Conditions and Rehabilitation of Shoulder and Arm DISTAL HUMERUS PDF

Conditions and Rehabilitation of the Shoulder, Arm and Distal Humerus PRAYER OBJECTIVES List down the unique clinical features and treatment approach of each of the following soft tissue injuries of the shoulder and arm. Review the clinical presentation of soft tissue injuries, f...

Conditions and Rehabilitation of the Shoulder, Arm and Distal Humerus PRAYER OBJECTIVES List down the unique clinical features and treatment approach of each of the following soft tissue injuries of the shoulder and arm. Review the clinical presentation of soft tissue injuries, fractures, and dislocations. Develop Specific guidelines in the evaluation and rehabilitation of patients with disorders of shoulder and arm. PAST BOARDS According to the APTA Guide for Physical Therapist Practice, the following are elements of patient management (in order of process during an initial session) A. Examination, assessment, impairment, treatment B. Evaluation, treatment, documentation, assessment C. Examination, evaluation, diagnosis, prognosis D. Interview, evaluation, tests and measures, diagnosis STERNOCLAVICULAR DISLOCATIONS Anterior Posterior More common (2⁄3 of all Less common (1⁄3 of all cases) cases) More painful & severe Direct trauma to the SC jt. Vascular problems Medial end of the clavicle Mediastinal structures at risk becomes more prominent Breathing & swallowing difficulty MOI: High energy ( MVA, contact Note: SC jt. D/L allots for less sports) than 1% of all jt. D/L in the body STERNOCLAVICULAR JOINT DISLOCATIONS Imaging Mx plain serendipity radiographic Treatment is generally views and AP views. observation of atraumatic or CT studies are generally chronic anterior dislocations. required to assess for sling, observation direction of displacement. Closed versus open reduction Study of choice is indicated for acute dislocations. Clavicular Fractures CLAVICULAR FRACTURES Mx: MOI: FOOSH or FOS Splint (Immob) or FIgure of 8 Bandage: Non-displaced or has a good Age: 40 years with Hx of impingement (+) rotator cuff tear in the elderly Clinical Features Point tenderness in the bicipital groove Positive impingement signs if associated with impingement syndrome Sharp pain, audible snap, ecchymosis, and visible bulge in the lower arm with tendon rupture Provocative Tests Imaging Non-specific Treatment Treatment Tendonitis Conservative treatment is appropriate for most patients. – ROM and strengthening as tolerated. Modalities Injection into the tendon sheath. (controversial) Rupture Tendon reattachment is not indicated in most patients. Biceps tenodesis: younger individuals who require heavy lifting may need reattachment. Some patients may request reattachment of biceps tendon for cosmetic reasons. CALCIFIC TENDONITIS OF THE SUPRASPINATUS TENDON Calcium deposits ( Hydroxyapatite) most commonly involving the supraspinatus tendon. Idiopathic SS and Sx: Sharp pain in the shoulder ROM, particularly with shoulder abduction and overhead activities Imaging  Treatment NSAIDS Steroid Injections PT ( Thera Ex) Modalities- Shockwave Therapy UTZ guided needle lavage- or Barbotage Surgical decompression of Ca Deposits- Adhesive Capsulitis Clinical Features AKA: DIABETIC periarthritis Idiopathic Gender: F>M MC in 40-60 y.o Capsular Pattern: ER>AB>IR Causes: ○ Diabetes ○ Immobilization ○ Recent Strain ○ Arthritis ○ Trauma Imaging X-RAY AP view, scapular Y and axillary Arthrography Ultrasound:C LABs: TSH and HgbAIC  Self- limited disease Treatment Restoration over 12-14 months NSAIDs and/or intra- Worse outcomes among diabetics articular steroid injections, physical therapy, heat and/or cryotherapy Surgical: capsular hydrodilatation, manipulation under anesthesia, and arthroscopic lysis of adhesions PAST BOARDS A patient presents to an outpatient clinic with complaints of shoulder pain. The therapist observes a painful arc between 70 deg and 120 deg of active abduction in the involved shoulder. This finding is most indicative of what shoulder pathology? A. Rotator cuff tear B. Acromioclavicular joint separation C. Impingement D. Labrum tear Scapular Winging  SCAPULAR WINGING Medial Winging Lateral Winging Nerve: Long Thoracic N Nerve: CN XI Causes: Radical Radical Neck Dissection ( MC) Mastectomy (Breast Traction Injury Surgery), chest tube placement Blunt Trauma( deep tissue massage) ST/ Maneuver: Punch-out Slight SH ABD 65 years old) elderly with osteoporotic bone two-part surgical neck fractures high-energy trauma are most common young individuals concomitant soft tissue and neurovascular injuries Classification Clinical Features Typically occurs in elderly women with osteoporosis after a fall. Pain, swelling, and ecchymosis in the upper arm, which is exacerbated with the slightest motion. In fracture at the surgical neck, the supraspinatus is the principle abductor (ie, supraspinatus causes abduction of the proximal