Shoulder Injuries

Infraspinatus muscle

- Lies in the infraspinatus fossa on the posterior surface of the scapula below the scapular spine - attaches to the greater tuberosity of the humerus - works closely with the teres minor to allow external rotation of the arm and shoulder

Pathophysiology of impingement syndrome

- Rotator cuff and deltoid keep the humoral head in the glenoid - rotator cuff and long head of the biceps keep the humoral head from migrating upward when the shoulder is abducted or flexed (keeps subacromial space open during ROM) - Teres minor is the muscle that is the most responsible for keeping humeral head depressed - Tear or injury to rotator cuff or biceps --> causes abnormal upward movement of humeral head i.e. when biceps is cut, humeral head can slide 2-6 mm upward when the arm is abducted from 45-90- 120 degrees in the plane of the scapula

Treatment of Humeral Fx's

A. 70-80% of humeral shaft fractures --> conservative trt 1. Functional bracing 2. Traction B. Transverse fx: - Traction not needed - Treat with sugar tong splint and standard sling C. Spiral, oblique, & comminuted fx's: - require some degree of traction restore alignment - Sugar tong splint, collar & cuff sling initially esp if swelling - Hanging arm cast for traction

SLAP lesion

Aka SLAP tear • SLAP = "superior labral tear from anterior to posterior" • injury to the glenoid labrum Causes: 1. Fall on outstretched arm 2. Fall on shoulder 3. Bracing oneself w/ arm outstretched in MVA 4. Lifting heavy objects repeatedly or too suddenly 5. Repetitive overhead activities --> throwing a baseball. COMMON in pitchers around 11, 12, 1 o'clock know the kinds of injuries associated w/ SLAP vs Bankart tear!!!

Biceps Tendonitis

Biceps --> long and short head 1. long head: originates w/i glenohumeral joint capsule, lies in the bicipital grove of the humerus 2. Short head: originates on the coracoid process - Conjoined muscle inserts on the radial tuberosity - biceps tendon can become strained or can rupture - Proximal damage --> usually presents as anterior shoulder pain - Distal damage --> pain in the antecubital fossa

PE findings for AC Injuries

Exam: 1. Palpate the SC joint, the entire length of the clavicle, the AC joint, the acromion, scapular spine, CC ligaments, coracoid process, and the humerus. Focal tenderness suggests injury to involved structure 2. Perform passive cross-body adduction of the arm to compress the AC joint (AC compression or crossover test). Will produce pain --> helps to confirm dx of AC joint injury 3. Also perform Distal neurovascular exam & cervical spine examination

External Rotation Technique:

For anterior shoulder dislocation • With the patients arm adducted & elbow flexed, slowly (over 5-10 min) externally rotate the forearm while the patient is in the supine position. Stop & wait when spasm is felt until it resolves.

Grading of Ligamentous Injuries

Grading system = Types I - VI • Range from isolated or combined partial and/or complete tears of the AC and CC ligaments to more severe • More forceful injuries can result in: A. displacement of the distal clavicle into/through the trapezius B. disruption of the muscular & fascial attachments of the distal clavicle C. complete disruption of the muscular supports of the shoulder • Associated injuries are common, reduction is urgent to relieve pressure on the neurovascular bundle, - Open reduction internal fixation (ORIF) for types V and VI

Neer Test

Neer's test - while stabilizing the scapula, the shoulder is brought into flexion, forearm in pronation --> long head of biceps or SST are impinged b/w acromion and greater tubercle of humerus (will hear popping over the edge of the acromion) Calcific tendonitis - you can see on an X-Ray

Surgical vs. nonsurgical Treatment for rotator cuff injury

Non-operative management = physical therapy Surgery considered only when conservative treatment fails EXCEPTION: an acute, full thickness traumatic tear injury --> immediate surgery - delay can lead to muscle atrophy, tendon retraction, & poorer surgical results

