Upper Extremity Shoulder/Humerus/Clavicle Fractures and Soft Tissue Injuries

MOI of clavicle fractures _______ and mid-high energy impact to the area MC males In children <2; suspect child abuse

FOOSH

Treatment of adhesive capsulitis

Nsaids, pt, intra-articular corticosteroid injections

Treatment of thoracic outlet syndrome

PT

Adhesive Capsulitis: -diffuse shoulder pain with progressive stiffness that results in severe ______ limitations ---> decrease ___ especially with external rotation Initially, pain worse at night --> increasing stiffness --> leading to more stiffness and loss of motion [stiff-pain cycle]

ROM

O'Brien Test (also known as the active compression test) is performed with the patient standing. -The patient holds his shoulder in 90 degrees of forward flexion with the elbow extended. The arm is then adducted 10 degrees. The patient is instructed to internally rotate his arm, pointing his thumb to the floor. The patient should hold his arm in this position against resistance while the examiner pushes the arm towards the floor. The examiner then applies the same force with the patient's arm externally rotated. The test is considered positive if the patient has pain or popping in the internally rotated position and the pain is eliminated in the externally rotated position. The test is thought to be sensitive for a SLAP (superior labral tear from anterior to posterior) lesion if the patient reports deep, diffuse glenohumeral joint pain. SLAP lesions can be secondary to an acute injury or chronic overuse, such as in overhead athletes. Patients may complain of clicking or mechanical symptoms, especially when the arm is the in cocked position of throwing or serving.

SLAP lesion

The shoulder is most vulnerable when _____ and ____ rotated. A fall or tackle with the arm in this position can cause an anterior shoulder dislocation. Posterior shoulder dislocations are less common and are associated with grand mal seizures and electric shock.

abducted and externally

Clinical Manifestations of Thoracic Outlet Syndrome: Vascular compression: swelling/discoloration of the arm especially with _______ of the arm (erythema, edema, or cyanosis of affected arm)

abduction

supraspinatus does

abduction

Inflammatory process that may follow injury ot the shoulder or arise on its own pts with DM have increased risk

adhesive capsulitis

Physical exam for thoracic outlet syndrome: ________ loss of radial pulse with head rotated to affected side

adson

Clinical Manifestation of Rotator Cuff Injuries: -dull aching in shoulder, pain caused by fibrosis inflammation and tears. - __________ ______ pain with decreased ROM especially with overhead activities - in addition pain especially with: ____ rotation or _____uction *pain w/ combing hair, reaching for wallet, inability to sleep on affected side - especially with tears, weakness, atrophy, continous pain*

anterior deltoid pain external rotation or abduction

PE will show arm abducted, externally rotated. Apprehension test positive. X-ray will show humeral head displaced inferiorly and medially Diagnosis is made by anteroposterior (AP) and axillary shoulder X-ray Most commonly caused by trauma from a fall or forceful throwing motion Complications: axillary nerve damage, Bankart lesion, Hill-Sachs deformity

anterior shoulder dislocation

Humeral head fractures are most commonly assessed by the Neer classification. Need to order ___, ___, and ____ x rays for humeral head fractures

ap, lateral, y

_____ may show decreased volume of the joint capsule and capsular contraction for adhesive capsulitis

arthrography

is secondary to an impaction injury of the posterosuperior aspect of the humeral head into the anteroinferior glenoid rim causing a fracture. It is often associated with an anterior glenohumeral dislocation from a force (often falling) with the arm in abduction and external rotation. It is best seen on CT; however, it can be identified by plain radiographics.

bankart lesion

Clinical Manifestations of Clavicle Fractures: -visible deformity present; proximal portion may be displaced superiorly because attachment of SCM. -pain with ROM - +/- tenting of skin/crepitus - May hold arm against chest to protect against motion - Look for _____ ____ injuries (pain, weakness, reflex and sensory abnormalities)

brachial plexus

Proximal Humerus/Humeral Head Fractures: MOI: FOOSH, Direct blow to arm. Common site for pathologic fractures in metastatic breast cancer ARM WILL BE HEALD IN ADDUCTION POSITION - CHECK DELTOID SENSATION TO RULE OUT________ OR _______ NERVE INJURIES

brachial plexus or axillary nerve

MC fractured bone in children, adolescents, newborns during birth

clavicle fracture

treatment of humeral head fractures includes: _____ reduction with application of a sling and swath (velpeau sling) and can treat most nondisplaced fractures - early mobilization with exercises is indicated to prevent FROZEN SHOULDER ORIF indicated for displaced humeral head fractures

