiparetic (arm tucked in, but comes up when they run), crouch (diplegic, have flexed hips and knees; increases energy consumption because they have trouble switching rockers), and toe-toe (festinating; short, hurried stride on their tiptoes). Weakness gaits: Foot drop (steppage; advancing foot hangs, leg lifted high), Trendellenburg, Duchenne compensation (can't get their knee back in ext when they step forward due to weak pelvic muscles; will compensate by walking on their toes), and waddling. Ataxic: Use a wide BOS. Dystrophic: Lordotic trunk, extended hip, extended knee, floor reaction foot pattern. Limb length inequality: Circumduction.

Circle concept

Anterior instability means that the posterior capsule will also be involved and vice versa; in other words, with an anterior dislocation, ligs and muscles in the back are ripped too. Don't ever want to miss the injuries on the opposite side of the dislocation.

Surgical anterior stabilization

Anterior stabilization surgery involves an arthrotomy, subscap reattachment or split (impairs ability to see; has to be moved somehow), a Bankart, and then anterior labrum/capsule reattachment. The axillary nerve is at risk (located below 5:30). Splitting the subscap in line with its fibers all the way through without taking it off its attachment prevents the need for subscap precautions after surgery. If the surgeon splits it partway, compromises its attachment on the glenoid, and then reattaches it with anchors, then there will be subscap precautions (RC takes longer to heal than the Bankart or capsule).

SC injury treatment

Anterior: Just trying to provide comfort for the pt by using a sling or figure of 8 strap (tries to keep the clavicle held back). Within the first 7-10 days, the clavicle will move in and out of the joint and eventually will stabilize. Often recurs. Posterior: Will need a surgery, requiring a thoracic surgeon in the OR (when the SC joint is reduced, vessels that had been punctured will start pouring blood). Will do a closed reduction with or without pin fixation. Is held this way for 4 weeks, and then any pins are removed (pins can migrate into blood vessels or into the heart). ROM can be done after pin removal.

Arthroscopy vs. open RC repair indications

Arthroscopy: Diagnosis, RC tears (partial, undersurface, complete, etc), glenohumeral clean out, bursal hypertrophy (will remove offensive bursa), PASTA (partial articular surface tendon avulsion of either the supra or infra; the undersurface of the tendon avulses), AC osteophytes, hooked acromion or traction spur, DJD AC joint, and associated instability. Anterior portals are made 2 cm anterior and 1 cm medial to the coracoid and are used to view posterior structures (e.g. infra, teres minor). Posterior portals are made 5 cm inferior to the acromion and are used to view anterior structures (e.g. subscap, supra, Hill Sachs lesion). Bigger tears will need more portals. Scope is inserted when they're on their side. Open: Acute traumatic tears (in large people with BP problems), in degenerative tears with marked atrophy and retraction, and with failed arthroscopic debridement.

LE positioning throughout lifespan

At birth: Femoral anteversion (30-45 deg), genu varum (16 deg), internal tibial torsion, metatarsal adductus (toes turned in). Babies legs won't turn in even though they're anteverted because the gluts are tight; their anteversion is hidden until they start walking, then their legs turn in. 18 months: No genu varum or valgum (linear; ASIS and patella are straight). 3-4 years: 12 deg genu valgum (knock knees). Adults: 15 deg femoral anteversion (will derotate 1 deg per year), 5 deg genu valgum, external tibial torsion (15 deg), metatarsal is in neutral (lateral border of the foot gets straighter)

Muscles of the shoulder

At least 26 muscles attach at and around the shoulder, including the rotator cuff (SSIT and also functionally includes the long head of the biceps) and scapular muscles (17 muscles cross the scapula). The RC forms a horseshoe and right in the middle runs the biceps. Subscap is the largest RC. All RC muscles are humeral rotators and depressors and dynamic stabilizers. Scapular muscles provide stability and mobility, with the serratus ant probably the most important (if the scapula isn't being held in the right spot, the humeral head can't work properly). Lats and both pecs also affect the shoulder (a tight pec minor will cause IR). Force couples (muscle pairs that work together): Upper and lower traps, supra and delts, and levator and serratus. Can use knowledge about force couples to teach pts to substitute when they have something like a long standing RC tear.

AMBRI

Atraumatic MOI, Multidirectional instability, Bilaterally affected, Rehab usually effective, Inferior capsular shift is key. Hard to determine if microtrauma comes first or instability comes first. Will have mild to moderate inflammation, general weakness, poor posture, and anxiety/impatience. Often happens in overhead athletes or workers that are 15-35 y/o and have associated pathologies (e.g. secondary impingement, overuse syndrome, muscle imbalance, faulty biomechanics).

Types of tumors in children

Bone: Leukemia, osteoid osteoma, osteoblastoma, eosinophilic granuloma, aneurysmal bone cysts Cord: Astrocytoma, ependymoma, neurofibroma, lipoma

Nerves of the shoulder

Brachial plexus (C5-T1 nerve roots) and cervical plexus are the two contributors of nerves. C5-C6 are the roots for all the major shoulder muscles; the closer to the ribs the muscle is, the more likely it will come off high on the plexus. The GH joint peripheral nerves are the axillary (runs through the quadrangular space), the suprascapular, and the musculocutaneous. Also very important is the long thoracic supplying the serratus (if lost, the scapula will ride up and in b/c the traps are unopposed; if the accessory nerve is lost, the scapula will go down and out b/c the serratus is unopposed). The axillary nn is at risk with posterior portals (with arthroscopy), and the musculocutaneous is at risk with anterior portals.

Disc herniation/apophyseal fx

Breaking the end plate is what happens more than a ruptured disc (rare). Has a family predisposition. Will get lumbar/sacral pain with nerve root irritation (radiating pain, esp with SLR).

Calcific tendonitis

Calcification due to a degenerative process that is a cause of primary impingement. Is more common in females, in the dominant shoulder, and in the supraspinatus (although sometimes it can happen in the bursa). Will have burning abduction pain. Use the same protocol as kidney stones; ultrasound is used to break it up, cortisone is used to reduce inflammation, and if necessary a needle can be inserted into it to break it up for the body to absorb. Once it is removed/absorbed, there will be a crater in the RC. This has to be fixed with an anchor, although it is easier to repair than an actual RC tear. Rehab like an impingement syndrome. No precautions.

CP classification

Can be hemiplegic (left or right half), diplegic (waist down), quadriplegic (both arms and legs), athetoid (writhing, abnormal movement that affects the whole body). Level 1: Toe walking Level 2: Braces Level 3: AD Level 4: Motorized devices Level 5: Total body care

Surgical tx for humeral shaft fx

Can do plate osteosynthesis, IMN, or an ex-fix. There is no role for stabilization of the humeral shaft by screw fixation alone due to the high bending and torsional forces imposed on the humerus during pt and extremity mobilization. The best functional results are with plates and screws because they allow for direct fx reduction and stable fixation of the humeral shaft without violating the RC. With ORIF, protect the repairs. Will have to sacrifice motion for healing.

Scapulothoracic joint

Can elevate/depress, protract/retract, and upwardly/downwardly rotate. Provides 1/3 of shoulder motion along with the AC and SC joints from 30-180 deg.

TSA post-op

Can only do flexion to 110, abd to 70, and ER to neutral early on. Post-op rehab is started immediately. Only restriction is the subscap. Complications include RC tears or glenoid loosening (rare; the component is the problem in this case). After 6 months they will get to 90% of where they're going to be. The next 6 months will get the other 10%. Won't see improvements after a year. After fully healing, they will have good ROM and increased IR. Can reach to the top of their head to accomplish ADLs. Heavy labor will always be restricted.

AC joint sprains

Caused by fall on the outer shoulder, driving the scapula downward, or hitting the clavicle on the ribcage (notice these are the same MOI as clavicle fx). 6 types of sprains. Old AC separations only cause disability for people who use a backpack or have to hold onto things overhead, etc.

Posteroinferior capsular tightness

Causes loss of IR and horizontal adduction. Happens when the capsule is injured and then it heals tight or when they have a lot of pain due to an AC problem (don't want to bring their arm across, so they lose motion).

Adhesive capsulitis associated pathologies

Cervical (C5/C6 may be affected in older women; a soft disc pushing on the nerve root will make them hesitant to move), periarthritis, bicipital tendonitis, pericapsulitis, bursitis, RC tendonitis (e.g. outdoor work like posthole digging), calcific tendonitis, traumatic OA, and impingement syndrome. These associated pathologies need to be addressed or the frozen shoulder will come back.

Greater tubercle fx outcomes and treatment

Closed treatment has 50-100% poor results if the fx is displaced .5-1 cm. ORIF provides good results.

Surgical neck fx outcomes and treatment

Closed treatment has yielded 60-90% satisfactory results.

Clavicle fx

Common in children and has frequent malunion rates (will always heal with extra bone). However it is rare to have a nonunion; if operated on, nonunion rates increase 10x. Remodels over a year. MOI is a side force (80%, affects the middle 1/3), a top force (15%, affects the distal 1/3), or a direct blow (5%, affects the site of the blow). Because the clavicle is shaped outward, it will break out rather than in (won't damage underlying structures).

Shoulder dislocation

Complete separation of joint surfaces. The shoulder is the most commonly dislocated major joint. 95% of the time it will be an anterior dislocation. In patients older than 40, they will need PT; 1/3 will have a supra tendon tear, 1/3 will have a greater tub fx, and 1/3 will have an avulsion of the subscap and capsule from the lesser tub (requires surgery). In pts younger than 40, they often have labral tears, ligamentous disruption, and Bankarts or Bankart variants. 15-20% will have their RC torn at the same time, so it needs to be ruled out with MRI. For throwers, anteroinferior dislocations are repaired right away. With anterior dislocations, may also get a biceps injury and will lack a deltoid prominence. Acute posterior dislocation will have a prominence posteriorly, a sulcus anteriorly, and can't fully supinate with the elbow extended nor ER when parallel to the floor (have a mechanical block from the humeral head stuck in the back).

