Block 4 Rheumatology - ORTHO Shoulder.pdf

Name Summary Etiology Fall or forceful throwing motion 95% anterior Shoulder Dislocation 5% posterior AC Separation Rotator Cuff Tear Multiple grades of ligamental laxity to tear Tear in any of the SITS connectors within a graded system MC: Supraspinatus Usually direct fall onto shoulder MC: Age-rel...

Name Summary Etiology Fall or forceful throwing motion 95% anterior Shoulder Dislocation 5% posterior AC Separation Rotator Cuff Tear Multiple grades of ligamental laxity to tear Tear in any of the SITS connectors within a graded system MC: Supraspinatus Usually direct fall onto shoulder MC: Age-related degeneration Trauma Athletic injury FOOSH MVA Direct insult Humeral Shaft Fracture Proximal Humeral Fracture Bony defects: Hill-Sachs: humeral head Bankart: Inferior glenoid rim May injure radial or axillary nerve Young and elderly patients Signs Special Tests XRAY: - AP: may mask injury - Y-view: Shows direction of dislocation General: - Visually displaced - Guarding area - Pain CMS: - Loss of ROM - Diminished or absent pulses General: - "Step off" appearance of clavicle - Pain in ROM General: Depends on grade - May be mild or asx - Weakness - ↓ AROM - Night pain - Grating/catching - Deltoid atrophy - Inappropriate shoulder "hiking" to raise arm U/S: - Vasculature, neural involvement Grade I and II: Scarf (Cross Over) Test: Reach hand to opposite shoulder. Provider may apply slight pressure in hug-like pattern. Drop Test: Failure to hold arm at 90° Clavicle Fracture MC in middle third of clavicle Proximal Bicep Tendon Rupture FOOSH Direct fall onto shoulder Usually older patients due to tendon weakening MC: Proximal long head Athletes SLAP: Superior Labral Anterior to Posterior lesion Brachial Plexopathy (Natal) (More in peds block) Brachial Plexopathy (Burner-Stingers) Impingement Syndrome (RC tendonitis & subacromial bursitis) Superior glenoid labrum & biceps anchor complex Degeneration Athletic injury Injury resultant from stretching/compressing C5-T1 during birthing process Shoulder displacement during birthing process ADULT (often athletic): Injury resultant from stretching/compressing plexus. C5-C7 Inflammation in SA bursa leading to pinching and pain Athletics (foosball) GSWs MVA Falls ↑ ↓← → ° ± General: - Sudden pop at time of injury - "Popeye muscle" - Eccymosis - Palpable defect O'Brien's Test: Arm at 90°, invert with thumb down. Provider applies pressure to superior side. Pain will reproduce. General: - Neuro deficits General: - Episodic burning/ paresthesia in limb Alarm sx: - Weakness - Neck pain - Bilateral sx Overuse injury resulting from - Pain with overhead motion repeatedly pinging on RC tendons - Anterio-lateral pain and subacromial bursa Treatment Overall GOLD: Reduction w/ sling - Min. 3 wk sling - Can use lidocaine or conscious Y-View: - Anterior = overlapping ribs sedation - Posterior = behind the "Y" Anterior dislocations: Stimson technique: add weight to Recurrent dislocations may ultimately damage the labrum. pt hand and allow to self-correct 90% chance to reinjure area after initial dislocation via gravity Longitudinal traction: 2-man with sheet; slow ROM traction Grade I & II: - Sling, ice, pain mgmt Grade III & VI (Visible step off): - Surgical management Return to activity when pain-free with abduction and crossover Conservative: - NSAIDs - Physical therapy - CS injection Surgical: If failed above or acute tear - Repair Mostly non-surgical: - Splint for 2 wks then: - Sarmiento Brace (6wks) - Sling - NSAIDs Neer Classification of severity Refer for further if: - >20° angulation Non-surgical (1 displacement): - Sling (3 wks) - NSAIDs General: - Limited ROM neck/shoulder - Pain in palpation - "Step off" appearance of clavicle - Pain laying on affected side General: - Limited ROM - Pain in palpation - "Step off" appearance of clavicle XRAY: - Coracoacromial arch view - AP: may show high-ride humeral head XRAY: - AP - Lateral * Pale forearm/hand = axillary nerve injury!* MC bony injury XRAY: - B/L AP Grade >II: You can probably just see the issue. Don't be a dick. General: - Severe pain - Radial nerve palsy - Deformity - Swelling at site General: - Severe pain - Radial nerve palsy - Deformity - Swelling of upper arm/ shoulder Tests Spurling's Maneuver XRAY: - AP AND Axillary - OR Scapular Y >/= 4 parts: - Prosthetic consult Mostly non-surgical: - Figure-8 harness GOLD: XRAY - Sling for comfort - AP - NSAIDs - 10° tilt cephalic view Refer for further if: - Nonunion at 12 weeks - MRI - EMG/NCS to determine neuro- - Open fx - Neurovascular compromise involvement type - Distal/proximal third Conservative: