shoulder

• Glenohumeral dislocation


  Anterior mechanism of injury (MOI): abduction, external rotation

  Posterior MOI: shoulder abduction, flexion, internal rotation (seizure or electric shock)

  Inferior MOI: high energy injury with hyperabduction like fall from a height
• Glenohumeral dislocation


  • Pain with limited range of motion, deformity, do neurovascular exam before/after joint reduction

  Patient may also have Bankart lesion, Hill-Sachs lesion, proximal humerus fracture, rotator cuff injury, brachial plexus injury
• Diagnosis of glenohumeral dislocation

  Xray
• Treatment of glenohumeral dislocation

  Acute reduction of dislocation, non-surgical gets sling for 2-4 weeks with early range of motion, avoid high risk positions and excessive range of motion/overhead activity, physical therapy/range of motion/strengthening at 6 weeks

  Surgical if labral injury, instability, rotator cuff injury, Hill-Sachs lesion, Bankart lesion
• Bicep tendon tear/bicipital tendon rupture


  Etiology: male smokers from aggressive elbow extension from flexed position; patient may have intrinsic degeneration or mechanical impingement; normally from impingement, overuse, SLAP injury
• Bicep tendon tear/bicipital tendon rupture

  • Anatomy: radial tuberosity avulsion/chronic changes

  Physical exam: palpable defect with sharp pain/deformity; Yergason's test with pain over bicipital groove; patient has loss of strength in supination>flexion; squeeze bicep like Thompson's test
• Treatment of bicep tendon tear/bicipital tendon rupture

  Fix for high demand is surgery; non-surgical for patient, exercise, NSAIDs if low demand/high risk patients
• Clavicular fracture


  Etiology: middle third of shaft, can be due to birth trauma
• Clavicular fracture


  • Physical exam: deformity, ecchymosis, skin tenting/blanching, neurovascular exam

  Group 1 is middle 1/3; group 2 is distal 1/3; group 3 is proximal 1/3
• Diagnosis of clavicular fracture xray is gold standard, but CT to help with traumatic evaluation
• Treatment of clavicular fracture

  Non-surgical with non-weight bearing but early progressive range of motion

  ORIF is open, subclavian injury; maybe if 100% displacement or 2cm shortening
• Proximal humeral fracture


  • History: examine for associated injuries, ecchymosis, complete neurovascular exam of upper extremity
• Acromioclavicular ligament sprain/tear


  Etiology: mechanism of injury is falling onto point of shoulder

  Anatomy: injury to acromioclavicular or coracoclavicular ligaments
• Diagnosis of acromioclavicular ligament sprain/tear


  Image with X-ray

  Grade 1: AC ligament strain

  Grade 2: AC tear, CC ligament intact

  Grade 3: AC, CC ligament tears <= 100% superior displaced

  Grade 4: Grade 3 with posterior displacement

  Grade 5: Grade 3 <= 300% superior displacement

  Grade 6: Grade 3 with inferior displacement
• Acromioclavicular ligament sprain/tear


  • Physical exam: pain, swelling, bruise, maybe deformity, check sternoclavicular joint, range of motion normal but painful, rule out brachial plexus injury through neurovascular exam
• Treatment of acromioclavicular ligament sprain/tear

  Grade 1/2: sling, rest, physical therapy with early passive range of motion, regain active range of motion 4-6 weeks, return to normal activity at 12 weeks

  Grade 3: normally non-surgical unless using daily

  Grade 4-6: ORIF or ligament reconstruction
• Rotator cuff tear/tendinopathy


  Etiology: trauma or degenerative. Older, smoker, hypercholesterolemia

  Anatomy: SITS (supraspinatus, infraspinatus, teres minor, subscapularis)
• Rotator cuff tear/tendinopathy


  • History: due to changes in collagen, water content of ligaments, vascular supply, chronic degeneration. Mechanical factors, dislocation, prolonged impingement, surgical iatrogenic

  Physical exam: pain in posterior deltoid, pain with overhead/behind the back activity; tests to isolate muscles

  Supraspinatus: abduction, empty can

  Infraspinatus: external rotation, shoulder extension

  Teres minor: external rotation, adduction/extension shoulder, abduction inferior scapula

  Subscapularis: internal rotation and shoulder stability
• Diagnosis of rotator cuff tear/tendinopathy

  MRI is gold standard
• Treatment of rotator cuff tear/tendinopathy


  Can skip surgery if older and inactive -> ice, NSAIDs, corticosteroids
• Shoulder impingement


  Rotator cuff compression presents as pain in shoulder with insidious onset, pain in posterior deltoid and overhead activities; normal strength, special tests (Neer's, Hawkins, Empty can, painful arc). Image for calcific changes/space narrowing on X-ray. MRI shows the degree of rotator cuff involvement in subacromial edema.
• Treatment of shoulder impingement

  Physical therapy to strengthen rotator cuff and increase range of motion... look to surgery if treatment doesn't work after 4-6 months
• Shoulder impingement syndrome occurs when the supraspinatus tendon becomes trapped between the acromion process and humeral head during abduction