RC pathology classification

Compressive failure: Caused by impingement (extrinsic cause). Affects the bursal side. Tensile failure: Caused by traction (as with throwers). Incomplete articular Tedinosis/tendinitis

Clavicle anatomy

Convex posteriorly and anteriorly, flattened laterally, and concave medially. S- shaped in the transverse plane. This allows it to break out, up, or away from the neurovascular structures running behind it; this is why clavicles are only surgically fixed if the pt is prevented from being functional.

Coracoacromial arch vs. coracohumeral interval

Coracoacromial arch: Formed by the clavicle, anterior acromion, AC arch, anterior coracoid, and coracoacromial lig (as seen in picture). Anything that decreases its size can cause impingement. Where the supra runs through. Coracohumeral interval: Where the subscap runs. If <6 mm, it can impinge the subscap.

Dead vs. heavy arm

Dead arm: Loss of control/instability leading to subluxation. Looseness of the shoulder causes traction of the axillary or suprascapular nerves, causing the dead arm feeling. Need to have corrected pathomechanics and an interval throwing program. Surgical treatment may be done; if >120 deg ER (this angle puts them at risk for injury) will tighten the anterior capsule (most commonly done), if <60 deg IR loosen posterior, and if >60 deg ER at 0 deg abd they will close the RC interval. Heavy arm: Loss of velocity, implying RC fatigue. Will surgically debride the RC, tighten the capsule, and do a SLAP repair as needed.

Surgical approaches for the shoulder

Deltopectoral: Done for subscap repairs and biceps tenotomy/tenodesis. The most common approach. Deltoid splitting: Take off the ant delt and have to repair it. Will need to be in a sling. Worried about the axillary nerve. Posterior: Done for a posterior RC repair. Percutaneous: Uses pins. Doesn't hold very well and there is risk of wire migration and hitting the axillary nerve.

Surgical approaches for humeral shaft fx

Dependent on the fx level and the need to visualize the radial nerve (the radial nerve can get caught in the reamer for IMN). Anterolateral: Is preferred for proximal 1/3, midshaft, or distal 1/3 fx. Is in supine. Proximal ext is possible via the deltopectoral interval. Allows for less direct exposure of the radial nerve since it lies posterior to the intermuscular septum. Can also make it difficult to apply the plate to the lateral aspect of the humerus for distal fx. Lateral: Gives good exposure to the whole shaft but is less familiar. Posterior: Can be used for midshaft or distal 1/3 fx. Allows for more direct exposure of the radial nerve and for application of a broad plate to the flat surface of the distal humerus for distal 1/3 fx. Requires lateral or prone positioning (can be problem for multitrauma pt). Requires nerve mobilization for plate application (may increase risk of iatrogenic palsy).

Rehab post-op AC surgery

Dictated by the procedure and the materials used, e.g. screws, pins, tape, wire, sutures. Return to full activities occurs in 6 months or less. Modify shrug exercises to avoid holding weights with their arms by their sides; support their elbows inferiorly or place resistance in the suprascapular area.

Arthroscopic acromioplasty

Done for small, complete RC tears with limited retraction and minimal atrophy where the pt is physically active and has pain and symptomatic weakness. The deltoid is split (meaning that the fibers aren't compromised) and the acromial attachment is preserved but weakened. Has fixation concerns, so a double row of special suture techniques is used (example of rehab modified surgery).

Operative treatment of primary impingement

Done when there is an associated RC tear. If young and active, will do an early repair. If 40 and older, will do a demand related repair (meaning if they're active and wanting to work overhead they'll do the repair). The size of the tear is the #1 outcome determinant. If it is a partial tear, they will do an acromioplasty (can be done open with suture anchors or arthroscopically). For small to large tears, most are repaired if it is the dominant arm. If massive (>4 cm, 50% failure), they will do an acromioplasty, mobilize the soft tissue to get adequate coverage/closure, secure it in a trough near the greater tub using marginal convergence (suture technique done with the pt's arm at their side to reduce strain on the repair and make short tissue long enough to reattach it; when the RC is torn it may retract back toward its origin), do a tendon transfer to try to stabilize/push down the humeral head (lats and subscap; lats more common, contraindicated for people going back to manual labor), and then stabilize the remaining tissue. They may use an allograft or pig mucosa. Will do an rTSA if >70 y/o with a massive tear. Surgical goals are to remove the impinging tissue and the impaired cuff and address the RC pathology by recreating the footprint of the supra.

Arthroscopic release for frozen shoulder

Done when there is failure after more than 4 months of PT. This procedure releases the CH lig and opens the RC interval. The axillary nerve (located at 6:00) needs to be avoided; the average distance from the nerve to each suture is 12.5 mm at the anteroinferior position. Arthroscopic releases are a last ditch effort because they aren't good; may be the only choice for IDDM though.

Nonsurgical tx for prox humeral fx

Done when there is minimal displacement (greater tub <5 mm). Will do a closed reduction with axial traction. Will wear a sling for comfort for 4 weeks, and then can start PROM at 10-14 days if the fx is stable. AROM is started at 6 weeks, and resistive exercises at 12 weeks. There is a high incidence of transient adhesive capsulitis because of the motion restrictions, but can't start exercises too early or the muscle can displace the fx.

Movement disorders

Dystonia: Repetitive, non-volutional movement that usually has a contortional component. Caused by basal ganglia or thalamus damage. Athetosis: Constant recurring series of slow vermicular movement due to cerebellar damage. Uncommon. Ataxia: Failure of muscle coordination/irregularity of muscle action due to a lesion of the cerebellum or SC. Cerebellar is tested with Romberg test and can be corrected by opening their eyes. Spinal can't be corrected by themselves. Friedreichs ataxia is sclerosis of the dorsal and lateral columns of the SC. Catatonia: Can't initiate a movement. True catatonia is rare.

Shoulder arthritis treatment

Early DJD: Arthroscopic synovectomy and debridement (CAM). Late DJD: If young, they will do an interposition arthroplasty (take a graft and use it for cartilage) or a TSA. If older/middle age they will do a TSA (gold standard). After failed surgery, chronic infection, or neurovascular flail arm (post trauma): Arthrodesis (fusion), not TSA! May resect the whole joint which isn't functional but they'll have less pain.

Indications for ORIF of the humeral shaft fx

Failed closed treatment (loss of reduction, poor pt tolerance or compliance), open fx, vascular/neurologic injury, segmental fx, floating elbow, associated intra-articular fx, associated injury to the brachial plexus, chronic problems (delayed union, nonunion, malunion, infection). Only open fx and fx with vascular injury are absolute indications for surgical intervention. Also bilateral fx of the humerus, pathologic fx, PD (will be shaking too much for the bones to stay together without a plate), polytrauma (head injuries, burns, chest trauma, multiple fx, pt unable to be upright).

Volkmann's ischemia

For adults: Severe pain with passive flexion and extension, loss of active flexion and extension of the fingers (paralysis), pulselessness (may be misleading), pulse oximetry (may be misleading), parasthesia For children: Anxiety, agitation, analgesia (pain meds don't help). Children won't show you the Ps. Stages: Deficient circulation (intermittent claudication) leads to ischemic fibrosis (Volkmann's contracture), then partial muscle necrosis and peripheral gangrene, and finally massive gangrene.

Primary impingement imaging

For radiographs, outlet view is used to look for superior migration of the humeral head, greater tubercle cysts, sclerosis of the underside of the acromion (spurs), and acromial morphology. Will have a narrowed distance (<6 mm) on both IR and ER views with loss of acromial convexity. For subcoracoid impingement, also looking for a large lesser tub and coracoid. May also do arthrograms, US, or MRI. MRI is used if concern for RC injury (all types of tears are visible); looking for fat infiltration on a T1 and loss of continuity of fibers on a T2. MRI also gives a large overview of osseous structures (although it misses subtle bony abnormalities. For full thickness tears, MRI is 97-100% sensitive and 94-95% specific. MR arthrography is used to look for labral tears and capsular abnormalities. CT can't detect tendinosis, partial or full thickness tears, nor muscle edema or atrophy. However CT can show bony abnormalities (os acromiale, AC DJD, acromial shape); doesn't do much more than plain radiographs unless done with arthrogram (can show full thickness tears).

Functional bracing for humeral shaft fx

Functional bracing has a 98% union rate with good functional restoration and minimal angular deformity. Will get nearly full ROM with minimal complications. Works via soft tissue compression and consists of an anterior and posterior shell held together with velcro straps. Can be applied acutely or following application of a coaptation splint. Success depends on an upright pt, tightening daily, and no leaning on the elbow. Contraindications are massive soft tissue or bone loss, segmental fx, skin problems, an unreliable or uncooperative pt, an inability to obtain or maintain acceptable fx alignment, or a fx gap (increases risk of nonunion). Can't be taken off at all; can get skin breakdown.

Exam for a newborn

General appearance: Smile, symmetry, movement to midline, syndromes Head: Up at 45 deg, size, fontanel (feel the head; should be soft, not bulging), sucking reflex (touch the side of their face; they should root toward you in that direction) Neck: Should have an asymmetric tonic neck reflex (sword fighter reflex, will disappear around 3 months of age). Watch out for torticollis, pseudoparalysis (due to fx), brachial plexus palsy Arms: Grasp (if you run your finger along their hands they should grasp it) and Moro (startle response; if you lean them back, they should flare out their arms) reflexes. Babies with cerebral palsy won't have reflexes. Shoulder: No hypotonia. If they slide through your hands when you pick them up, they are hypotonic. Back: Midline defects, e.g. dimples in the spine, holes, CSF leaking out. Hip: DDH (developmental dislocation of the hip) Knees and feet: Walking, plantar grasp, and toe curl reflexes

Inferior and multi-directional instability

Generalized hyperlaxity due to Ehlers-Danlos (a group of CT disorders that causes overly flexible joints; will be able to bring their thumbs to their forearms, hyperextend their elbows and MP joints, and have high arch palates and loose forehead skin) or another related collagen vascular disorder. The SGHL, coracohumeral lig, and IGHL are lax and there is a large RC interval (sulcus sign) even with ER. The humerus will drop very far down on a weighted view x-ray. Will have an initial episode of subluxation with multiple subsequent events and current symptoms.