fragment of the humerus). Loss of sensation is seen if there is neurologic involvement. Diminished radial pulse Treatment Conservative: Rehabilitation; Sling and early ROM ( 6 weeks) Surgical: ORIF Complications Brachial Plexus Injuries Avascular Necrosis Arterial Injury ( Uncommon but in older pts- surgical neck) PAST BOARDS A patient has been determined to have a developing Type I complex regional pain syndrome on the left upper extremity. Which of the following signs and symptoms are observed in Stage 2 of the condition? a. Brittle nails b. Burning, aching, throbbing pain c. Accelerated hair growth d. Skin becomes cool, pale, bluish, sweaty Complex Regional Pain Syndrome AKA: CAULSALGIA ; RSD Types: Complex neuropathic pain I- RSD (no nerve involvement) syndrome characterized by II- Causalgia (c nerve severe pain & autonomic dysfxn involvement) that may lead to S/sx: Sensory Changes, Trophic crippling contractures of the Skin ,Changes, Autonomic limb Dysfxn, Motor & Pain Distal Predominance *STAMP  STAGES OF CRPS TYPE 1 STAGES SYMPTOMS TIME FRAME ACUTE Pain: Burning, aching,throbbing Within weeks of Injury & sensitive to Touch; Swelling, Mm spasm, stiffness, LOM & LOF, Skin may change from red, warm, dry to cool, pale, Sweaty, Hypertrichosis ,accelerated hairgrowth usually dark hair in thick patches DYSTROPHIC Pain severity increasing, inc swelling, mm atrophy, 3-6 months Skin becomes cool, pale (Cyanotic bluish), Hyperhidrosis, Nail bed changes (cracked, ridges, grooves), Bone demineralization ATROPHIC Osteoporosis, Irreversible tissue > 6months Damage, Mm atrophy and Contractures, Skin becomes thin and shiny, nails are brittle, pain may worsen, improve or stay the same  IMAGING Vascular studies X-Ray Bone Scan- EMG-NCV Blood test  Common Sites: Between the scalenes -AKA: Scalenus Anticus Syndrome Between the coracoid process & pecs minor AKA: Hyperabduction Syndrome Between the clavicle & 1st rib (MC) - AKA: Costoclavicular Syndrome THORACIC OUTLET SYNDROME S/sx: TREATMENT Weakness, pulselessness, Conservative: Paresthesia Analgesics,NSAIDS, Muscle ST: relaxants, Massage, CHARAW Hydrotherapy, PT Costoclavicular Brace Test Behavioral Modification/ Halstead Test avoidance of provocative Allen’s Test activities Roos’ Test Improvement -50-90% Adson’s Test Surgical Wright Test Conditions and Rehabilitation of the Elbow LATERAL EPICONDYLITIS -Also known as tennis elbow -Also seen in golfers. Mechanism of Injury Activities that require repetitive wrist extension and/or forearm supination. Overuse and poor mechanics lead to an overload of the extensor and/or supinator tendons. Poor technique with racquet sports: Improper technique for backhand swings – Inappropriate string tension Inappropriate grip size Pathology Clinical Features Tenderness just distal to the lateral epicondyle at the extensor tendon origin. Pain and weakness in grip strength Imaging Treatment Conservative PRICE NSAIDS or steroid injection Physical Therapy Correction of poor biomechanics and techniques Bracing (forearm band), taping Surgical ECRB debridement MEDIAL EPICONDYLITIS Also known as golfer’s elbow or Little Leaguer’s elbow (children) or pitcher’s elbow. Caused by repetitive valgus stress to the elbow ( late cocking and acceleration phase in throwing and swinging motion (backswing and downward follow- through swing just prior to ball impact) of a golfer Pathology & Clinical Features Inflammation of the common flexor tendon at the elbow-> tenderness distal to medial epicondyle Recurrent microtrauma- hypertrophy Children: Long-term repetitive valgus stress -> medial epicondylitis, traction apophysitis and medial condyle apophysitis Other features: ulnar neuropathy and pain on resisted wrist flexion and pronation Imaging Not needed but may do MSK UTZ X-Ray- calcification at the medial epicondyle Treatment Conservative Short term: rest, ice, NSAIDs, immobilization Long term: activity and modification of poor throwing mechanics extremely important Surgical pinning Reserved for an unstable elbow joint  A 14-year old girl place excessive valgus stress to the right elbow during a fall from a bicycle. Her forearm was in supination at the moment the valgus stress was applied. Which of the following is most likely involved in this type of injury? A. Ulnar nerve B. Extensor carpi radialis C. Brachioradialis D. Annular ligament OLECRANON BURSITIS Also known as draftsman’s elbow, student’s elbow, or miner’s elbow. Mechanism Repetitive trauma, inflammatory disorder (gout, pseudogout, RA) Pathology and Clinical Features Imaging and Treatment OLECRANON BURSITIS Imaging: none needed Treatment: Fluid aspiration and culture Conservative: rest, NSAIDs, elbow padding PAST BOARDS A physical therapist is speaking to a group of avid tennis players. The group asks how to prevent tennis elbow (lateral epicondylitis). Which of the following is incorrect information? A. Primarily use the wrist and elbow extensors during a backhand stroke. B. Begin the backhand stroke in shoulder adduction and internal rotation. C. Use a racket that has has a large grip. D. Use a light racket. DISLOCATION OF THE ELBOW The most common type of dislocation in children and the second most common type in adults (second only to shoulder dislocation). Young adults between the ages of 25 and 30 years account for almost 50% of these injuries Mechanism, Symptoms and Imaging FOOSH injury Most common is posterior dislocation Sx: inability to bend elbow, pain in shoulder and wrist Imaging Plain AP and lateral radiographs Treatment DISTAL BICEPS TENDONITIS Overloading of the biceps tendon commonly due to repetitive elbow flexion and supination or resisted elbow extension. Imaging, Treatment None needed but may do MRI Tx: Conservative or Surgical TRICEPS TENDONITIS/AVULSION Clinical Features Tendonitis: overuse syndrome secondary to repetitive triceps extension. Avulsion: decelerating counterforce during active elbow extension. Imaging and Treatment VALGUS EXTENSION OVERLOAD (VEO) SYNDROME OF THE ELBOW Common in baseball players Repetitive valgus forces ( cocking and acceleration phase) Common in posteromedial olecranon Pathology, Clinical Features and Imaging Olecranon osteophytosis and loose body formation (+) VEO test X-Ray APL Tx: surgical and post op PT MEDIAL (ULNAR) COLLATERAL LIGAMENT (MCL) SPRAIN  Due to A repetitive valgus stress Pathology: inflammation of the anterior band of UCL (+) valgus stress test Imaging: X-Rays plain and valgus stress radiographs  Conservative Surgical if needed TREATMENT LATERAL (RADIAL) COLLATERAL LIGAMENT (LCL) SPRAIN Elbow dislocation from a traumatic event Recurrent locking or clicking of the elbow with extension and supination. Lateral pain or instability on varus stress with the elbow flexed 20–30 ̊ if the RCL is torn. Special test: varus stress test and lateral pivot shift test Imaging: Varus stress radiographs FRACTURE OF THE HUMERAL SHAFT FRACTURE OF THE HUMERAL SHAFT Clinical Features Mechanism severe arm pain swelling Direct trauma (eg, MVA) weakness Fall on outstretched arm deformity - characteristic of a displaced fracture of the humerus. (+) radial nerve palsy – if radial nerve is affected FRACTURE OF THE HUMERAL SHAFT Imaging Treatment AP and lateral x-rays. conservative (ie, splint for 2 weeks CT Scan intraarticular extension coaptation splint or hanging arm CTA- if with vascular injury cast). PT ( ES, exercises, Modalities and with radial nerve palsy EMG-NCV- 6 months and after a (+) splint ( volar or dorsal splint if ) year 95% of patients will regain their nerve function within 6 months. OT (- ADL retraining, work modification, therapeutic exercises,nerve gliding exercises etc) Surgical: ORIF, IM nailing, External Fixation FRACTURE OF THE DISTAL HUMERUS  AO/OTA Classification of Distal Humerus Fractures Extra-articular (supracondylar fracture), 80% are extension type; Type A epicondyle Intraarticular- Single column (partial articular-isolated condylar, Type B coronal shear, epicondyle with articular extension). Intraarticular- Both columns fractured and no portion of the Type C joint is contiguous with the shaft (complete articular) Each type further divided by degree and location of fracture comminution FRACTURE OF THE DISTAL HUMERUS Clinical Features Classification can be complex. (+) swelling The most useful way to consider them is displaced (+) ecchymosis or nondisplaced. pain at the elbow A displaced fracture involves one or both condyles, Inability to flex the elbow. and the joint surface may or may not be involved. Inspect for an obvious deformity. Mechanism Neurovascular compromise. Radial, median, MOI: low energy falls in elderly; high energy and ulnar nerves all may be affected. impact in younger population Complications – Neurovascular injury – Nonunion – Malunion – Elbow contracture - Heterotopic ossification – Poor range of motion FRACTURE OF THE DISTAL HUMERUS Imaging Treatment AP/lateral, Oblique x-rays of the Orthopedic referral. elbow – Nondisplaced fractures can be treated by splinting and early CT- for surgical planning motion. MRI- not indicated for acute – Displaced fractures—except cases severely comminuted fractures— require ORIF ( screws, pinning, metal plates) Post Operative: PT and Ottretament depending on the problems identified PAST BOARDS A physical therapist performs an examination on a patient diagnosed with thoracic outlet syndrome. During the examination, the therapist initiates a special test as shown in the image. Which of the following would be considered a positive finding when performing the special test? A. Inability to maintain the test position for three minutes B. Subjective report of fatigue in the arms C. Absence of a radial pulse after one minute D. Failure of the hands to regain their normal color after 30 seconds References Braddom De Lisa Ortho Bullets Physiopedia THANK YOU!!