Musculoskeletal System > Shoulder > Flashcards

Shoulder Flashcards

Present a review of orthopedic problems in the shoulder and their tx. Etiology, signs, Sx, and management (143 cards)

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1
Q

What is the common symptom orthopedic problems?

A

Pain

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2
Q

What are associated orthopedic problems?

A 
numbness- swelling can be associated
deformity 
loss of function 
lacerations 
psychological problems - whether or not they have pain is difficult to tell
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3
Q

Pathways of clinical discussion

A 
CC- why are they here 
Hx of CC
physical findings 
suspected differentiated diagnosis 
objective testing 
specific diagnosis 
tx
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4
Q

severity of pain

A 
burn?
aching pain?
numbness?
swelling ?
redness?
what makes it better or worse?
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5
Q

Hx of CC

A 
initiating circumstances 
time factors 
past hx of similar conditions
past hx of tx
previous illness that may be related
family hx of similar problem
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6
Q

Notes of Hx of CC

A 
How was it treated before? Aspirin
Any recent injuries?
Family history with similar condition or pain?
How did it start ? 
Is it short term or long term ? 
Has it hurt like this before ?
Numbness before?
Tx in the past ? 
Any illnesses? 
Cough or cold urinary problems 
Arthritis or gout in the family?
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7
Q

which joint usually sublux (dislocate) anteriorly?

A

glenohumeral joint

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8
Q

Apprehension test

A

subluxation upon test show shoulder instability (COMMON)
90 degrees abduction to see it if sub luxes
Subluxation of a joint means a condition where a joint is dislocated

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9
Q

What is a normal degree of full abduction

A

180

look for loss of abduction

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10
Q

Physical findings of shoulder

A

inspection (general appearance, symmetry, atrophy, color)
Symmetry between mirrored anatomical structure make for a direct non pathological comparison

Anatomical ROM needs to be known
Palpation
stability
neurovascualar status

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11
Q

Degrees of shoulder ROM

A 
Flexion - 160
Extension - 45 
abduction - 180
adduction - 45
internal rotation - 90
external rotation - 100
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12
Q

Objective testing

A

Radiograph -
Electrodiagnostic
Vascular
Provocative

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13
Q

CAT Scan

A

bony details - fx of intraarticular

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14
Q

MRI

A

if you don’t know if it is a fx or not and there may be infection

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15
Q

Arthrograms

A

if you can’t do an MRI (patient has pacemaker) - inject to see soft tissue (CONTRAST)

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16
Q

ultrasound

A

rotator cuff tears

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17
Q

Pain in shoulder - nerve

A

can be radicular pain (nerve root)

or may be coming from the neck

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18
Q

EMG

A

see how the nerve functions by EMG
whether or not nerve is functioning or is irritated
DO IT for Axillary n.

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19
Q

Nerve conduction velocities

A

speed of the nerve signal

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20
Q

What kind of electrodiagnostic testing is used for carpal tunnel syndrome?

A

EMG/NVC

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21
Q

What is the non-invasive vascular testing?

A

sonogram

=sound

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22
Q

When do you do an objective PROVACATIVE testing?

A

Not sure what is wrong e.g. rotator cuff tear vs neck problem
inject needle under SUBACROMIAL AREA = if pain relieved from site anesthesia, then rule out origin of pain from the neck because it is localized and directly from the shoulder

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23
Q

Can nerve root and localized nerve functioning both contribute to pain?