Inferior/multi-directional instability treatment

Generally have non-op treatment. This consists of biomechanical adjustments (need to do a work assessment and involve the coaches) and functional strengthening progressions for 4-8 weeks. Used to do arthroscopic thermal shortening to tighten the ligs, but this makes them gooey so they later require reconstruction; completely ineffective procedure. Surgeries done now are a capsular shift with RC interval closure, advancement of tissue to the humerus, or advancement of tissue to the glenoid (attaching to the glenoid puts less strain on the tissue than attaching to the humerus). Can be done arthroscopically, but that is very challenging. Will be in a post-op abduction brace with the shoulder extended. Risk of recurrence is increased with >20% glenoid loss, a large Hill-Sachs lesion, and inadequate tissue. Reconstruction with an allograft is done if they have recurrent stretching out of the capsule or they previously had a thermal shortening done; basically when the tissue is inadequate. Osteotomies are only done for large Hill-Sachs lesions.

GIRD

Glenohumeral IR deficit due to gaining too much ER (gaining ROM in one direction usually means taking ROM from the other direction). Will have 20% less IR compared to the contralateral side and 10% less total rotation compared to the contralateral side. More due to bone than soft tissue, although the capsule or the muscles around the joint can contribute to the deficit.

GLOM

Glenoid labrum ovoid mass. When a labral fragment breaks off of the glenoid.

GLAD

Glenolabral articular disruption caused by impact of the humeral head due to abduction and forced ER. A superficial tear of the anteroinferior labrum with associated injury of the articular cartilage.

The functions of general bony landmarks

Grooves and sulci protect structures that run through them while prominences are attachments for tendons.

Grade 1 AC sprain

Has no increase in AP motion, just soft tissue swelling (AC joint capsule and lig just sprained/incomplete tear, CC lig uninjured). Will have min-mod pain and tenderness over the AC joint with no palpable displacement of the joint. Pain with AROM but x-rays normal (including weighted AC). Treated with ice, a sling for 1-3 days and oral anti-inflammatories after 72 hours. Can expect full ROM and strength (traps and delts) at 1 week and return to activities after 1-2 weeks (upon completing a push up progression; start against the wall 10x10 with a forehead touch, then progress). Should wear a protective pad for contact sports.

Hemiarthroplasty indications

Has very small usage/indications. Young/middle age: For non-reconstructable articular surface (severe head split) or extruded anatomic neck fxs. Elderly: Many are done for 4 part fxs, sometimes done for severe 3 part fxs. Most are for head splits. Works best for this population and for AVN.

Outcomes and treatment for 4 part humeral fx

Have poor results with closed treatment. Can do a plate fixation, hemiarthroplasty, rTSA, or IMN (not great idea; have to cut through RC and if they end up with a nonunion the revision requires an even larger cut through the RC). Hemis give satisfactory pain improvement but are unpredictable with functional results. The pt often has bad bone so it won't want to heal; will often end up taking out the hemi and doing an rTSA. ORIF in younger pts has 50% or more satisfactory results, but has increased risk of AVN. Overall 4 part fx don't have great outcomes. Can get neurovascular injury, thoracic injury, shoulder stiffness (almost everyone) or impingement (if the plate is put above the tub, every time they elevate they will get impingement), nonunion (uncommon with plates unless diabetic, smoker, etc) or mal-union, and myositis ossificans (due to bad trauma or hematoma; treated with steroids to reduce bone growth, but this can be harmful to the fx). Up to 34% get osteonecrosis.

Primary impingement causes

Having an abnormal acromial morphology (types I; straight, II; curved, and III; hooked, seen in picture; can change from one to the other) or orientation can predispose you to primary impingement. Acromial abnormalities are diagnosed with x-ray. Spur formation on the undersurface of the acromion due to calcification of the coracoacromial (CA) lig can also cause primary impingement. Other causes include hypertrophic bursa, posttraumatic bony deformity, DJD (causes AC joint spurring), greater tubercle prominence (after fx; sometimes when the supra avulses a piece of bone off the greater tub, it retracts it back into the joint and the piece of bone will actually cause impingement), os acromiale (unfused acromion) and RCT thickening (more common in people with short tendons) due to inflammation, scarring, calcium deposits (due to change in pH after surgery), or partial tearing.

Impingement/RC special tests

Hawkins-Kennedy (shoulder and elbow flexion 90 deg, horiz add 20 deg, passively IR), active impingement test (the pt places one hand on the opp shoulder, then elevates their elbow by flexing their shoulder), Neer's (with a fixed/supported scapula, passively flex shoulder fully), provocative tests for GH stability, and elective muscle/tendon recruitment and stretching. 45 deg elevation + ER draws the subscap under the coracoid and tells you if they have ant impingement. Full can looks at supra strength while empty can looks for supra inflammation/impingement by pulling the supra under the CA lig. Lift off/Gerber test looks for AROM issues due to lower subscap compromise (C5-C6 lower subscap nn affected), while the belly press/abdominal compression test (pt's fist on their belly, bring their elbow forward and then let go and see if they can hold it; shouldn't hurt) looks for AROM issues due to upper subscap compromise (C5 upper subscap nn affected). AC problems are tested with the pt's hand on their opposite shoulder, then push down on their elbow. Bear hug is similar, but instead of pushing down on elbow, try to lift their hand up and off their shoulder (looks for subscap tear; won't be able to get arm up in this position with an acute injury, so instead do the belly press).

Diagnosing SC injury

History: Mechanism of injury is a side force from falling onto the point of the shoulder (e.g. sports) or from a direct blow to the SC (e.g. MVC). Physical exam: Tenderness, stridor/difficulty breathing (compression of trachea with a posterior injury), venous swelling (post injury), differential pulse/BP (if artery is compromised). X-ray: Aren't useful. CT scan: Doesn't show the ligs but can be implicated. MRI: Can be used along with CT or alone.

HAGL

Humeral avulsion of the GH lig (more specifically the AIGHL). 8x less frequent than a Bankart. MR arthrography is used to visualize these. Can also have bony involvement.

Scheuermann kyphosis

Hyperkyphosis of the thoracic vertebrae with thoracic or thoracolumbar pain. Neurologically normal but on radiographs will have vertebra wedging, end plate irregularity, disc space narrowing, and Schmorl nodes. Have a stiff rigid back; you ask them to stand straight and they physically can't.

Head split outcomes and treatment

If CT shows a segment is attached to the lesser tubercle, then they will do an ORIF. If severe fragmentation of the articular surface, then they will do a hemi.

Shoulder CT

If can't do an MRI or there is a complex fx/dislocation. Can identify bony abnormalities. 3D CT is used to see how big of a piece of bone came off (e.g. off the anterior glenoid) and to look for continuity of bone.

Biceps tendon rupture treatment

If only an isolated biceps rupture, non-op management is more common. May purposely rupture the tendon all the way if it is only partially ruptured to eliminate pain; will have them use steroids to cause necrosis of the tendon and then do curls until it pops. Will have cramps for 12 weeks, and then it won't hurt again. Operative management involves a groove tenodesis (more commonly open than arthroscopic). This is where the subscap is taken down to get to the biceps and then the biceps is released and fixed into the groove. The transverse lig that holds the tendon down in the groove is disrupted and the subscap has to be repaired. If they also have an RC tear, op management is more common, and they may or may not do a groove tenodesis. Post-op don't do resisted elbow flexion for 6-12 weeks (will be in a sling for 6 weeks).

AC joint surgery

If the AC joint becomes arthritic, it will be removed with a Mumford. This takes 2-4 weeks to stop hurting (hurts like a 2a AC separation). Will have increased motion front to back which goes away with time (conoid and trapezoid still intact, plus the region of missing clavicle will grow in with fibrous tissue). Won't have delt precautions with a Mumford (come from below rather than taking off the ant delt). Will also do surgery for types 4, 5, and 6 AC joint sprains. May do surgery for types 2b and 3 if they are symptomatic throwers. Return to play is 12-24 weeks after surgery. Surgery for chronic type 3 has 85% good/excellent results. Surgery for AC sprains consists of a Mumford (makes the joint space bigger; ACJ would definitely get arthritis in the future, so it prevents sx later on), repair of the AC lig, and reinforcement/reconstruction of the coracoclavicular lig (done using an auto or allograft by drilling through the clavicle and coracoid; started seeing fx between the two holes on the clavicle, so the placement had to be changed).

Adhesive capsulitis operative manipulation

If they have less than 90 deg abd and <60 deg IR/ER, they will need to be taken to the OR with regional block plus sedation or general anesthesia. Will do posterior glides, horizontal add, forward flex, inferior glides, abd, rotations in abd at 90 deg (ER, IR, then IR with horizontal add), and finally ER at 0 deg abd. Will then give an injection of 10 cc lidocaine and 2 cc depomedrol. The straight planes (first 5 motions) create space in the posterior capsule (horizontal add), then the anteroinferior capsule (flex), and finally the posteroinferior capsule (abd) to allow for the rotations at the end. ER at 0 deg is crucial for stretching the RC interval and helps them get their coat on.

