Chapter 45- shoulder

Question 1

Describe the sensory and motor components of the brachial plexus

Answer 1

Question 2

Label the following diagram

Answer 2

1. Spine of scapula
2. Clavicle
3. Acromioin
4. Humerus head
5. GH joint
6. Shaft of humerus
7. Medial boarder of scapula
8. Humeral head (greater tuberosity)
9. acromion
10. GH joint
11. Lateral boarder of scapula
12. clavicle
13. coracoid process

Question 3

Label the ligaments in the diagram

Answer 3

A (yellow) coracoacromial ligament
B (red) coracohumeral ligemant
C (blue) Glenohumeral ligements
D (white) coracoclavicular (trapezoid +

Question 4

Label the following rotator cuff muscles:
For each include the insertion and function

Answer 4

Green: subscapularis
Insertion: lesser tuberosity
Function: internal rotation

Red: supraspinatous
Insertion: greater tuberosity
Function: shoulder abduction

Blue: infraspinatous
Insertion: greater tuberosity
Function: external rotation

Yellow Teres Minor
Insertion: greater tuberosity
Function: external rotation

Question 5

List 8 ddx for extrinsic shoulder pain

Answer 5

• Disorders of the c-spine
• Thoracic outlet
• ACS
• Subdiaphragmatic abscess
• Pneumonia
• Pancoast tumour
• Diaphragmatic irritation
  ○ Ruptured ectopic
  ○ Cholecystitis
  ○ Pancreatitis
  ○ Gastritis
  ○ Splenic rupture

Question 6

List 4 special tests for rotator cuff pathology. For each test, list the muscle it is testing

Answer 6

Question 7

List 3 XR views of shoulder

Answer 7

1. AP
2. Posterior trans-scapular lateral or ‘Y-view’
3. Axillary view

Question 8

List 6 indications for orthopedic consultation for clavicle fractures

Answer 8

1. Open fractures
2. Associated neurovascular injuries
3. Type II lateral fracture - 30% non union
4. Severely comminuted
5. Displaced fractures of the middle third
6. Type III

Question 9

Describe the allman and neer classification for clavicle fractures

Answer 9

Allman Classification:
Group I: Fractures of the middle third (midshaft).

Group II: Fractures of the lateral (distal) third.

Group III: Fractures of the medial (proximal) third.

Question 10

Describe the Neer classification of distal (lateral) clavicle fractures

Answer 10

Type 1 - stable and minimally displaced (coracoclavicular ligament remains intact)
Non-operative

Type 2 -Significant medial displacment
IIA- intact Conoid and trapezoid ligament
IIB -torn Conoid and/or trapezoid ligament
**both require surgical fixation

Type 3 -intra-articular fracture, minimal displacement
-non operative

Type 4: Physeal fracture that occurs in pediatric patient. intact Conoid and trapezoid ligament
-non-operative

Type 5: Comminuted fracture pattern
Conoid and trapezoid ligaments remain intact
***Unstable, require surgical repair

Question 11

25 F with blunt trauma from MVC. Step off deformity with skin tenting over L clavicle

Physical exam: weakness of external rotation with the arm in adduction

Diagnosis?
What is the significance of the physical exam finding?
Management?

Answer 11

a. Type 2B clavicle fracture
Unstable

b. suprascapular nerve injury most common

Ortho consult in ED
ORIF <72hr

Question 12

10 yo M with blunt force trauma to L shoulder. Obvious clavicular deformity

Diagnosis?
Mangement?

Answer 12

Type 4 lateral clavicular fracture

(Physeal fracture that occurs in the skeletally immature
Conoid and trapezoid ligaments remain intact)

Stable-non operative
sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks

Question 13

Outline the management for stable clavicle fractures

List clavicle fractures can be treated non-operatively

Answer 13

sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 weeks

stable fractures
- Neer Type I, III, IV
- pediatric distal clavicle fractures
- non displaced middle third
- non-displaced medial third

Question 14

List 4 absolute and 4 relative indications for operative repair (ORIF) of clavicle #s

Answer 14

absolute
1. open or impending open fractures
2. subclavian artery or vein injury
3. floating shoulder (distal clavicle and scapula neck fractures with > 10mm of displacement)
4. symptomatic nonunion