A

Yes

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24
Q

AC joint

A

acromion process and clavicle

Acromioclavicular joint/ superior acromioclavicular ligament

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25
SC joint
Sternoclavicular joint / / anterior sternoclavicular ligament clavicle and manubrium (not sternum)
26
Glenohumeral joint
glenoid cavity and head of the humerus
27
Scapulothoracic joint
suscapular fossa and medial border of the scapula to the thorax (ribs)
28
Coracovicular joint
corocoid process of the scapular to the clavicle | oracoclavicular ligaments – trapazoid and coracoid ligaments
29
G-H joint problems
``` Instability Impingement rotator cuff bicipital tendon degenerative joint disease adhesive capsulitis (arthritis) ```
30
Diagnosis of G-H instability
subluxation - usually anteriorly head of the humerus can move from the glenoid fossa hyaline cartilage not seen in the joint space when collapsed
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G-H joint subluxation
superiorly | inferiorly (acute dislocation)
32
How to view inferior G-H joint subluxation
lateral and Y view x-ray | not just AP
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CC of G-H instability
``` Pain Painful ROM Weakness in abduction apprehension of instability guarding spontaneous dislocation ```
34
Pain ROM in G-H instability
deformity
35
Weakness of abduction in G-H instability
won't be able to move the arm if complete dislocation can indicate nerve injury to the axillary n. which supplied the deltoid (abduction function) = decreased abduction of the arm if ax. n. traumatized
36
apprehension of instability (apprehension test)
stress test to stretch the joint and they will feel pain and think the shoulder will dislocate
37
Guarding
CLINICAL SIGN OF G-H INSTABILITY -Patient won't abduct think they will dislocate the arm
38
Spontaneous dislocation
Instability of the joint will cause spontaneous dislocations shoulder will pop out of the place ; pt has to be sedated to have it put back into place FOOSH injury
39
Hx or cause of G-H instability
TRAUMA CONGENITAL INFECTION
40
Trauma
acute - fall on arm; FOOSH | chronic overuse - that wears out the supporting structure of the shoulder (shoulder tend to sublux)
41
Congenital (born with it)
Chronic laxity - lax shoulder | deformity of joint
42
Congenital deformities of the G-H joint
Ehler’s Danlos syndrome – how the collagen fibers are laid down in the capsular structures -weakened capsular structures -lax everything: elbow hyperextended, thumb hyperextended, and knee caps dislocated glenoid may be shallow
43
Infection
destroy articular spaces and destroy joint better tx infections quickly eliminate the possibility of this joint becoming post-infection
44
Physical findings of G-H instability
``` asymmetry weakness decreased functional ROM palpatory hypermobility TESTS!!!!!! ```
45
What are tests for G-H instability
APPREHENSION TEST RELOCATION TEST- pop it back in ANTERIOR DRAW TEST
46
Weakness of G-H joint
cause instability joint sublux where the head of the humerus used to be SULCUS SIGN - DEPRESSION AT AREA where humeral joint would normally be -weakness particularly if shoulder is CHRONICALLY INSTABLE
47
Decreased functional ROM at G-H joint
won't have the ability to move the arm - feels like you would dislocate that arm
48
Objective testing for G-H instability
1. X-rays - AP, exillary Y -view r lateral view) orthogonal XR should be initial objective testing 2. CT scan - Hill Sachs lesions 3. MRI - labral tear, bankart lesion 4. Arthrogram - when you can't do a MRI
49
Hill Sachs lesions
seen in CT occur @ G-H joint head of the humerus gets pushed on and dislocates by the head of the glenoid rim creates a defect in the head where the head is being pushed
50
How do you see a Hill Sachs lesion?
CT
51
How do you see a bankart lesion?
MRI or arthrogram if can't do MRI on a patient with pacemaker or other devices
52
Bankart lesion
``` torn labrum which is cartilaginous it creates a lesion labrum is torn off usually can do it with MRI located in the BACK of the joint ```
53
How to Tx G-H instability?
Dont do SURGERY if Ehler's Danlos (upper brachial plexus injury) or collagen type II defect
54