Imaging for instability

Imaging is used to establish the diagnosis of a suspected instability, to rule out other entities (e.g. RC pathology, biceps tear), determine if it is an intra-articular and/or extracapsular problem, and plan for surgery. Radiographs can evaluate an acute dislocation, give the direction of the dislocation, show associated fx, and show the adequacy of a reduction. CT is useful for complex fx/dislocations with intra-articular bone fragments. CT has been largely replaced by MRI (now the gold standard), but is still used in pts with contraindications to MRI. MRI is more sensitive than CT at detecting labral abnormalities and has superior soft tissue contrast with multiplanar imaging. MR arthrography shows distension of the joint and is more accurate than standard MRI at diagnosing labral tears, detachment, and degeneration. However it takes longer, is more expensive, is invasive, requires fluoroscopy, and the contrast medium is not FDA approved for intra-articular use (it is used off-label).

Non-op treatment for anterior instability

Immobilization for 3-4 weeks. Will have similar rehab principles as post-op (e.g. 60 deg flexion/60 deg abduction is a safe zone for anterior stability) for 10-12 weeks. Can RTS once neurologic sx are gone, subscap strength is good (dynamic control with the subscap is the key to ant stability), and they are using their brace. Non-op treatment is seldom successful, esp with 15-19 y/o who have instability in their dominant arm (70-90% recurrence rate). Therefore most will have surgery post season.

Total shoulder arthroplasty (TSA)

Indications: OA, AVN, RA or other autoimmune disease (pts with RA and horrible pain will almost always have glenoid involvement, so both the humerus and glenoid need to be resurfaced), post-traumatic. Approach: Subscap, so will have limited ER for a while. Prosthesis: Can modify the height, amount of retroversion (only do 10 deg retro usually because if more, can dislocate posterior), cement (uncemented is preferred), material (pegged glenoid vs. keel; metal went away due to osteolysis from the body reacting) and stem (can do stemless; doesn't change rehab, but may reduce pain).

Reverse TSA (rTSA)

Indications: RC insufficiency (subscap or supra chronic failure), glenoid morphology (significant retroversion; 30-40 deg), fx, low demand elderly pt with GH OA. Post-op: Will use a sling for 6 weeks and do elbow/wrist ROM (no PT prior to 6 weeks). No shoulder ROM is done until 6 weeks, and then gentle stretching and strengthening is done. Done to reduce pain and do ADLs; won't be doing crazy things afterwards (will only regain around 120 deg flex at best; won't get full flexion back).

Secondary impingement

Internal looseness of anterior ligs allowing the RC to rub on the superoposterior labrum Associated with posterior glenoid cysts. Will have tight posterior ligs (anterior looseness goes with posterior tightness and vice versa) and internal impingement. Caused by loss of adequate dynamic humeral head depression/stabilization due to RC/biceps tendon failure. Will have a forward head, protracted scapula posture due to loss of adequate GH ER and scapular retraction.

Humerus anatomy

Its articular surface is 1/3 of a sphere with a 120 deg arc. The humeral head upwardly tilts 45 deg with regards to horizontal (the angle between the humeral head/neck and the shaft of the humerus is 130-150 deg). The head is also 30 deg retroverted (it faces backwards relative to the epicondylar axis). Can become more retroverted if they are a thrower in childhood. TSA needs to be at these angles; if it isn't, you are asking the joint to overcome the body's forces and the body will always win, causing the joint to loosen and break. The diaphysis extends from the upper border of the insertion of the pec major proximally to the supracondylar ridge.

Scoliosis

Lateral curve greater than 10 degrees in the spine. Occurs in 2-3% of kids and is 5x more likely in females. Can be idiopathic (comes on with growth spurt) or caused by neuromuscular, congenital, muscular, or other (tumor, infection) problems. Will do a spinal fusion if >50-55 deg curvature. If 25-40 deg of curvature, will try bracing.

Fx in babies/children indicating child abuse

Lone bone: Think child abuse if the child is younger than 2. Ribs: In a baby rib fx down their back indicates the baby was squeezed really hard. Neck: Shaken baby (can also cause brain damage). Humerus on the growth plate: Arm is jerked.

Physeal injury

Look at the Harris line (growth line) and physis using MRI (8 months after injury). A break here can stimulate growth. If it happens during the transformation into valgus in early childhood, they will get much more valgus compared to the other leg. The ankle will start to grow back towards midline to compensate, and then the bone will remodel and naturally straighten out (leg length discrepancy will disappear).

Proximal humerus fx epidemiology

Makes up 5-10% of all fx, 45% of all humerus fx, and is the 2nd most common UE fx. More than 2x more common in women (77% of all prox humeral fx are female), esp women in their 80s who have osteoporosis (low energy in elderly). In the elderly their bone usually fails before the soft tissue does (don't usually dislocate). Can also happen with falling from a height or with MVC (high energy in young people; not usually a sports injury).

Outcomes and treatment for 3 part humeral fx

May do non-op if it is minimally displaced or an inactive pt that sustained it from low energy forces (since they might not be suitable candidates for open reduction). However closed treatment yields unpredictable results (15-70% satisfaction rate). ORIF with good reduction has 60-80% good to excellent results. Can get neurovascular injury, osteonecrosis, thoracic injury, shoulder stiffness (almost everyone) or impingement (if the plate is put above the tub, every time they elevate they will get impingement), nonunion (uncommon with plates unless diabetic, smoker, etc) or mal-union, and myositis ossificans (due to bad trauma or hematoma; treated with steroids to reduce bone growth, but this can be harmful to the fx).

Osteolysis of the distal clavicle

Meniscoid degeneration and resorption of the distal clavicle. Happens due to repeated microtrauma to the distal clavicle, usually with weight lifters and collision sports. Can lead to arthritis later on. Treatment is a Mumford (often arthroscopically). Non-op rest, meds, novacaine injections (1st injection lasts 6 months, 2nd lasts 3, and by the 3rd injection you can usually convince them to get surgery) modalities, and exercise are done first, then surgery if not successful. Rehab post-op includes a sling for comfort for 1-3 weeks, and progressive ROM and strengthening exercises. Avoid repetitive overhead and across body movements. Modify benchpress grip to underhand (bad for biceps but good for the RC) and use a wider grip for less AC compression.

RC disease

Most RC disease is due to progressive changes from impingement of the cuff as it passes between the acromion and humeral head. Stage 1 is swelling and tendinosis, usually from overuse. Stage 2 is fibrosis and thinning of the RC leading to partial tears (most commonly supra). Stage 3 is complete RC tears. For partial tears on MRI, will see a fluid signal filling an incomplete gap in the tendon along with signs of impingement. Partial tears can be on the bursal surface, articular surface, or interstitial. Full thickness tears will show up as a hyperintense fluid signal filling the gap in the tendon; AKA a bald spot sign (can be hard to differentiate from partial thickness tears and myotendinous cysts). Will have nonspecific fluid in the SA/SD bursa. Biceps tenodesis (cutting the tendon and then reattaching it farther down on the humerus) is often good for RC problems, but we aren't sure why.

Non-op tx of humeral shaft fx

Most are amenable to closed, nonsurgical tx. Rigid immobilization is not necessary (won't put them in cast, will get too stiff), nor is perfect alignment (although it does have to have an acceptable reduction). The arm can accommodate 20 deg of anterior or posterior angulation, 30 deg varus (less in thin pts), and 3 cm of shortening without a significant compromise of function or appearance. However the treating physician must understand that the postural and muscular forces need to be controlled, and there needs to be close pt supervision and follow up. The pt must also be cooperative and preferably upright and mobile. Will have initial immobilization with a hanging arm cast or a coaptation splint (preferred b/c it offers support proximal to the fx) with conversion to a functional brace in the subacute phase (when swelling and pain have improved, usually after 7-10 days).

Limb length discrepancy

Needs no treatment if 2-2.5 cm or less. Measured by putting things under one foot until the pelvis is level, and then measuring how high those things are.

Shoulder MRI

Needs to be done in the 1st week after injury. Done to identify impingement syndrome, muscle edema/atrophy, tendinopathy, Hill Sachs, paralabral cysts, pts >40 with dislocation, partial or full thickness RC tears, labrum tear (can be hard to see), AVN, tumor, or arthritis (either septic or inflammatory). Non-invasive with improved soft tissue delineation. However it can't be used with claustrophobic pts (10% of pts need valium to calm down enough for the MRI), it takes a long time, and it can be misread (can get motion artifacts). Open MRIs have a weight limit of 400 lbs. Contraindications are vascular clips (metal; esp worried if in the brain or abdomen), pacemakers (electrodes), and sheet metal workers (would need an eye x-ray first).

Classifications of proximal humerus fx

Neer: Can be one part, two part, three part, or four part; humeral head, greater tub, lesser tub, and humeral shaft. Can also be classified by if the displacement is >1 cm or if the angulation is >45 deg (arbitrary numbers). Unusual to shear just the articular surface off (fx through the anatomic neck) by itself, for these would do a hemi-TSA. Surgical neck fx at the greater tub occurs with ER and abd (unusual in young people), and at the lesser tub with IR and add. Greater tub avulsion fx causes impingement and pain and the supra will lose its moment arm. Other classifications: Articular involvement (indicates a high velocity injury), vascular integrity (may have to do a TSA if really bad vascular damage), impaction, displacement, dislocation, malalignment, angulation.

Wolff's law

New born is formed in concave areas and resorption predominates in convex areas.

Pec major rupture treatment

Non-op for a partial tear at the muscle/tendon interface (proximally). Non-op leads to deformity and decreased horizontal add strength by 60%, but they will still have full ROM. Operative treatment is for full tears; will just attach the muscle or the tendon left on the muscle down onto the humerus over the biceps. Done for tears <6 weeks after injury; if >6 weeks after, an allograft may be used (have to go slowly with rehab; won't bench for a year). Will be in a sling for 4-6 weeks. Start with Codman's exercises (pendulum) after the repair. Can do active biceps flexion early on. One of the first exercises that can be done is flexion/extension to 90 deg to keep the pec from scarring down. Don't maximally stretch into abd/flex/ER, but can still do some AROM for the first 6 weeks. Rerupture rate is <5% and will regain full strength with a repair. Need to complete the pushups progression without pain before RTS.