Relative
1. unstable fracture patterns (Neer Type IIA, IIB, V)
2. brachial plexus injury (questionable because 66% have spontaneous return)
3. closed head injury
4. Seizure disorder
5. polytrauma patient

Question 15

Describe the AARD syndrome with clavicle fracture

Answer 15

AARD - atlantoaxial rotary displacements. The pathophysiology of AARD is not well
understood but it is suspected that the clavicle fracture and AARD occur sequentially and
may be associated with a lax or disrupted alar ligament. Sternocleidomastoid muscle spasm may also be a contributing factor. Give-away is the ‘cocked-robin’ position with patient, often
pediatric female, head bent towards fracture side but rotated away. You see an injured robin
in your ED, CT it!

Question 16

List 4 complications associated with clavicle fractures that are treated non-operatively

Answer 16

○ Delayed union
○ Non-union
○ Symptomatic malunion
○ Type III - AC joint osteoarthritis

Question 17

Describe the classification of scapular fractures (4)

Which is most common?

Answer 17

Type I-
- acromion process
-scapular spine
-coracoid process

Type II
scapular neck

Type III
intra-articular # of glenoid fossa

Type IV
scapular body
***most common

Question 18

25 M with blunt force trauma from fall (3ft off a ladder onto his R shoulder)

Diagnosis?
Management?

Answer 18

Scapula fracture
Displaced fracture of the scapula lateral border
Fracture line passing through the scapula body

• Analgesia
• Immobilization in a sling for comfort and passive ROM exercises
• Pendulum sling usually 2-4 weeks
• Physical therapy
• F/U assessment if displacement

**Nondisplaced fractures of body, spine, acromion process do not require further therapy

Question 19

List 6 indications for surgical repair of a scapula fracture

Answer 19

1. Open fracture
2. Intra-articular fracture
3. Complete loss of rotator cuff function
4. Severe displaced/angulated neck/body/spine
5. Acromion:
   □ Displaced impinging on GH joint
   □ Superior dislocation of humerus causing acromial #
6. Coracoid if severely displaced > 1cm (ruptured CC ligaments)

Question 20

List 3 acute and 3 delayed complications associated with scapula fractures

Answer 20

Delayed
■ Pneumothorax
■ Hemothorax
■ Pulmonary contusion

Acute
■ Rib fracture
■ Humerus fracture
■ Clavicle fracture

Question 21

Describe the Neer’s classification of Proximal Humerus fractures

Answer 21

Neer system divides the proximal humerus into four parts and considers displacement as being significant in terms of classification.

1 - Anatomic neck
2- Surgical neck
3 - Greater tuberosity
4 - Lesser tuberosity

Considered displaced if:
1. Angled > 45 degrees
OR
2. Separated > 1cm from neighbouring segment

Categorize based on number of parts that meet the displacement criteria as above

1 –> 1 part (no fragments meet criteria for displacement
2 –> 2 part displacement (one segment is displaced)
3 –> 3 part displacement (two parts are displaced)
4 –> 4 part displacement (three parts are displaced)

Question 22

60F with shoulder trauma~fell from standing with impact to R shoulder

Answer 22

Transverse fractures of the surgical neck (red line)
Fracture line (yellow) causing separation of the greater tubercle

there is only minor displacement with moderate impaction and angulation (~30 degrees), with the glenohumeral joint remaining enlocated.

This would be considered a one-part fracture, as although both a greater tuberosity and surgical neck of humerus fracture are present neither are significantly displaced (<1cm) nor are they significantly angulated (<45 degrees).

Question 23

What is the most common associated nerve injury with proximal humerus injuries

Answer 23

axillary nerve

Question 24

Outline the management for proximal humerus fractures

Answer 24

sling immobilization followed by progressive rehabilitation
**immediate physical therapy results in faster recover

most proximal humerus fractures can be treated nonoperatively including
minimally displaced surgical and anatomic neck fractures

ORIF indications:
1. greater tuberosity displaced > 5mm

2. displaced 2-part fractures
   3-, and 4-part fractures in younger patients
3. head-splitting fractures in younger patients

Urgent ortho consult for all pediatric proximal humeral epiphysis #s

Question 25

List 5 complications associated with proximal humerus fractures

Answer 25

1. Adhesive capsulitis 2. OA 3. AVN 4. NV injury - axillary nerve -axillary artery -anterior/posterior humeral circumflex artery - brachial plexus 5. Myositis ossification

Question 26

Describe the clinical presentation for anterior vs posterior sternoclavicular joint dislocation.