Bankart Tear

Often associated w/ anterior shoulder dislocation • specific type of labral tear involving the anterior- inferior glenoid labrum • occurs as a result of the force associated w/ an anterior humeral head dislocation • As shoulder pops out of joint, it often tears the labrum, esp. in younger patients. • tear occurs at the inferior glenohumeral ligament

Hill-Sachs Lesion (Deformity)

Only seen in anterior shoulder dislocation As humoral head is dislocated from the glenohumeral cavity, it is driven up into the anterior edge of the glenoid --> results in a divot or flattening in the posterolateral aspect of the humeral head, usually opposite the coracoid process, sometimes with cortical sclerosis

Borders of the Scapula

Superior Lateral (axillary) Medial (vertebral)

Rotator cuff impingement

Tendons of the rotator cuff are squeezed b/w the humerus & the acromion (Most Common) Can result in: 1. Rotator cuff tendonitis - Repetitive overhead use of the arms (painting or throwing) causes a painful strain injury. 2. Subacromial bursitis - Inflammation of the small sac of fluid (bursa) that cushions the rotator cuff tendons from the acromion

Treatment of rotator cuff Injuries

Treatment depends on: 1. the duration of symptoms 2. shoulder dominance 3. the type of tear (partial vs full thickness) 4. age, comorbidities, & activity level shoulder --> worst tendon/joint to get operated on b/c recovery is so long & many ppl still have issues

Teres minor

lies in upper 2/3 of the axillary border of the scapula & attaches to the greater tuberosity of the humeral head (w/ the infraspinatus) - allows external rotation of the arm and shoulder (w/ the infraspinatus)

Physical Therapy for Rotator Cuff Injury

• Activity modification • Stretching of the shoulder capsule to restore flexibility & maintain ROM • Strengthening of periscapular, rotator cuff, deltoid muscles • Therapy similar for partial & complete tears

Frozen shoulder (adhesive capsulitis)

- humerus adheres to the scapula and glenoid, causing shoulder pain and stiffness - due to prolonged fixation and/or disuse Symptoms resolve w/ time & therapy, or release under anesthesia. (closed procedure under anesthesia - can hear all of the tendons etc)

Follow up of Non-displaced Proximal Humeral Fx's

- Total healing time in adults --> 6 - 12 mos. including complete remodeling. Early callus noted at 4 - 6 wks. - First follow up in 4 - 7 days. Obtain X-ray to re-evaluate for significant displacement. - If minimal pain & no displacement of fragments --> start pendulum exercises in sling to avoid ROM loss - Start passive elbow ROM, isometric strengthening early for biceps & triceps - Subsequent visits — Q 2 wks until healed --> focus on pain control and upper extremity ROM - D/C sling w/i 2 - 4 weeks & perform gentle, PROM exercises of the elbow & shoulder - Pendulum and wall climb exercises BID. Refer to PT if patients are unable to perform these exercises on their own

The subscapularis

- lies in the subscapular fossa on the anterior surface of the scapula - inserts on the lesser tuberosity of the humeral head - fibers have a diagonal arrangement (like the infraspinatus) & a diagonal line of pull - allows internal rotation of the shoulder

Absolute indications for referral:

- open fractures - displaced fractures - fracture dislocations - growth plate fractures (kids) - fractures with associated vascular injuries - associated articular (joint) injuries - unstable joint - ipsilateral forearm fractures (floating elbow injuries - fragment that is not attached to bone) - pathologic fractures - Due to weakness - can be caused by bone cysts - concomitant (additional) traumatic fractures or neurovascular injuries • Referral is advised for all shaft fractures w/ suspected radial nerve injuries at presentation

Treatment of Frozen Shoulder

1. GOAL --> treat any underlying process & stretch gleno-humeral joint to restore ROM 2. Most cases resolves on its own (self-limited) & responds well to conservative therapy 3. ROM exercises & strengthening exercises in PT 4. NSAID's or intra-articular corticosteroids 5. Intra-articular injection of saline to stretch the glenohumeral joint (hydroplasty)