Tx acute G-H dislocations
Need to be put back in place !!!! | use safe technique - stimson's technique
55
Surgery for G-H instability
Trauma - ACUTE bankart lesion (fix the labrum) CHRONIC RECURRENT DISLOCATIONS instable shoulder (subluxed) - not yet dislocated ; tighten up the capsule and repair the glens
56
What are chronic recurrent dislocations of G-H?
patient will continue to dislocate unless something is done surgically CHRONIC DISLOCATIONS DO REQUIRE SURGERY
57
What is the safest way to put G-H joint back in place?
Stimson's technique | joint dislocation
58
Stimson's technique
weight on the arm the muscles will relax and the weight will put the bone and put into the place give med for the pain FIRST LINE TX
59
What is the tract-countertraction method for putting back G-H joint back into place?
pull it back into place sheet through the axillary complex place heat PROBLEM CAN OCCUR : AXILLARY N CAN BE DMAGED IN THE PROCESS OF PULLING the method may not be effective in putting it back into place - usually doesn't go bakcin to place
60
What is an acceptable method of putting back G-H joint ?
series of movements: externally rotate and internally rotate to pop it back into place RELOCATE THE JOINT
61
WHEN TO NOT PERFORM KOCHER'S METHOD?
an elderly woman who is osteoporotic because you can fx the humerus
62
What to do after you relocate the G-H back into place?
immobilize the joint | if first time dislocation, there is a 100% chance that redislocation is common
63
Redislocation of G-H joint
Older you are age 40 and up the more common it is Young people who has anterior dislocation frequently - redislocation can occur again = requires a swathe (sling) to further immobilize the joint
64
Why use sling and swathe for G-H joint?
prevent redislocation immobilize the joint after putting it back into place strap keeps the patient from EXTERNALLY rotate the arm if it is a rotator cuff injury, USE ABDUCTION PILLOW !!!!!!!!!!
65
What is an associated pathology of the G-H joint instability?
traumatic anteroinferior glenohumeral dislocation most commonly injures the anterioinferior labrum and anteriorinferior glenohumeral ligament TORN LABRUM BANKART LESION
66
what is the redislocation rate for anterior dislocation?
100 % in adolescents with open growth plate | 55-95% in 18-30 in air force academy study
67
Adolescents
redislocate after an anterior dislocation 100% of the time
68
Tendon tear
surgery is required | labrum is anchored by a screw
69
Complications of G-H dislocations!!!!
Redislocation Torn glenoid labrum Hill sachs lesion anxillary n damage
70
How to surgically tx hills sachs lesion?
UNIQUE cover the lesion wi with tissue metal screws will be placed in the lesion occur at the articular surface of the humerus
71
Which muscle is usually injured with shoulder dislocation?
Deltoid m.
72
Subacromial impingement (G-H)
impinge rotator cuff tendons between undersurface of acromion and greater tuberosity of the humerus = INFLAMMATION of the bursa and the tendons MORE COMON THAN DISLOCATED SHOULDER
73
common CC impingement
Painful lifting or working overhead
74
Other complaints due to impingement
1. painful abduction of the shoulder - raying arm up 2. difficulty throwing 3. crepitance or catching
75
What is crepitance?
means grinding e.g. patient who ACHONDROMALACIA will show crepitance on rotator cuff
76
A patient who is a car mechanic or an electrician are likely to have painful abduction because of this...
impingement
77
What is a physical finding for impingement?
palpating the edge of the rotator cuff and resting ROM = pain !
78
Why are swimmer unique when they present with impingement?
they don't have bone impingement They have a hypertrophy of the subscapularis m. They will come in with pain in the muscle They have impingement in the BURSAL contents
79
What is the abnormal contact between acromion and greater tuberosity in mid-abduction?
1. bursa can hyperthrophy 2. Trauma of AC joint can create bone spurs compromises the subacromial space and movement of the joint Compromises the amount of space the rotator cuff can move through
80
Hx of impingement
``` Over head work Muscle hypertrophy Trama to AC joint Congenital deformity !! Degenerative joint disease !!!! - impingement CAUSE COMPRESSION ```