Answer 26

anterior dislocation - deformity with palpable bump posterior dislocation: dyspnea or dysphagia tachypnea and stridor worse when supine

Question 27

Describe the classification for grading sternoclavicular dislocation and outline the management for each

Answer 27

Grade 1= mild sprain of sternoclavicular and costoclavicular ligaments Tx: Sling immobilization, primary care follow up Grade 2 = subluxation of the joint (ant/post) 2/2 disruption of sternoclavicular ligament and capsule Tx: Sling immobilization and patient referred for orthopedic follow up care, 4-6 weeks Grade 3 = complete rupture of sternoclavicular and costoclavicular ligaments a. Anterior --> reduced in ED b. Posterior --> true ortho emergencies, may need to be reduced in ED if airway obstruction or vascular compromise

Question 28

List 5 complications associated with traumatic posterior sternoclavicular joint dislocation

Answer 28

Complications: 1. Subclavian compression and laceration 2. Brachial plexopathy 3. Pneumothorax 4. Esophageal rupture 5. Tracheal compression 6. Trachea-esophageal fistula 7. Thoracic outlet syndrome

Question 29

What is normal AC joint and CC joint distance on XR?

Answer 29

Normal AC joint 5-8mm normal CC distance 10-13mm

Question 30

Describe the AC joint injury classification (Rockwood) and subsequent management

Answer 30

Type I sprains of AC with no separation of acromion and clavicle. Mild swelling and tenderness. Full ROM ● Sling immobilization, follow up PCP, ROM and strength exercises when pain subsides (1-3w) Type II -AC (>7mm) with <25% clavicular elevation. Mild swelling and tenderness. Full ROM ● Sling immobilization, follow up PCP, ROM and strength exercises when pain subsides (1-3w) Type III - completed disruption of AC ligaments, CC ligament and muscle attachment. Coracoclavicular distance increased by 25-100%. Arm abducted ++ pain ● Sling immobilize and early ortho follow-up Type IV - type III + clavicle displaced posteriorly into trapezius. Arm abducted ++ pain ● Call ortho - early surgical treatment Type V type III + clavicle displaced superiorly > 100% ● Call ortho - early surgical treatment Type VI - rare inferior displacement ● Call ortho - early surgical treatment

Question 31

List 4 types of anterior shoulder dislocations

Answer 31

1. Subcoracoid (common) 2. Subglenoid (common) 3. Subclavicular 4. Intrathoracic

Question 32

Outline the classification of anterior shoulder dislocations

Answer 32

1. traumatic vs atraumatic 2. primary vs recurrent 3. anatomic position a. Subcoracoid (common) b. Subglenoid (common) c. Subclavicular d. Intrathoracic

Question 33

25 M W L shoulder injury during contact sport. Dx? Management?

Answer 33

Anterior shoulder dislocation with likely hill sachs deformity humeral head is dislocated anteriorly and inferiorly with some flattening of the corresponding part of the humerus. Tx: Reduce + immobilize with sling x3 withs with early ROM and outpatient ortho follow up

Question 34

60 F presents with severe right shoulder pain and immobility. She fell down the steps outside her house and landed on her right side two hours prior to presentation. On exam, her right arm is abducted and externally rotated. She has decreased sensation to touch over the lateral aspect of her right shoulder Dx?

Answer 34

anterior shoulder dislocation with bankhart lesion with axillary nerve injury Bony Bankart - avulsion of the anteroinferior glenohumeral ligament with capsulolabral detachment

Question 35

List 4 complications associated with anterior shoulder dislocation

Answer 35

1. Brachial plexus injury 2. Axillary nerve injury 3. Axillary artery injury 4. Rotator cuff tear or sprain 5. Shoulder instability 6. Recurrent dislocations -High risk if Bankhart's lesion, Hill-Sachs deformity, Glenoid rim fracture