Risk Factors for Frozen Shoulders

1. Most common cause --> rotator cuff tendinopathy. 10 % of pts w/ this disorder will develop a frozen shoulder (because they don't use the shoulder & then don't go for treatment/physical therapy). 2. Others: acute subacromial bursitis, humeral fx, & CVA predispose for the development of frozen shoulder, esp. if a sling is used 3. Pts w/ DM, low pain thresholds, & poor compliance to exercise therapy are at greatest risk

Tests for rotator cuff injury

1. Painful arc sign: pain w/ active flexion & abduction > 90 deg (SST) 2. Drop arm sign (failure to smoothly control shoulder adduction) - have them slowly bring their arms back to their sides when you let go 3. Weak external rotation against resistance (infraspinatus and teres minor) 4. Neer's Test 5. Hawkins test - with shoulder and elbow both flexed 90 degrees in front, the humerus is internally rotated. The long head of the biceps or SST are impinged b/w the acromion & greater tubercle of humerus.

Shoulder Fractures and dislocations

1. Proximal humeral fracture 2. Clavicular fracture (covered in Pediatric Orthopedics - summer session) 3. Scapular fracture 4. Shoulder dislocation 5. Shoulder subluxation

Rotator Cuff Pathology

1. Rotator cuff impingement (Most Common) A. Rotator cuff tendonitis B. Subacromial bursitis 2. Rotator cuff tear 3. Frozen shoulder (adhesive capsulitis)

Muscles of the Rotator Cuff

1. Supraspinatus 2. Infraspinatus 3. Teres minor 4. Subscapularis As a group, the rotator cuff stabilizes the humeral head within the glenoid The larger extrinsic muscles like the latissimus dorsi, pectoralis major, trapezius, & deltoid are responsible for gross arm & shoulder movements

Findings in Frozen Shoulder

1. reduced ROM of the glenohumeral joint NOT due to glenohumeral arthritis, tendinopathy or fx 2. X-rays usually negative but should be taken to rule out glenohumeral degenerative joint disease (DJD) 3. Additional studies not usually needed for clear-cut cases - MRI for less obvious pts Might have a bone fragment stuck in the joint space DJD = osteoarthritis of shoulder

Treatment for severe frozen shoulder

<10 % of patients require surgical therapy: 1. release by manipulation under anesthesia 2. arthroscopic capsular release (surgically & cut the adhesion holding the shoulder joint in place) 3. Pts should be told that recovery can take 6-18 mos. 4. Loss of > 50 % of external rotation or abduction --> associated w/ incomplete recovery, esp in pts w/ DM

The Rotator Cuff

= is a group of tendons and muscles in the shoulder, connecting the humerus to the scapula. - these tendons provide stability & allow the shoulder to rotate (internally and externally) & flex (arms out in front) Muscles of the rotator cuff: 1. Supraspinatus 2. Infraspinatus 3. Teres minor 4. Subscapularis Each muscle originates from the scapula & has a tendon that inserts on the humerus forming a cuff

Impingement Syndrome

caused by upward migration of the humeral head --> rotator cuff tendons become sandwiched b/w the humerus & inferior surface of the acromion & coraco-acromial ligaments Biceps Tendon works w/ the rotator cuff muscles to keep the humoral head depressed Teres minor is the most effective at keeping the humoral head from moving up

The Neer Classification of Proximal Humeral Fractures

classification system for whether surgery is necessary 2 main components: A. number of fracture parts B. Amt of Displacement 4 parts: 1. humeral head 2. greater tuberosity 3. lesser tuberosity 4. surgical neck and shaft

Stimsons Technique

for reduction of an anterior shoulder dislocation - pt is placed prone on the stretcher with affected shoulder hanging off the edge - weights are fastened to the wrist to provide gentle, constant traction