Posterior dislocation treatment

Non-op will do 4-6 months of strengthening the cuff muscles and scapular stabilizers. Will only treat non-op if the humeral head is okay. Won't be able to rehab/non-op the lead shoulder in a batter with dynamic stabilization; will need surgery. Acute dislocation will attempt a closed reduction. If chronic, will only do an open reduction and will assess the head defect. Surgical indications are failed PT for 4-6 months, ADLs or other activities are compromised, or there is a humeral head defect (20-45% of the head involved will do a subscap/lesser tub transfer or an osteochondral allograft; if 50-60% involved, will do a hemiarthroplasty).

Shoulder exam

Observation: Look for muscle wasting (can indicate long standing RC tear or nerve damage, e.g. axillary nerve damage with delt wasting), asymmetry, scapular winging, etc. Palpation: Most important bony landmarks are the SC, AC, acromion, greater tub, and bicipital groove. ROM: Look for systemic laxity (Beighton classification: Elbow hyperextension >10 deg, 1st metacarpal to forearm, >90 deg ext at the MCP joints, knee hyperextension >10, trunk flex with hands flat on floor). Normal flex is between 180 deg (functional is 150), ER at 0 deg abd is normally 90 deg (functional is 30 deg), ER at 90 deg is still normally 90 deg (up to 120 in throwers, 70 is functional), IR is 70 deg (functional is 60 deg, if IR is measured by trying to reach their hand up their spine it's normal to get to T4-T10; easy for them to cheat this way though), abduction is functional at 90 deg, and add is normal at 20 deg.

IMN for humeral shaft fx

Offers a biologic and mechanical advantage over plates and screws. Can be inserted without direct fx exposure, minimizing soft tissue scarring. Because it is closer to the mechanical axis than a plate, it is subject to smaller bending loads and less likely to fail by fatigue. Indicated for segmental fx where plate placement would require considerable soft tissue dissection. Also for osteopenic bone, pathologic fx, highly comminuted fx, or shaft fx with extension into the surgical neck. Antegrade insertion will lose motion in 6-36% of cases. Causes less shoulder pain with an anterior acromial approach vs. lateral delt splitting approach. Retrograde insertion gives a more predictable long term function without elbow dysfunction (as long as there are no associated injuries in the same arm). Nonunion rate is 0%-8% for locked IMN (bone fragments aren't touching each other or moving).

Other impingement classifications

Other types of impingement are postural impingement and impingement due to scapular dysfunction. Impingement can be defined as external (subacromial or subcoracoid) or internal (posterosuperior). Posterosuperior impingement is impingement of the supra and infra tendons between the humeral head and posterior superior glenoid (can cause PASTAs of the posterior supra and anterior infra as well as a SLAP). Often seen with throwing (during the cocking phase), swimming, and other overhead activities.

Rehab following OR/in office manips

PT needs to be started the same day within 4 hours of the manip. 4 visits should be made the first week, 3 the second week, and then progress as needed. 10 PT visits total on average. Must have an HEP!! Can use a towel stretch to improve IR or can also use an arm pulley.

Primary impingement physical exam

Painful arc of motion (80-120 deg elevation), decreased ROM (due to posteroinferior capsular tightness), greater tubercle tenderness, and decreased strength in ER, abduction, and IR that is secondary to pain and tendon failure. Check mobility of the AC and SC joints.

Spondylolysis/lysthesis

Pars interarticularis defect that is present in 5-7% of adults and 4% of grade school kids (not present at birth). Have lumbar/sacral pain with extension activities (football lineman, gymnasts, figure skaters) that is relieved by rest. Will be neurologically normal bu have tight hamstrings. Treat with core stability and hamstring stretches.

3 things that can happen to children that can't happen to adults

Physeal fx, growth alterations, and plastic deformation (microfracture all the way down the bone causing it to bend or rotated finger from someone twisting it; doesn't remodel well).

Clavicle fx diagnosis

Physical exam: Tenderness, swelling, more motion, crepitus. More motion and pain will be felt a week after the injury than right after the injury. If mid-clavicle, may start to have neurovascular sx at 4 weeks (when the bony callus is forming and starting to press on these structures; the callus will last another 4 weeks). X-ray: Classified as type 1 (lateral to the conoid and trapezoid ligs), type 2a (medial to the ligs), type 2b (between the ligs; 25-55 mm from end of AC joint), type 3 (into the joint), and type 4 (an avulsion of the ligs pulling off the periosteum/piece of the clavicle; sometimes confused with AC separation).

AC joint arthrokinematics

Primarily has posterior axial rotation (30-60 deg needed for full upward rotation of the scapula). With elevation of the arm is elevation of the clavicle. Has minimal AP (prevented by AC lig) and superior/inferior (prevented by conoid/trapezoid) motion.

Ossification centers of the humerus

Proximal humerus has 3 ossification centers; the humeral head ossifies at 6 months, the greater tub ossifies at 1-3 years, and the lesser tub ossifies at 4-5 years. The tubs coalesce at 6-7 years and then fuse to the humeral head at 7-13 years. The physis closes at 14-17 years in girls and 16-18 years in boys. The proximal physis is extra-articular except at the medial aspect; this means only the medial aspect can have a bone infection that goes into the joint.

Nerve injury impairments

Radial: Extend wrist and thumb Ulnar: Cross the middle finger over the index finger (all dorsal and palmar interossei innervated by the ulnar nerve) Median: OK sign. Anterior interosseous: Gun fighter sign (FPL and FDL lost) Long thoracic: Arms out and down, cough (teres major) C4: Shoulders up C5: Anterior shoulder, bring scapula back C6: Tip of thumb, thumbs up and arms out C7: Tip of long finger C8: Tip of 5th finger T1: Inner arm/axilla S1: Dorsal tip of 5th toe L5: Dorsal interspace of 1st-2nd toe L4: Just behind medial malleolus L3: Medial inner knee

Glenoid osteotomy for posterior instability

Rarely done. From a posterior approach, the bone just proximal to the glenoid is cut parallel to the articular surface and then graft is stuffed in. This posts up the posterior glenoid. May take bone from the acromion or the iliac crest to use as a graft (usually will use the iliac crest because you can choose how much bone you want to take).

Pitchers that are at risk and prevention of injury

Really fast pitchers (3-5 SD above average; 85 mph or more for an adult) are identified so that we can prophylactically stabilize their shoulders/elbows and restrict the number of pitches they do and the amount of force they use. Kids that are this fast are told to use 50% of their max force to prevent risking their growth plates. Kids in the red zone for risk/talent should limit the number of pitches they make per outing to 4x their age. Kids in the orange zone should limit their pitches to 5x their age, and kids in the yellow zone should limit to 6x their age. Should have 3 months of the year where they aren't doing any overhead activities. After 1-45 pitches, take one day off, after 45-60 pitches take 2 days off, and after >60 pitches, take 3 days off. Pitchers have more retroversion and ER which puts them more at risk. Fast acceleration and deceleration also stresses the UE joints.

Primary impingement history

Repetitive overhead use, pain with or following activity, night pain (usually when they roll over, can't go to sleep; also will be thinking tumors esp if they're a smoker), and decreased velocity in throwers.

Provocative reduction

Reproduce the pt's pain with a special test, then give them an injection into the region you think is affected/causing the problem (e.g. the subacromial space, AC joint, or biceps tendon), and then repeat the special test. If you were right about what the problem was, they should be pain free. As PTs, we can accomplish this with e-stim.

Non-op treatment of primary impingement

Rest, education on biomechanics, treatment of pain and inflammation, injections (after steroid injection they have to wait 12 weeks to fix it; only used on tears smaller than 1.5 cm because larger tears can get bigger and will need surgery right away), NSAIDs, and rehab. Teach substitutions.

Ligaments of the shoulder

SGHL runs from 12-1, MGHL from 1-3, and AIGHL/PIGHL from 3-7:30 (PIGHL from 6:30-9, AIGHL from 3-5:30; PIGHL is thickest at 6:30-7:30). The coracohumeral lig and SGHL are tested at 0 deg abduction. They are the primary restraint to inferior GH translation and tighten with ER. The MGHL prevents anterior translation in mid abduction and extension. The AIGHL resists anteroinferior subluxation at 90 deg and max ER; it is the key to anterior stability. The PIGHL resists posterior subluxation at 90 deg and IR. Tested with the Kim's test.

Avascular necrosis after prox humeral fx

Significant incidence with 3 and 4 part fx. Higher when treated with ORIF (strips the periosteum, which is a necessary evil that takes away some of the blood supply). Unlike the hip, incidence doesn't correlate directly with symptoms; may or may not hurt because people don't walk on their hands. Can be minimized with decreased soft tissue stripping and no encroachment of the circumflex or arcuate arteries.

Scapula anatomy

Sits at a 30 deg angle anterior of the coronal plane (in the scapular plane; in other words, the glenoid rests more anterior than the medial border so the whole scapula can rest against the rib cage). Scap mobs are very important after most shoulder surgeries (the only reason you wouldn't do them is if they had a scapulothoracic fusion; same concept as with the patella in that patellar mobs are almost always a good idea!). The glenoid has 5 deg of upward tilt and 7 deg retroversion. It is pear shaped and allows motion in abduction. The acromion rests superior to the humerus.

Clavicle fx treatment

Sling or figure 8 strap and a marcaine hematoma block (injection of anesthetic into the fracture site to allow them to go home and shower without pain; won't want to again for a while). ORIF is only done for open fx, floating shoulder (fx on the clavicle and glenoid meaning that both the scapula and clavicle are unstable), neurovascular injury, or nonunion (can happen with type 2b and Z fxs). Possibly done if there is a >2cm displacement and a Z fx (Z fxs don't heal well, are always type 2a). Resection of the lateral 1/5th of the clavicle (Mumford 1, 2b, 3, and 5) is rare. Will try to reinforce the capsular ligs (costoclavicular, coracoclavicular) after clavicle removal because they are often compromised. If too much clavicle is taken out, can cause a type 2 AC separation. Need to be careful about infection because this bone is near the mouth so it is more at risk.

Abnormal muscle tone

Spastic: Velocity dependent increase in motor tone due to a lesion to the cerebral cortex or SC. Will have a clasp knife response (if you push on a stiff segment, it will resist at first and then relax), clonus, exaggerated knee and ankle jerk reflexes, and if you shake the segment when it is stiff it will relax. Rigid: Stiffness or inflexibility of muscle tone due to a lesion to the basal ganglia or middle lobe of the cerebellum. Can be lead pipe (hard to push but smooth) or cogwheel (jerky). Myotonia: Decreased power of muscle relaxation (delayed relaxation). When you shake their hand they will have a hard time letting go, and they will get a club foot (easily corrected but will return to the deformity). A problem with the muscle (Ca2+ and K+), e.g. myotonic dystrophy, paramyotomyotonia, Thompson's disease (have large muscles that are weak).

Exam for 1 year old

Speech: 3 words Head and neck: Drink from a cup. Arms/hand: Can put a block in a cup; if you give them things they can drop them. Back: Not kyphotic Hips/knees/feet: Cruises (walks while holding onto things)

Exam for 6 month old

Speech: Jabbers (baby talk) Head and neck: Symmetrical tonic neck reflex (can prop themselves up by extending their neck and arms) and no head lag Arms/hand: Reaches (not locked into a grasp; can pass things between their hands) and feeds self (cookie test) Back: Body righting reflex (Landau, parachute; tilt them back and forth while holding them in standing and they should be able to right themselves). Hips/knees/feet: Genu varum, stands with weight on legs while being held at the waist/chest.

SLAP tear

Stands for "superior labrum anterior posterior". The biceps attaching to the superior labrum from 11-1 o'clock is compromised. Usually a chronic throwing injury (from the deceleration phase) but can be acute from bracing on a steering wheel, a FOOSH (shoulder in abduction and forward flex), or from sudden traction (carrying something heavy with someone and then the other person suddenly drops their side). Graded 1-4 by severity; grades 1 and 3 only involve the labrum, but grades 2 and 4 involve both the labrum and biceps tendon. Grade 1 (32% of cases) is a partial tear/degeneration of the superior labrum; the edges are rough along the free margin, but the labrum is not completely detached. Grade 2 is the most common type (47%) and is where the superior labrum is completely torn off the glenoid. Grade 2 can get fluid leakage onto the infraspinatus portion of the suprascapular nerve. Grade 3 (5%) is a 'bucket-handle' tear where the torn labrum hangs into the joint and causes locking and clicking. Grade 4 (16%) is where the tear of the labrum extends into the long head of biceps tendon.

Shoulder stabilizers

Static: Ligamentous (e.g. superior, middle, inferior, and posterior GHLs; stabilize at end range), labrum (anterosuperior portion has poor blood supply), articular anatomy, negative intra-articular pressure, adhesions. Dynamic: RC (stabilize at mid range), biceps long head, pericapsular structures (stabilize at mid range)

Indications of shoulder problems

Subacromial space: Should have more than 6 mm minimum of space between the acromion and the head of the humerus. If less than 8 mm, already starting to worry about an RTC problem. Reduction in ER: Could be a SLAP tear pushing on the infra. Supra/infra weakness: The suprascapular nerve innervates both. Depending on where it is pinched (front or back), both muscles may be affected or just infra will be affected.

Tendons of the shoulder

Supraspinatus (most common tear; >60% of all RC tears), infraspinatus (2nd most common tear; torn by FOOSH with the arm out behind the person), teres minor, subscap (largest and strongest), and long head of the biceps (LHB). Collectively they envelope 75% of the glenohumeral articular surface. Made up of multiple layers of type 1 collagen.

RC functions

Supraspinatus: Initiates abduction Subscap: Primary IR (although pec is much stronger at it) Infra/teres minor: Primary ER Together: Minimize displacement and provide adequate horizontal compression of the humeral head to counter shear forces and provide dynamic stabilization of the humeral head. When there is an RC tear, the biceps hypertrophies to try to compensate but the pt ends up losing function and getting pain anyway because the humeral head will ride up. Will end up needing an rTSA.

Diagnosing adhesive capsulitis

Sx: Diffuse ache around the front and lateral aspect of the shoulder, lack of arm mobility with increased symptoms when elevating the arm, and often worse pain at night. #1 indicator is loss of motion. Clinical exam: Restriction in both AROM and PROM (capsular pattern; ER, abd, IR). Examine the humeral head translation in all planes with the pt supine. Will have the least pain with abd or ext. Need to rule out a myriad of other possibilities. X-rays: Done before motion is back to check for calcific tendonitis and osteophytes. MRI and/or arthrogram: Done after motion is back. Would expect to see tears in the soft tissue because of the manip.

Scapular winging

Tested with a door press (wall push-up) with the arms rounded. Long thoracic nerve (C5-7) affected: The scapula will elevate and move medially. Treated non-op or operatively with a pec transfer. Spinal accessory nerve (CN XI) affected: The scapula will depress and move laterally. Almost always caused by lymph node biopsy. Treated operatively with levator or rhomboid major and minor transfer. With these muscle transfers, the pt will lose 1 unit of strength (if they were 5/5 before, they will go down to 4/5 at best).

Primary impingement definition

The abutment of suprahumeral soft tissues (tendons and bursa) against overlying structures including the anterior acromion, acromioclavicular joint, coracoid process, and coracoacromial ligament with glenohumeral elevation (flexion/abduction) in 80-120 deg range. A problem of not enough space causing mechanical rub.

Grade 6 AC sprain

The clavicle goes between the deltopectoral interval, inferior to the coracoid process and posterior the biceps/coracobrachialis tendons. Every time they move it is excruciating. Needs to be repaired.

Grade 3 AC sprain

The clavicle is still touching or near to the acromion but there is loss of both AP and sup/inf stability (AC and CC lig complete tears). Essentially an AC dislocation. The pt will keep their arm supported and close to their body. The UE is often depressed with the clavicle prominent superiorly under the skin. Will have moderate pain which increases with motion (esp adduction). Will have tenderness over the AC joint and coracoclavicular interspace. Stress x-rays are positive (have to give marcaine injection first to numb them or they will tighten up); the AC joint is completely displaced. May have associated fx of the clavicle, acromion, and coracoid. Treatment can be non-op or op (more likely to be op if pitcher, backpacker, climber, etc). Non-op will immobilize for 1-8 weeks (varied opinions). Will then start a strengthening program. At 12 weeks can expect to be asymptomatic and functionally performing.

Grade 4 AC sprain

The clavicle slips behind the acromion into or through the traps. Will do surgery.

Grade 2 AC sprain

The conoid and trapezoid are fine so there is no superior migration but there is increased AP migration (AC lig torn completely, CC lig sprain but largely intact). Will have moderate pain and tenderness over the AC joint and ROM produces significant discomfort. X-rays may reveal a widened AC joint but stress x-rays (weights hanging from wrists with arms at side) are negative. Treated with ice, a marcaine injection, a Kenny Howard sling for comfort, shoulder girdle isos starting the first week, and a progressive ROM and total limb strengthening program emphasizing the delts and traps. Return to heavy activities and contact sports takes 2-4 weeks (need to complete a push up progression and have no pain). Have increased risk of late arthritis due to increased motion causing osteophyte formation. Type 2b is a subtype that has a positive posterior stress view and persistent traps spasm due to compromise of the raphe between the trap and the clavicle. If there is persistent trap pain at 12 weeks (caused by the clavicle banging into the trap) they will do surgery.

Bristow/Latarjet reconstruction

The coracoid process (along with its attached muscles) is transferred to the glenoid process to make up for bony loss after a dislocation. A soft tissue sling is formed by weaving the attachments to the coracoid through the split in the subscap, further increasing stability. The musculocutaneous nerve is put at risk and it can be difficult to revise. Also check the ulnar nerve (have them spread their fingers) after surgery because it can become upset with brachial plexus injury (brachial plexus runs just underneath the coracoid). First the subscap is split, then the coracoid is taken off (including the conjoined tendon) and placed on the glenoid where the bone is missing. This holds the humeral head in place from outside the capsule.

Critical zone of the RC

The critical zone is a region of decreased vascularity that is 1 cm proximal to the insertion of the supra tendon. This zone is position dependent; there is less circulation to the critical zone with the shoulder adducted than with it abducted.

Glenohumeral joint

The humeral head is convex and the glenoid is concave. the humeral head is 3x the size of the glenoid (like a golf ball on a tee). The GH joint contributes 2/3 of total shoulder movement. Spins, rolls, and slides. 0-30 deg abduction is all GH joint, while 30-120 deg is 1/2 GH and 1/2 scapulothoracic contribution. In the scapular plane, with more abduction is more contact area and decreased contact pressure (just like the patella). Has a labrum that is fibrocartilaginous and has a poor blood supply (just like the meniscus).

Shoulder instability

The inability to maintain the humeral head in the glenoid fossa. A spectrum including dislocation, subluxation, and laxity. Can be of the GH joint or scapular from repeated overhead use of the shoulder. The bones, GH ligs, joint capsule, and labrum are all affected with instability. Will have pain and/or diminished function. Classified as acute or recurrent, traumatic or atraumatic. GH instability is also classified as anterior, inferior, posterior, or multi-directional. Usually multi-directional instability is anterior + inferior or posterior + inferior. If they have anterior + posterior instability, then they have 360 deg instability. Special tests for it are the sulcus sign, apprehension test, and drawer tests.

