Shoulder 1 Flashcards by Nayla Mansoor

What is the musculature of the shoulder

Rotator cuff (Supraspinatus, Infraspinatus, Teres minor, Subscapularis)
Deltoid
Stabilizers: Trapezius, levator scapulae, rhom major/minor, pec minor, serratus anterior

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What do the muscle of the rotator cuff do

Supraspinatus: Abduction
Infraspinatus: External rotation
Teres minor: External rotation
Subscapularis: Internal rotation

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What are the bursas of the shoulder

Subacromial bursa

Subdeltoid bursa

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What specific MSK questions are important to ask when evaluating shoulder pain

Sensation of instability 
weakness
popping, crepitus
stiffness
numbness/tingling

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What specific MOI indicate specific injured structures

Fall directly onto anterior/superior shoulder= AC joint injury (shoulder separation)
Arm forcefully abducted and ext. rotated= Sublux/anterior dislocation

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MOI can help you

determine radiologic needs

Age helps differentiate likely injury (complete rotator cuff tear more likely if >45 y/o)

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What does this clinical scenario sound like
56 y/o male presents of R shoulder pain since yesterday when he was playing football. He jumped for a ball when someone tackled his legs and he landed on his shoulder. Pain when he lifts his arm overhead. No radiating pain, numbness, or weakness. No prior injuries

AC joint tear AKA shoulder separation
Presents with focal ttp at AC joint and superior coracoid
Pain limits abduction and forward flexion past 90 deg.
Pain reproduced with passive flexion and horizontal adduction
Increased deformity if you pull down on arm
Neurovascular intact!

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What are the aspects of the AC joint

AC joint ligament
Coracoclavicular ligament complex
Delto-trapezial complex

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AC joint injuries are MC in

Men

44% in 20 y/o patients

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Common AC joint injuries include

*Direct force: falls on AC joint w/ arm at side
Force applied to superior acromion forcing acromion inferior and medial
-rarely can be 2/2 indirect force, like FOOSH, in which force may send humeral head superior into acromion and cause a tear

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How do you classify AC joint tears

I: AC ligament sprain, but AC and CC joint intact
II: AC ligament ruptured, CC joint intact but sprained
III: AC and CC ligaments ruptured
IV-VI are less common and involve clavicle

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What PE is associated with different grade AC joint injuries

I: Pain w/o deformity
II: Pain and deformity. <50% vertical displacement (downward?)
III: AC joint dislocation, shoulder displaced inferiorly. CC space >uninvolved shoulder. Pain and deformity

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Inspection of an AC joint separation shows

Elevated distal clavicle (no ligaments hold it down)
Step deformity (grade I-III) 
Other deformities (grade IV-VI) 
Swelling

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Palpation of an AC joint separation reveals

Local pain and swelling
Step deformity (I-III)
Trapezius muscle spasm

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What functional tests can you use to assess AC joint separation

Cross-arm adduction (will have pain with passive horizontal adduction)
Traction test

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How do you perform a traction test

Basically you put your hand on top of shoulder to stabilize scapula and clavicle
Apply downward force to humerus to see if you can separate it from scapula and clavicle

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What tests can be used to assess impingement

Neers: put one hand over posterior shoulder and scapula. Passively forward flex the shoulder. + is pain in anterolateral shoulder
Modifies Hawkins-Kennedy: Flex shoulder 90, and elbow 90. Stabilize elbow and internally rotate arm. + is pain in anterolateral

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What type of XR should you get for suspected AC joint sprain

Bilateral AC series w/ 10 degree cephalic tilt

Some clinicians like it w/ and w/o weights

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How do you treat AC joint type I-II

Non-operative
Ice and protection until pain subsides (7-10 days)
Return to sports/ADL in 1-3 weeks (when no more pain)
Braces are not proven to help

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How do you treat grade III AC joint sprain

Depends!
Non-op: Sling and harness 10-14 days. Return to sports in 3-4 weeks
Conservative Tx except in a throwing athlete or overhead worker.
Repair is avoided in contact sports 2/2 high re-injury
Operation is basically a little clip inserted that sits over superior clavicle and inferior coracoid

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Complications of AC joint injuries are

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OA of AC joint
Osteolysis of distal clavicle (loses blood supply)- fix w/ distal clavicle resection
Inability to return to optimal functioning

Where is it most common to fracture the clavicle

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MC: Midshaft
Then lateral
LC: medial (closest to sternum)

Who is at risk for a clavicle fracture

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Contact sports
M <25/40 or >55
Women >75

What is Allman classification

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Basically just classifies where you can fracture a clavicle
Grade I: midline (MC)
Grade II: distal (or lateral)
Grade III: medial

What MOI can lead to clavicle fracture

Direct fall on shoulder with arm at side Direct blow FOOSH

Inspection of a clavicle Fx shows

Deformity at fracture site (grade with ROM)

Palpation of clavicle fracture shows

Local tenderness, crepitus, +/- can feel defect

What PE exams should you preform if you suspect clavicle fracture

Neuro and Lung auscultation! | Subclavian vessels and brachial plexus

What radiographs are necessary for clavicle Fx

AP clavicle Cephalic tilt view (is either one pref?)