Traction-Countertraction method

for reduction of anterior shoulder dislocation

Joints of the Shoulder

greater mobility than any other joint 3 bones: clavicle, scapula, & proximal humerus 4 joints (or articular surfaces): 1. sternoclavicular joint 2. acromioclavicular joint 3. glenohumeral joint - aka "shoulder joint," is the main joint 4. scapulothoracic joint - not a true synovial joint - formed by convex (rounded outward) surface of the posterior thoracic cage & concave (rounded inward) surface of the anterior scapula - joint forms at subscapularis & serratus anterior muscles

supraspinatus muscle

lies on the posterior surface of the scapula above the scapular spine and attaches to the greater tuberosity on the humeral head works closely w/ the deltoid muscle to raise the arm in flexion (in front) and abduction (out to sides)

Rotator cuff tear

rotator cuff tendon tear caused by weakening w/ age or wear and tear. Supraspinitus - most common tendon that gets torn Symptoms: Weakness in the arm & pain

Shoulder Subluxation

• Excessive laxity of the glenohumeral joint capsule in all directions - unable to keep head of the humerus centered w/i the glenoid socket • Recurrent episodes of pain & instability w/ the shoulder slipping or popping in & out • can result from trauma or hx of joint laxity • Treatment --> strengthening exercises • often resolves w/ aging as joints generally stiffen over time** Grow out of subluxations and grow into gleno-humoral arthritis (Joint ends up fusing together) Connective tissue disorders --> people with lax tendons & ligaments

Complications of Shoulder Reduction

• Fails in 5 - 10 %, most often because of entrapment of biceps tendon, joint capsule or fracture fragments • Nerve and vascular injuries occur rarely • Rotator cuff injury can be noted post reduction esp in older patients - 14% have a complete rotator cuff tendon tear If there is a piece of bone in the joint space will not be able to reduce

Follow up for shoulder dislocation

• Immediate ortho referral if reduction fails • After successful reduction, immobilize with a sling/swathe/immobilizer & follow up w/ ortho in a wk Recurrent dislocation occurs in: - very common in <20 y/o - less common in > 40 y/o Immobilize for: - 3 wks <30 y/o - 1 wk >30 y/o Shoulder rehab to limit joint stiffness, prevent frozen shoulder. If its a first time dislocation = send to ortho young people have more frequent dislocations

Shoulder Separations: AC Joint Injuries

• Injury to the acromioclavicular (AC) joint --> occurs from direct trauma to the superior or lateral aspect of the shoulder (acromion) w/ the arm adducted i.e. a direct blow or falling onto the shoulder Force correlates with injury: AC, then CC - Low force typically causes an AC sprain -Progressive increases in force --> cause AC ligament rupture - intense forces --> sprain and rupture of the coracoclavicular (CC) ligaments takes less force to injure AC vs CC

Shoulder Dislocations

• Majority (95 - 97%) are anterior Mechanism of injury: - caused by anterior force to the distal abducted, externally rotated, and extended arm (eg, blocking a basketball shot) - less commonly --> a blow to the posterior, proximal humerus or a fall on an outstretched arm

Rotator Cuff Injuries

• Most rotator cuff lesions start as partial tears of the undersurface of the supraspinatus tendon • progress to full thickness tears & can include supraspinatus, infraspinatus, subscapularis, teres minor, & biceps tendons

Exam for Shoulder Dislocation

• Neurovascular examination --> distal pulses & axillary nerve function, which is most commonly injured causing typical "shoulder patch" distribution

Neurovascular Injury in Proximal Humeral Fx's

• Occurs most often with displaced fxs or fx-dislocations • Can involve the radial, axillary, suprascapular, or musculocutaneous nerve (4 nerves most commonly associated with a humeral fracture***) 1. Axillary nerve injury = deltoid muscle weakness & diminished sensation over deltoid region of the lateral shoulder 2. Suprascapular nerve injury = weakness of the supraspinatus (abduction) & infraspinatus (external rotation) muscles 3. Musculocutaneous nerve = sensation to the extensor aspect of the forearm