closed

Treatment for rotator cuff injuries ______ including: decrease aggravating factors, nsaids, local steroid injections, PT ---> IF pain continues; surgical repair

conservative

if the clavicle is fractured in the proximal third what do we do

consult ortho

Impingement test: pain with inability to lift arm above shoulder level or hold it or severe pain when slowly lowering the arm after the shoulder is abducted to 90 degrees

drop arm test

proximal humerus fractures are most commonly seen in ______ patients MC seen at the surgical neck (epiphyseal-diaphyseal junction) never forget to assess distal neurovascular status- motor, sensory, pulse examination Neer classification: based on number of displaced (> 1 cm) or angulated (> 45°) parts Most common fracture: one part fracture Orthopedic consultation for displaced fractures

elderly patients

diagnosis of thoracic outlet syndrome

electrodiagnostic

infraspinatus & teres minor

external rotation

treatment of clavicular fracture in children

figure of 8 splint or arm sling 4-6weeks

Patient will be complaining of a mass in wrist, sometimes painful Most commonly caused by repetitive activity causing tear or degeneration in joint capsule or tendon synovial sheath Treatment is observation or needle aspiration Comments: most common soft tissue tumors of the hand

ganglion cyst

impingement tests

hawkins neers

impingement tests: Elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation

hawkins test

-Most fractures of the _______ ______ occur in older patients with osteoporosis F>M - Pain, swelling, tenderness especially in region of greater tuberosity -ecchymosis appears 24-48hrs after injury -PT will hold affeted extremity against chest wall -look for injuries to brachial plexus and or axillary artery

humeral head fractures

subscapularis

internal rotation

MC site of clavicular fracture

middle third

Impingement Test: Arm is fully pronated (thumbs down) with pain during forward flexion (while shoulder is held down to prevent shrugging).

neer test

majority of radial head fractures in adults will ____ require operative management Radial head fractures are typically caused by indirect trauma (e.g., fall on an outstretched hand). Patient will be an adult with a history of fall on an outstretched hand PE will show localized swelling, tenderness, and decreased motion X-ray will show fat pad 'sail sign'

not

Caused by repetitive minor trauma Swelling, pain on elbow ↓ Active ROM Full passive ROM NSAIDs,compression dressing, ice should not have warmth and erythema

olecranon bursitis

Complications of clavicle fractures include: _______, coracoclavicular ligmanet disruption, hemothroax, brachial plexus injuries

pneumothorax

Humeral Shaft Fractures - Must R/O : _______ _____ injury ASAP May cause ______ -MOI: MVC, FOOSH, Penetrating injuries (GSWs) - degree of comminution and amount of soft-tissue injury relate directly to the amount of energy causing the fracture -Pain, arm swelling, deformity and shortening are all possible complaints need AP + lateral views that include elbow and shoulder

radial nerve injury may cause wrist drop

This injury is common in athletes or laborers performing repetitive overhead movements MC caused by impingement of supraspinatus tendon in adults

rotator cuff injury

Patient with a history of fall on an outstretched hand (FOOSH) Complaining of dorsal radial wrist pain with decreased range of motion PE will show anatomical snuffbox tenderness Treatment is thumb spica splint

scaphoid fracture

PAIN WITH OVERHEAD ACTIVITIES pain with brushing hair or teeth pain at night when rolling onto shoulder baseball pitchers

shoulder impingement

Positive Neer and Hawkins test

shoulder impingement

acromioclavicular joint dislocation involves tearing of the acromioclavicular and or coracoclavicular ligaments MOI: Direct blow to an adducted shoulder

shoulder seperation

Superior labral tear from anterior to posterior

slap lesion

Treatment of AC dislocations: Conservative management for mild to moderate injuries because they can be managed with a ______ and analgesia More severe injuries require surgery; type _____

sling type III

treatment of clavicular fracture in adults

sling X6 weeks

Clinical features of AC dislocation include ____ -___ appearance at the AC joint

step off

_____ _______ test: may help to distinguish tendinopathy from tears Normal strength with pain relief= tendinopathy Persistent weakness seen with large tears

subacromial lidocaine test

MC injured rotator cuff

supraspinatus

empty can test

supraspinatus

Idiopathic compression of the brachial plexus MC then subclavian vein or artery group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed. This can cause pain in your shoulders and neck and numbness in your fingers.

thoracic outlet syndrome

Clinical Manifestations of Thoracic Outlet Syndrome: -Nerve compression: pain/paresthesias to forearm, arm or _____ side of hand

ulnar