Question 36

List 6 techniques for reduction of anterior shoulder dislocation

Answer 36

a. Stimson / hanging weight ■ Prone with 10-15l;bs on forearmover 20-30 min b. Traction-counter traction ■ Folded sheet in axilla providing counter traction c. Cunningham ■ Seated/ upright, adduct affected arm with elbow flexed at 90. with pts hand resting on operators shoulder. operator applies downward traction while pts shrugs shoulders/ rotates superior and posterior. 2nd operator can be useful to massage surrounding muscles and assist with shoulder rotation d. External rotation method ■ Supine, elbow at 90, slow gentle external rotation e. Milch ■ Supine, HOB 20-30, slow abduction with ext. rotation. If 90 abduct and 90 ext. rotation, then gentle traction f. Scapular manipulation ■ Repositioning of glenoid fossa. First obtain traction then rotate scapula clockwise from inferior tip, while stabilizing superior tip g. Fares Patient lies supine or prone, grasp affected arm’s wrist, gently oscillate arm up and down, apply gentle traction to arm and slowly abduct, once abducted to 90 degrees then externally rotate, continue with oscillation and traction until reduced

Question 38

Describe the stimson technique for CMR of ant. shoulder dislocation.

Answer 38

Patient is prone with affected limb hanging over the edge the exam table. a 10-15 lb wht is attached to wrist (provides traction in forward flexion) Traction overcomes the spasm and can often result in reduction within 20 minutes.

Question 39

Describe the cunningham technique for CMR of anterior shoulder dislocation.

Answer 39

Cunningham: Sit facing the patient, patient moves shoulders up and back (shrug), massage patient biceps as the patient holds arm adducted and elbow flexed.

Question 40

Describe the Fares technique for CMR of anterior shoulder dislocations

Answer 40

- Patient lies supine - Operator oscillates arm up and down, apply gentle traction to arm and slowly abduct, once abducted to 90 degrees then externally rotate, continue with oscillation and traction until reduced

Question 41

Describe the scapular technique for CMR of anterior shoulder dislocations

Answer 41

often used in combination with Stimson technique; provider is behind patient with the superior aspect of the shoulders stabilized; the scapula is manipulated in a counterclockwise motion with superior stabilization and a medial force applied to the inferior angle.

Question 42

Describe the milch technique for CMR of anterior shoulder dislocations

Answer 42

Patient supine steady downward traction is applied at the elbow combined with slow external rotation and abduction of the limb. Can use free hand to manipulate humeral head laterally and superiorly.

Question 43

Describe the traction-counter traction technique for CMR of anterior shoulder dislocations

Answer 43

gradual traction applied to the affected arm while an assistant uses counter traction.

Question 44

List 2 absolute contraindications for closed manual reductions of anterior shoulder dislocation in the ED.

Answer 44

1. Delayed presentation in the elderly 2. Dislocation + humeral neck fracture (causes AVN of humeral head)

Question 45

outline post reduction care for anterior shoulder dislocation

Answer 45

1. Immobilize in internal rotation - 3 weeks in younger - 1 week in the elderly (higher risk of adhesive capsulitis) 2. Activity: - no overhead lifting - early ROM with gentle shoulder pendulum exercises daily, as well as elbow ROM exercises 3. Outpatient follow up with ortho or sport med

Question 46

Describe sensory testing for anterior shoulder dislocation

Answer 46

Ulnar= lateral aspect of tip of pinky median= Radial aspect of tip of index radial= 1st web space Axillary= military patch of deltoid

Question 47

List 3 fractures to look for in a post-reduction x-ray of a patient with an anterior glenohumeral shoulder dislocation

Answer 47

1. Avulsion of greater tuberosity 2. Hill sachs lesion 3. Bony bankhart

Question 48

28 M presents to ED after a fall while riding his mountain bike. The patient states he went off a six-foot ramp and landed on his right shoulder. On exam: he is unable to move his right shoulder and is holding his R arm in internal rotation. X-ray of the right shoulder is obtained, as seen above. Which of the following is the most likely diagnosis?

Answer 48

Posterior shoulder dislocation MOI: caused by an axial force applied while the shoulder is internally rotated and abducted or by a direct blow to the anterior shoulder. Clinical presentation: arm will be held in adduction and internal rotation, and there is mechanical obstruction with active external rotation of the extremity.