Follow up care

• Patient should be seen every 1 - 2 weeks until X-ray confirms clinical dx • Begin ROM exercises at 1 wk, ROM & strengthening post cast removal • Transverse fx can switch to a functional upper arm brace after a few weeks Healing times: Adults --> Takes 8 - 14 weeks to remove sling & use arm Kids --> takes 6-8 weeks Complications in adults (very rare in kids): 1. nonunion - 2 - 5 % (will not heal on their own & they will have to go for surgery) 2. radial nerve injury - 10 - 18% (75 - 90% are temporary) - main nerve that is injured

Reduction of Anterior Shoulder Dislocation

• Reduction w/ or w/o sedation and/or intra-articular lidocaine • Recent (<24 hr), low-force or recurrent dislocations often can be reduced easily w/o sedation or analgesia • Multiple reduction techniques --> all are effective New dislocation --> have to push against spastic muscles

Glenoid Labrum

• Shoulder joint = ball & socket joint, shallow, not as stable as hip • Shoulder joint has a cuff of cartilage ( fibro-cartilaginous rim) around the margin of the glenoid cavity, called a labrum, that forms a deeper socket for the head of the humerus --> this helps compensate for it's shallow socket • This cuff of cartilage makes the shoulder joint much more stable & allows for a very wide ROM (shoulder has greater ROM than any other joint)

Scapular Fractures

• Usually occur w/ high force injuries such as MVA & falls from heights • Evaluation: chest CT in most pts w/ scapular fx b/c of risk of associated injury • consultation w/ trauma and orthopedic surgery • If chest CT neg & no extra-thoracic trauma on PE & no comorbidities, pts can be sent home

Anterior Shoulder Dislocation: X-Ray

• X-ray before & after reduction of anterior shoulder dislocation Risk of Fracture-dislocation --> 25% Factors assoc w/ fracture: 1. >40y/o 2. first-time dislocation 3. traumatic mechanism (eg, fight or fall) The chance that there is no fracture is pretty high if none of those factors apply to the patient

Posterior and Inferior Shoulder Dislocations

• X-ray of posterior dislocation on a standard AP view is subtle, often missed Should ALL be referred to ortho: 1. higher risk of fx and nerve injury 2. In inferior dislocations, rotator cuff tears or greater tuberosity fractures are present in 80%

Evaluation of Rotator Cuff Injuries

• X-rays often negative • MRI best for partial/full rotator cuff tears • Use the MRI for confirmation of what you have already diagnosed or hypothesized There is a high rate of asymptomatic tears

Frozen Shoulder (Adhesive Capsulitis)

• a stiffened glenohumeral joint that has lost significant ROM (abduction & rotation). • partially reversible in almost all cases • Idiopathic (randomly) or due to disuse (immobilization or pain) • Most common in middle-aged pts

Proximal Humorous Fracture

• most common in older adults, uncommon in kids • Elderly --> FALLS • Younger pts --> direct blows, MVA, FOOSH, or by throwing an object forcefully • Classified based on presence or absence of displacement Signs/Symptoms: 1. severe pain in the midhumeral area 2. referred pain to the shoulder or elbow 3. swelling and ecchymosis Exam: • Carefully document median, radial and ulnar nerve function as well as distal pulses

Scapular Manipulation Technique

• no analgesia or sedation needed • Stand behind the patient and locate the scapula • Simultaneously push the tip medially and the acromion inferiorly using the thumbs, thereby rotating the scapula. • At the same time, an assistant provides gentle forward or downward traction on the arm.

Role of supraspinatus fibers on the humoral head

• supraspinatus fibers maintain a horizontal line of pull, which balances deltoid's vertical line of pull • weakness or damage to the supraspinatus causes deltoid to drive humeral head (up) vertically against the acromion process • supraspinatus is the most commonly injured muscles of the rotator cuff