SCFE

The neck slips anterolateral. Pain in the hip, groin, and knee with loss of IR and a limp. If you passively flex their leg, it will ER. Risk factors are male gender (2.4x more likely), obesity, and African American. Occurs in boys around 13.5 y/o and in girls around 11.5 y/o. If younger than 10, consider endocrine and renal problems. 25% are bilateral, with 30-40% more converting to bilateral in 18 months. Can be stable (can walk, but with pain; no movement under fluoroscopy) or unstable (painful and can't walk, movement under fluoroscopy). Treated with pin fixation, osteotomy of the proximal femure, bone peg, or a cast. Complications are AVN, chondrolysis (premature closure of the greater troch physis, synovitis), fx, or deformity.

Hueter-Volkman Law

The physis adjacent to a malunited fx tends to realign perpendicular to the force that acts through it (growth plates will straighten themselves out to be perpendicular with no treatment). The changes of the joint surfaces are preferably caused by relatively greater growth of the bony parts which are under relatively less pressure. Alterations in the growth of long bones is the result of tension and compression on the epiphyseal plate. Bones in children will straighten themselves out until they are 15-16 y/o.

SC joint anatomy

The posterior capsule has the most AP stability. The costoclavicular lig is very strong and it takes a lot to get injured (just like the popliteofibular). The disc within the joint is fibrcartilaginous (similar to the AC joint and the meniscus). Is a meniscoid saddle joint with strong ligs. Can elevate/depress, protrude/retract, and upwardly/downwardly rotate.

Posterior capsular shift

The posterior labrum is repaired, the IGHL and posterior band of the capsule are tightened, and the soft tissue is plicated. They go in between the infra and teres minor. Will need to wear a post-op abduction brace with their shoulder extended; won't see these pts for 6 weeks until their brace can come off.

Shoulder relocation

The pt must be relaxed to relocate. Apply traction to the humerus, then if that doesn't reduce it, ER/IR the arm to relax the subscap and allow the humerus to go back in. Always check neurovascular status before and after relocation (musculocutaneous and ulnar nerves are at risk). An x-ray post reduction MUST be taken. Dislocation recurrence rate is up to 83%, so early detection and repair is essential. Even after being reduced they can have apprehension and fear that the joint will dislocate again.

Prox humeral fx examination

The pt will keep their arm internally rotated and supported by their contralateral hand (won't want to move their elbow even though it's not involved). Will have painful ROM. Make sure to do a neurovascular exam, esp of the axillary nerve (check it with gentle abd). Check the radial pulse on both sides.

Subacromial space

The roof is formed by the superior acromion, CA lig, and distal clavicle. The floor is formed by the superior humeral head (greater tub). Contains the subacromial bursa, supra, and long head of the biceps.

Grade 5 AC sprain

The same as type 3 but the clavicle goes superior more than 1 width of itself due to disruption of muscular attachments. Needs to be repaired.

Blood supply of the shoulder

The subclavian artery turns into the axillary artery (has the anterior and posterior humeral circumflex arteries branching off it that feed the humeral head), and then the brachial artery. The younger you are, the better the collateral flow you will have. The cephalic vein is at risk of DVT after arthroscopy. The posterior humeral circumflex is likely the most important supplier to the humeral head because it goes to the greater tub and posterior cuff muscles. The anterior humeral circumflex just goes to the lesser tub. The posterior circumflex runs through the quadrangular space.

Rotator cuff footprint

The surface area of tendon insertion for the rotator cuff muscles (where Sharpey's fibers attach the tendons to the bone). For the supraspinatus, it's footprint is 25 mm wide and 12 mm long (it begins on the anterosuperior articular surface and extends posteriorly onto the greater tubercle).

SLAP treatment

The type of SLAP tear changes what is done. However for all you need to correct their pathomechanics and put them through an interval throwing program. The pt can use O'Brien's as a self test; if that doesn't cause pain before practice, they know they can progress. Because blood supply to the labrum is poor, NSAIDs shouldn't be used (will decrease blood supply even more, just like with meniscal repair). Surgery is done arthroscopically to reattach the labrum/biceps complex to the glenoid; often an MGHL repair is needed as well. Two anchors are put in at 12 o'clock and two posterior to 12 o'clock. Need to be careful that the knots don't rub on the biceps. If the biceps is split, they will do a tenodesis. Will RTS 9-12 months after surgery. If done on someone older than 35, they will be unlikely to RTS unless a subpec biceps tenodesis is done with one anchor. Someone this age also won't be able to fix the labrum with just two anchors.

How tendons age

They get decreased cellularity and vascularity with disorganization of their collagen networks and increased type 3 collagen and GAGs.

Expectations after impingement surgery

To get to the region they will compromise 1/2 the delt attachment which will come back fine because it's a robust muscle, however anterior flexion shouldn't be done at first. For a massive RC repair we need to rehab the ant delt and teres minor. For open or arthroscopic acromioplasty, they will need 6 weeks of active rest (or the delt will rupture). Therefore, rarely are RC repair pts sent to PT before 6 weeks. After subacromial decompression, they should be functional 8 weeks after. The clean and jerk and inclined bench aggravate the supraspinatus, so these should be the last to do after supra repair. Won't see allografts as PTs until 10 weeks or more (take longer to incorporate).

Tone vs. contracture

Tone: In the red meat portion of the muscle. Contracture: In the fibrotic portion of the muscle.

Shoulder MOI and the associated pathologies

Traction: High likelihood it will cause an articular surface partial thickness tear of the lower layer of supraspinatus tendon (PASTA tear). FOOSH: Usually causes an infraspinatus tear. Fall with arm outstretched behind: Will have an interval problem with the long head of the biceps tendon at risk.

Humeral shaft fx

Traditionally treated nonsurgically with predictably satisfactory outcomes. Used to be a strong bias against surgery due to a high rate of complications, but both operative and non-op treatments have been refined and improved. Fx alignment is determined by the location of the fx relative to the major muscle attachments (pec major and delts). If the fx is distal to the pec major and proximal to the delt tuberosity, the proximal fragment will adduct (will pull up and in toward the pec). If the fx is distal to the delt tub, the proximal fragment is abducted and the fx site is shortened due to pull of the biceps and triceps.

TUBS

Traumatic MOI, Unidirectional instability, Bankart lesion (the pathology), Surgery (a Bankart repair) is required. Done when a healthy shoulder has a traumatic event, e.g. anterior dislocation. A Bankart lesion is any lesion of the labral-ligamentous complex from 3-5 o'clock (on the R glenoid). It is the most common lesion caused by anterior dislocation. Can have bone (fx of the anteroinferior rim of the glenoid from humeral head impact; amount of bone lost has direct impact on RTS) or no bone (just soft tissue) involved. The AIGHL is compromised with 20% bone loss. CT is used to determine amount of glenoid loss (1/4 or more lost needs surgery). Surgery should be done immediately so that bone isn't worn away. Anchors are made in the bone to hold the labrum in place until it has time to heal. Not trying to get back full ROM; will settle for 70 deg of ER. However decreased ROM can cause arthritis, so have to choose between that and repetitive instability.

Posterior shoulder instability

Types are dislocation (acute <6 weeks, chronic, fixed, or locked >6 weeks), subluxation (component of multidirectional instability; can be voluntary or involuntary), and traumatic recurrent. Can be from falling on the shoulder during a seizure (arm is adducted and flexed) or from being a batter (the lead shoulder is affected). Can also be from an axial load on a fully extended and adducted arm. Accounts for 2-12% of instability cases and 50% of cases are missed. The IGHL (esp the posterior band), SGHL, posterior labrum, and posterior capsule (almost always under-developed) are lax. Rarely will have glenoid malalignment. Will surgically stabilize the posterior capsule. May also have a subscap (unusual) or biceps rupture. For a biceps rupture, they will tenodese it and the pt will still have relatively good mechanics. Move these people early.

Vascular injury after humeral shaft fx

Uncommon, but can get injury to the brachial artery with a gunshot or stab wound, vessel entrapment by fx fragments, or occlusion after hematoma or swelling in a tight compartment. The brachial has the greates risk of injury in the proximal and distal 1/3 of the arm. Arteriography is controversial. Arterial inflow must be established within 6 hours. At surgery, the vessel should be explored and repaired along with fx stabilization. If limb viability is not in jeopardy, bone repair may precede vascular repair. Ex-fix may also be considered. May need short term dialysis (kidney failure) due to the lactic acid build up from vascular injury.

Shoulder pathologies from pitching

Undersurface RC tears (PASTA lesions), impingement (secondary to instability/laxity; the humeral head and therefore the RC ride up because the depressors aren't pulling down), and scapulothoracic problems (due to increased thoracic kyphosis and protracted scapula). Lots of force goes through the AIGHL, resulting in laxity in the front and hypomobility in the back. Can have trouble with muscular with muscular balance and control (force couples; throwing requires sequential, coordinated muscle firing) leading to pathology; work assessments, biomechanical activity analysis, and coaching may be necessary to help prevent problems.

Shoulder ultrasound

Used for RC tears and other soft tissue lesions. Use is on the rise, predominantly in Europe.

Shoulder radiographs

Used for identifying fx, tumor, loose bodies, subacromial spurs, acromion type, subluxation, os acromiale, etc. The most common views are AP (used to look for calcifications on things like tendons; can be IR, ER, or neutral), axillary (AKA west point, the most important view; used to detect Hill Sachs and Bankart lesions as well as labral involvement, also shows if the humeral head is where it should be), and stress (weighted AC) views. If the clavicle goes up in a stress view, the conoid/trapezoid are compromised; if the humeral head goes down, then there is an RC interval problem. Outlet views are used to look for spurs and Stryker views (shown in image) are used to look for AC pathology. There are many others depending on the technician doing the x-ray.