Question 49

List 4 XR findings in posterior shoulder dislocation

Answer 49

1. Loss of half moon elliptical overlap of humeral head and glenoid 2. Rim sign b/w glenoid and articular surface of humerus 3. Light bulb or drumstick appearance 4. Trough Sign --> reverse Hill-Sachs

Question 50

List 3 types of posterior shoulder dislocation

Answer 50

- Subacromial (most common) - Subglenoid - Subspinous

Question 51

List 3 injuries associated with with posterior shoulder dislocation

Answer 51

1. humerus surgical neck # 2. Reverse hill sachs injury (usually requires usrgery) 3. Rotator cuff injuries

Question 52

List 4 common causes of posterior shoulder dislocation

Answer 52

1. Seizures/ epilepsy 2. electrocution 3. falls with axial force in internal rotation + adduction 4. Trauma

Question 53

What is the best XR view for diagnosing posterior shoulder dislocation?

Answer 53

Posterior shoulder dislocations are commonly missed. Common x-ray findings are insensitive for the diagnosis. The axillary view is best for diagnosis

Question 54

Outline the management for posterior shoulder dislocation

Answer 54

Reduction (CMR): □ Internal rotation + lateral traction □ Stimson technique can be used (f no engaged Hill-Sachs and no humeral neck fracture) - Immobilize with simple sling / external rotation sling - Ortho follow up in 1-2 weeks

Question 55

35M with fall from a ladder and tried to catch himself with his right arm Patient was unable to put his arm down on exam On exam: Arm locked overhead in 110-160 degrees of abduction What is the most likely diagnosis?

Answer 55

Luxatio erecta uncommon shoulder dislocation ~ inferior displacement of the humeral head with loss of articulation with the glenoid fossa caused by severe arm hyperabduction **high rate of axillary nerve neuropraxia and branchial plexopathy

Question 56

Out ine the management for Luxatio erecta

Answer 56

CMR + immobilization with sling (same as anterior ) Traction/countertraction maneuvers Surgery for young healthy active

Question 57

Describe 4 special tests for Impingement syndrome

Answer 57

1. Painful arc - pain with active ROM 60-90 degrees (subacromial) or 120-180 degrees (acromioclavicular) 2. Neer impingement sign - pain with forced forward elevation while examiner locks the scapula in place. This is resolved by injection of 10cc beneath ant. Acromion 3. Hawkins-Kennedy - Arm placed into 90 degrees of flexion followed by internal rotation 4. Infraspinatus muscle test - resistance to external rotation with arm adducted and elbow flexed to 90

Question 58

Describe expected physical exam findings with the following rotator cuff muscle tears: List one special test for each rotator cuff muscle a. Supraspinatous b. Infraspinatous c. Teres minor d. Subscapularis

Answer 58

a. Supraspinatous: Weakness to resisted elevation in Jobe position - Drop arm test - Pain with Jobe test b. Infraspinatous: ER weakness at 0° abduction - ER lag sgn c. Teres minor : ER weakness at 90° abduction and 90° ER - horn blowers sign d. Subscapularis: IR weakness at 0° abduction -Belly Press - Lift off

Question 59

Outline the management for rotator cuff tears

Answer 59

MRI gold standard for diagnosis. Clinical dx in ED > out patient MRI analgesia immobilize in sling for comfort Physiotherapy ortho follow up 1-2 weeks Early surgical repair (< 4 months) is preferred in young or active individuals

Question 60

Describe 2 special tests for biceps tendonitis

Answer 60

1. Yergason Test: - arm adducted and elbow flexed to 90 --> supinate against resistance and see if there is anterior shoulder pain (50% of cases) 2. Speed's Test: - forward flexion of the shoulder (elbow extended and forearm supinated) carried out against resistance and produces pain in the bicipital groove

Question 61

What is the most common site for calcific tendonitis? How is it diagnosed? Outline the management?

Answer 61

a. supraspinatus tendon near its attachment to great tuberosity b. Diagnosis XR > calcific deposits in the involved tendon POCUS can identify and effectively localize calcific deposits c. Management: - Sling for comfort - NSAIDs - avoid offending activities - Refer to PCP / sports med in 1-2 weeks (may benefit from steroid injections or needle lavage procedures)

Question 62

List 4 risk factors for adhesive capsulitis

Answer 62

1. Female 2. Age 40-60 3. Thyroid disease 4. DM

Question 63

Define adhesive capsulitis

Answer 63

- Idiopathic inflammatory reaction within the capsule and leads to restricted active and passive ROM