81
Physical findings of impingement
1. Difficulty lifting arm above head 2. Crepitance with abduction - grinding underneath acromial process 3. impingement sign 3. provacative test- whether or not it's a nerve root injury or from the shoulder itself
82
What is the impingement sign (physical finding)?
Passive forward flexion over 90 degree causes pain (physician flexes arm forward)
83
What is the hawkin's test?
it is used in subacromial impingement | it is when you feel a grinding or crepitance when raising the arm forward
84
Objective testing for impingement
XR Arthrogram MRI
85
What is XR used for in impingement
Degenerative joint disease of the AC joint | Calcifications of tendon of the rotator cuff (WHITE TENDON) = CHRONIC !!!!
86
What is arthrogram used for in impingement?
to see soft tissue | usually normal
87
What does MRI show in impingement?
MUSCLE hypertrophy | congenital downsloping of the acromion
88
What are the congenital acromion downslopping types?
``` BIGLIANA CLASSIFICATION Type I - flat acromion Type II - curved acromion Type III - hooked acromion (pointed down) ****MOST common HOW TO SEE IT? CT ```
89
Tx of impingement
1. Meds 2. Modification of activity - don't raise arm over the head 3. PT 4. Surgery
90
Tx impingement with meds
Oral - ibuprofen injection - cortisone - prevent inflammation inotophoresis
91
What is inotophoresis?
Take cortisone cream and put it on the skin and use electric current through the subcutaneous tissue Get rid of the inflammation
92
Surgery options for impingement
acromioplasty - acromion is removed Mumford - clavicle and acromion process Arthroscopic decompression - take off part of acromion off
93
What is mumford procedure?
Take off a part of the clavical to the coracoclavicular ligament (open up the joint) and acromion process Also take out Subacromial bursa which causes inflammation
94
What is athroscopic decompression?
take part of the acromion process off
95
Dx of Rotator Cuff Tear
Partial thickness tears = incomplete tear = repetitive microtrauma Full thickness tears - tear the tendon = either full on trauma
96
How does rotator cuff tears occur?
SITS = 4 muscles of the rotator cuff impingement it enough that it can tear 1. Can be caused by Wear and tear OR 2. VASCULAR cause weakening and rupture
97
What is the common demographic for rotator cuff tears?
50 years | Usually Occur in the elder man
98
Watershed area of the supraspinatus - vascular injury to ROTCUFF
Undernearth the acromion bursa - has very little blood supply
99
The critical area of rotator cuff injury is?
the tendons that fuse and attach to the greater tuberosity
100
Early vs late complete tears
late tear shows resolved tendons at the ends
101
CC of Rotator cuff tear
``` weakness in abduction painful abduction can't lift arm overhead can't lay on arm can't throw can't work overhead pain at rest ```
102
How to test for rotator cuff tear?
DROP ARM TEST- can't abduct arm (weakness and painful)
103
Hx of rotator cuff injury
microtrauma - over use Chronic impingement -> can cause micro trauma (partial tears) Trauma
104
What are the mechanisms of injury rotator cuff tears?
Microtrauma - overhead work, repeated lifting chronic impingement - acromion downsloping Trauma - fall, pulling and lifting (stretch tendon)
105
2 cause theories for rotator cuff
vascular insufficency in critical zone (supraspinatus) | micro trauma from chronic impingement
106
Physical findings of R-C tear
``` weakened and painful abduction muscle spasms !!!! DROP arm test gerber's lift off empty can ```
107
What is the GERBER'S LIFT OFF?
test R-C tear test subscapularis m. HAND AT OR BELOW THE SCAPULA = ATTEMPT TO LIFT HAND
108
Empty can tests which important m. in R-C injury?
supraspinatus | a common m. injury in R-C tear
109
Objective finding of R-C tear
X-ray MRI Arthrogram
110
XR will show the following in R-C tear
bony spurs (will form from tendon) and DJD narrowing ! resorption will show as a subluxed humerus (superiorly) = no tissue to prevent sublux
111
MRI will show an important R-C finding
``` tears bony spurs DJD narrowing resorption ```
112
Arthrogram - RC tear
contrast that spreads outside the bursa to see area
113
Tx of RC tears