Standard of care for clavicle Fx is

Non-operative Tx! | +/- Simple sling or figure 8 brace

What is the difference between simple sling and figure 8 brace

Functional and cosmetic results are the same | Figure 8 is a little more uncomfortable

What situations would require surgical Tx of clavicle

Open Fx Associated neurovascular injury Skin tenting (clavicle sits so high up it looks like a tent)

Relative indications for surgical Tx of a clavicle Fx are

``` Widely displaced Fx Multiple fracture segments Displaced lateral 1/3 Dominant extremity in overhead athlete Cosmetic concerns ```

Relative indications for surgical Tx of a clavicle Fx are

``` Widely displaced Fx Multiple fracture segments Displaced lateral 1/3 Dominant extremity in overhead athlete Cosmetic concerns ```

What injury does this clinical scenario indicate: 26 y/o MMA fighter w/ R shoulder pain and loss of function. Injured 6 hrs ago when his arm was forced overhead while grappling and he felt a shift in his shoulder. No numbness, tingling, or radiation. Dominant RUE

Shoulder dislocation! | Can be caused by traumatic or non-traumatic (Grand-Mal seizure)

What directions can a shoulder dislocate

Anterior (subcoracoid)** Mc Posterior Inferior (subglenoid)

Posterior shoulder dislocations are associated with

Seizure or electrical shock- Most have associated Fx of lesser tuberosity they are commonly missed on XR

With anterior dislocations, we are worried about this associated injury

Neuro injury! 20-40% Radial, Medial, and Axillary injury (axillary and brachial plexus basically)

Anterior shoulder dislocations are associated with

Abduction and external rotation injuries

Anterior dislocation complications are

Nerve injury Hills sachs lesion (impression Fx to posterolateral humeral head from anterior rim of glenoid hitting it while injured) Bankart tear (Ant/Inferior Glenoid labrum avulsion/detachment)

Inspection of a shoulder dislocation shows

``` Flattened deltoid Full anterior chest Prominence of acromion guarding Capsular laxity ```

What imaging should you get for shoulder dislocation

``` AP view Axillary view Y view (almost like a side view) Articular Fx concern: CT scan Soft tissue patho: MRI arthrogram ```

What provocative tests help assess shoulder dislocations

Apprehension Jobe relocation (differentiate pain v instability) Release (surprise test) Sulcus sign (hold distal to elbow and pull down to see if you get a sulcus under acromion)

What is the MCC of recurrent instability after a shoulder dislocation

Bankart tear! B/c of the torn capsule, the shoulder will always slip in and out more easily You can do a Bankart repair in which you drill holes and anchor sutures to labrum and glenoid ligament

Hill-Sachs lesion can cause

destabilized GH joint and predisposition to further dislocation

What must you do prior to reducing a dislocated shoulder

Neuro testing! and document everything | AP and axillary radiographs to document dislocation and r/o fractures

How do you reduce a shoulder

Apply O2 mask/nasal cannula | Fentanyl 100mcg IV over 1 minute, repeat q3-5 min until sedated

Techniques for shoulder reduction are

Hippocratic: old foot in the shoulder, now you put a towel under arm pit and have someone pull oppo as you pull the arm Stimson: Pt lies prone, you put a weight on their wrist (but takes a long time) Hennipen: Pt is supine, elbow flexion 90. Adduct arm and flex shoulder 20. Externally rotate arm, then internally rotate

After shoulder reduction

Confirm with radiograph Immobilize arm in sling (but tell pt to remove sling and extend elbow a few times a day to prevent elbow stiffness) Begin isometric exercises for rotator cuff Consult ortho

What are outcomes of a shoulder dislocation

<30: High recurrence if traumatic anterior 2/2 Bankart lesion >45: Recurrence less common First time dislocation in pt older than 40 likely w/ rotator cuff tear

Compliactions of shoulder dislocations are

``` Brachial plexus injury Recurrent dislocation (common if more active)- Tx w/ anterior shoulder reconstruction and bankart repair ```

Shoulder 1 Flashcards

(51 cards)