Back pain in children

Used to be rare, but isn't anymore; occurs in 23-25% of children and 35-50% of adolescents. <10 y/o: Won't necessarily say they have back pain, may just hold their back. At this age, back pain indicates a serious problem, e.g. discitis, vertebral osteomyelitis (ages >5 years, gradual onset with back pain), congenital vertebral anomalies (e.g. syringomyelia, lipoma, tethered cord, bone deformity), or neoplastic disorders (indicated by a poker board back; will lean to one side and have a very stiff back). Red flags are significant trauma, neurologic sx/findings, night pain, systemic sx (e.g. losing weight), stopping pleasurable activities/changing activity levels, <7 y/o. >10 y/o: Trauma (spondylolysis, stress fx), disc disorders, apophysis injury, Scheuermann's hyperkyphosis, neoplasia, congenital vertebral anomalies.

Superior capsular reconstruction

Used to treat massive RC tears. Will use a patch to create a bumper between the acromion and the humeral head to restore stability. Rehab them extremely slowly because they're not at risk of getting stiff. Start ROM at 8 weeks.

Paralabral cysts

Usually associated with labral tears and may indicate the direction of instability. Hypothesized to arise from extrusion of fluid through labral tears into the surrounding soft tissue. Analogous to the meniscal cysts of the knee. Will have symptoms of compression neuropathy.

SC injuries

Very unusual to have an injury here. The SC joint growth plate is late to close (17-18 y/o), so these can become injured up until this point. Can have an injury where the SC is driven anterior. Can also have an SC injury where the SC is driven posterior (e.g. a car accident or fall), which is life threatening (can press on the trachea and cause isolated unilateral swelling on the face due to arterial compromise). Thankfully no major nerves pass directly behind the SC joint that could be compromised.

Adhesive capsulitis in office treatment

Will do a DEXA scan first with post-menopausal women to make sure their bone quality is good enough to manip them. Will stretch them in the office if they have abd of at least 90 and ER/IR >60. May do injections of 30-60 cc (20 cc of .25 lidocaine, 2 cc depomedrol, and the rest saline). This is done by filling the joint with the fluid, then sucking it out, then filling it up more with fluid, etc. Then it is left to sit and after that the shoulder is manipulated (the manipulation is called a "brisement"). This prevents them from feeling the pain of the manipulation. Oral meds (NSAIDs and analgesics) are given post manipulation. Diabetics won't do as well with this treatment (they have crazy fibroblasts and therefore a very thick capsule, so they are more likely to break the bone the capsule is attached to).

Arthroscopy for anterior shoulder instability

Will do an arthroscopic exam if more than 7 days after the incident. Arthroscopic repairs can be done for first time dislocations with soft tissue Bankarts that may or may not have been caused by a collision sport. Requires 3 anchors. Will start PT 4 weeks post-op. Bony problems can't be addressed with arthroscopy.

Arthroscopy for posterior shoulder instability

Will fix the labrum, do a posterior capsulorraphy, and do a capsular shortening. 91% will have a reverse Hill Sachs lesion, but that doesn't always have to be fixed. Will almost always anchor (will use 2-3 anchors) and will plicate 1 cm or more (takes up the slack of the capsule from being stretched and centers the humeral head). The RC interval is closed when there is a positive Kim's test, a positive sulcus sign with >60 deg ER at 0 deg abduction, and a positive sulcus sign with IR at 90 deg abduction.

Pec major rupture

Will have a pop with a deformity. Usually some tendon is still attached to the muscle and often the clavicular head (innervated by the medial pectoral nerve, C8-T1) stays attached. At 1 week will be bruised everywhere (both the biceps and the chest wall). Swelling will be so bad there will be loss of the axillary fold and will only be able to abduct to 90 deg. MOI is during the last 30 deg of lowering the bar for a bench press; the chest bounce during the eccentric phase of contraction. Needs an MRI of the chest, not the shoulder (unless it's unclear what the problem is, then both is needed).

Subscapularis rupture

Will have a pop with pain that may or may not occur with shoulder subluxation anteriorly and glenoid fx. MOI is resisted ER. The main associated pathologies are biceps tendon rupture (biceps tendon gets stuck under the subscap; this is really painful, while the subscap itself isn't that painful) and damage to the anterior capsule; humeral avulsion of glenoid ligaments (HAGL; 8%). Will have deep anterior tenderness and a positive abdominal compression test (indicates the upper 1/2-2/3 of the tendon is damaged; this is the portion that needs to be fixed). May or may not have positive lift off and apprehension tests. Will have loss of resisted IR.

Biceps tendon long head rupture

Will have a sudden pop with pain near the shoulder (if pain is in the bicipital groove, biceps is most likely the issue). MOI is max elbow flexion or resisted elbow extension (same idea as with a quad/patellar tendon rupture). The main associated pathology is a RC tear (addressed at the same time). Only 1/2 of people who get a rupture will have a popeye sign. Functional loss is minimal at the shoulder and elbow for a proximal rupture but disabling for a distal rupture (loss of supination). Will lose 10-15% of strength.

Anterior shoulder instability

Will have apprehension in the high five position (fulcrum/crank test is supine in high five position, then pushing anterior; pushing posterior should reduce apprehension/pain); the humeral head drops down in its socket with abduction. Done in prone for large and anxious pts. Will also have a dead arm when throwing. The anterior and superior labrum will be affected (can have SLAP lesions) and the anterior capsule will be lax. Rarely will have glenoid hypoplasia (an underdeveloped glenoid). 20% will have post-traumatic glenoid insufficiency (AKA inverted pear glenoid; this shape indicates significant bone loss because the glenoid is normally pear shaped). The AIGHL (located from 3:00-5:30 on the labrum) and MGHL (from 1-3 o'clock) will also be lax. May be able to put their shoulder in/out on purpose ("party subluxers") indicating general laxity. Tests for anterior instability are the anterior drawer, apprehension, fulcrum, relocation, and clunk tests. The clunk test is for a torn labrum that may or may not have instability and is very sensitive but not specific.

SLAP diagnosis

Will have deep anterior pain with clicking and positive O'brien (AKA active compression test; hands back to back in front of them with thumbs down, apply downward pressure) and Kocher (method of relocating arm; with 90º elbow flex and arm adducted against the body, slowly externally rotate between 70º to 85º until resistance is felt, then flex as far as possible, and finally IR) tests. X-rays and MRI will be negative but MRI with contrast is sometimes positive (if there was a previous surgery or leaks). Have to check renal function before using dye, but may be the only way you can see the tear.

AC joint arthritis

Will have impingement (often positive impingement tests), spur formation (seen on x-ray), meniscoid tears and degeneration, and cartilage erosion. May be TTP and have pain with horizontal add and a positive AC compression test. Often have pain with end-range flexion. More than 25% will have GH pathology; will see DJD of both the AC and GH joints on x-ray. Non-op treatment is rest, meds (injection of long acting steroids), and modalities like ionto using dexamethazone. Operative treatment involves arthroscopic debridement for a GH pathology and/or a Mumford. At first rehab involves maintaining full PROM, then at 4-6 weeks you can begin strengthening and AAROM. Avoid excessive resistive exercises, esp overhead. Start with a push up progression.

Tests for posterior instability

With recurrent post instability they will have a positive clunk test and may or may not have a positive Kim test (a painful clicking with axial load and an inferior shear force). Other tests are the posterior drawer, jerk, load and shift, tightening IR, push-pull, and 20 degrees tests. Posterior stress tests are the done by pushing posterior in the Hawkins position (arm horizontally adducted and flexed with the elbow flexed) or in the offesnive linemen pass block position.

K wires

With the pt in a beach chair position (sitting up, reclined), they will do a closed manipulation and then use an oscillating drill (prevents catching a vein or nerve) to place terminal thread pins (at least bidirectional; threaded to keep them from tracking down into the bone). The pins are then cut beneath the skin. Will sling and swath them, and then follow them closely. Easiest to do (compared to plating and tension bands), however it has more complications/problems; nerve injury (axillary), pin loosening, migration, no early motion. Used for 2 or 3 part fx when other techniques aren't afavorable.

Tension bands

With the pt in a beach chair position, the delt splitting or deltopectoral approach is used to place a k wire and then reattach the tubs to the metaphysis with a tension band (suture or wire). Associated problems: Cuff constriction, limited head fixation to the shaft, and wire migration. The bands can break and jab the surrounding structures. Used for greater tub, lesser tub, or when both tubs are displaced with an undisplaced surgical neck fx. Rarely done anymore; were more done before locking plates (screws lock into the plate, not the bone) were invented.

Locking plates for prox humeral fx

With the pt in a beach chair position, the deltopectoral approach is used to place a plate lateral to the bicipital groove with minimal tissue stripping. Screws in the shaft are non-locking (the bone is good and hard here), while the ones in the humeral head are locking (prevents sliding of the bone). Has a learning curve. Penetration of the humeral head with osteoporotic bone can be problematic. If they have pain anteriorly, they will cut the biceps and tenodese it in case that's the problem. Advantages: No impingement (with a properly positioned plate), stable superior head fixation, easily combined with suture fixation of the tubs, early full ROM. Offers rigid fixation and is better for osteoporotic bone. Has a lower failure rate; will only fail due to operator error/poor technique or if the bone is really bad. Certain plates have little holes for K wires or stitches to tie down the RC and repair it if needed.

Hemiarthroplasty technique and outcomes

With the pt in the beach chair position, a deltopectoral approach is used. Will retain the tuberosity fragments with the cuff attachments, then do a combined suture repair of the tuberosities with a bone graft from the head if needed. Follow the TSA protocol. Outcomes are unpredictable from a functional standpoint; you're asking a bone to heal that was already of crappy quality (if in an older person). Requires bony healing of the tuberosities. Bone graft, RC repair, and height/size/retroversion of the prosthesis can limit outcomes.

Biceps special tests

Yergason's tests bicep's tendon subluxation or tendonitis by having the pt do resisted ER and supination with the arm adducted. Speeds looks for biceps tendonitis by adding some resistance to the pt's flexion. O'brien's looks for long head of biceps involvement or SLAP (thumbs down, back of hands together).