``` Rest Abduction sling physical therapy modification of activity meds surgery ```
114
Tx of Incomplete RC tear
Simple traction
115
In surgery, a massive RC tear will show what
no muscles on top of the head of the humerus
116
Surgery method for RC tear impingment
Arthroscopic method to remove subacromial bursa and also partial acromionectomy - can't also place in screw to put RC tendon back into place on humerus
117
Bracing RC after surgery
Shoulder abduction brace
118
Dx of Biceps tendon
Proximal Distal weakness in SUPINATION
119
CC of BC Tendon Tear
Pain - rubber band Weakness - supination deformity - pop eye = on the anterior forearm, a bulge will be seen
120
Hx of BCT tear
Lifting and supination impingement overuse - microtrauma Iatrogenic- cortisone injection into the tendon (NEVER DO THIS!!!!)
121
How does a doctor cause BCT tear?
from cortisone injection to the biceps tendon | RUPTURE THE TENDON
122
Physical finding of BCT tear
Tenderness over tehe bicipital groove popeye muscle yerguson's test
123
Yerguson's test
Hold patients hand and feel bicipital groove as you supinate the arm
124
Objective finding of BCT Tear
MRI - see the muscle tear | Ultrasound
125
Tx of BCT tear
skillful neglect- will heal but the deformity will remain; leave it alone and monitor it surgery
126
Grades of AC joint separations
1 Sprain the AC ligament 2 Tear the cap - AC ligament 3 complete tear of AC, and trapezoid and cuboid? ligament
127
Classifications of AC separations
Type I = sprain like grade 1 Type II torn AC lig and acromion moves downward Type III - torn of all the ligaments and acromion moves inferior Type IV the clavicle move inferior when ligaments are torn Type V Clavicle moved superior when ligaments are torn Type VI clavicle moves inferior to the biceps tendon
128
CC of AC separation
Pain at rest and with ROM Crepitance - grinding palpable deformity
129
AC joint separation = THINK....
HOCKEY!!!!
130
Hx of AC separations
Trauma - common - FALL or HOCKEY | Infection - RARE
131
AC separation from trauma can show this
Elevated joint but at grade 3 separation inflammation will there
132
Physical finding of AC joint separation
1. pain directly over AC joint = after 90 degrees AC joint rotates = ILICIT pain 2. palpable deformity 3. warmth 4. painful ROM
133
AC joint function
rotation | plane = gliding joint
134
What is unique about taking a XR of the AC joint?
compare load-bearing vs. non-load bearing | when pt. is given weights
135
Objective testing of AC separation
1. XR - common 2. CT 3. MRI
136
Tx of AC separation
1. Skillful NEGLECT for grade 2 and below 2. sling 3. AC strap 4. surgery if severe subluxations and dislocations
137
What tx method for AC separation not popular?
AC strap
138
Snapping scapula
CC - catching THE ARM when raises arm Hx - congenital Physical findings - PROMINENCE ON THE RIBS AS YOU ROTATE THE SCAPULA Objective test - CT, XR Tx - injections underneath the scapula! AVOID SURGERY scapulo-thoracic impingment
139
Adhesive capsulitis AKA .... FROZEN SHOULDER SYNDROME
``` Frozen shoulder syndrome Scarring down of the articular capsule CC: cant raise arm Hx : slow progression of loss of motion Physical : passive and active ROM is lost Testing : MRI to see capsule Tx : meds, PT, manipulation ```
140
Etiology of frozen shoulder syndrome
Due to trauma or Disuse (OLD PEOPLE) Inflammaton of the shoulder capsule Complication fx or dislocation of the humerus
141
Adhesive capsulitis AKA .... FROZEN SHOULDER SYNDROME
``` Frozen shoulder syndrome Scarring down of the articular capsule CC: cant raise arm Hx : slow progression of loss of motion Physical : passive and active ROM is lost Testing : MRI to see capsule Tx : meds, PT, manipulation ```
142
Adhesive capsulitis AKA .... FROZEN SHOULDER SYNDROME
``` Frozen shoulder syndrome Scarring down of the articular capsule CC: cant raise arm Hx : slow progression of loss of motion Physical : passive and active ROM is lost Testing : MRI to see capsule Tx : meds, PT, manipulation ```
143
Etiology of frozen shoulder syndrome
Due to trauma or Disuse (OLD PEOPLE) Inflammaton of the shoulder capsule Complication fx or dislocation of the humerus
Musculoskeletal System
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