Shoulder

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    Shoulder Overview

    • 4 Bursae
      • Subacromial bursa (btwn rotator cuff and deltoid)
      • Subcoracoid bursa
      • Scapular burase (separate scapula from chest wall - inferior and superior part of scapula)
      • photo (18).JPG
    • Imaging:
      • AP view
      • "True" AP view (Grashey view) [beam is 45° in medial to lateral direction - see subtle joint incongruity]
      • Scapular Y view (body, spine, and coracoid process of scapula)
      • Axillary view
      • NOTE: often seen "fat fluid level" on AP often indicative of articular surface fracture.  Often see pseudosubluxation of humeral head due to the secondary hemarthrosis.
    • Attachments (important)
      • Rotator cuff:
        • Greater tuberosity: supraspinatus, infraspinatus, teres minor
        • Lesser tuberosity: subscapularis (avulses lesser tuberosity)

    Shoulder Fractures

    Proximal Humerus Fractures

    • commonly in elderly
    • Attachments to greater tuberosity tend to pull fragments in superior direction (supraspinatus, infraspinatus, teres minor)
    • Fracture classification developed by Neer:
      • 1. Humeral Head
      • 2. Humeral Shaft
      • 3. Greater Tuberosity
      • 4. Lesser Tuberosity
    • Displacement defined as: 1cm displacement or 45° angulation to the remaining humerus. 
    • Each fragment that is "displaced" as per above definition... characterized as
      • One part-fracture: nondisplaced, without angulation.
      • Two part fracture: one fragment is "displaced" (>1cm or angulated >45°)
      • Three part fracture: two fragments "displaced"
      • Four part fracture: three fragments "displaced".
      • Screen shot 2013-08-07 at 10.20.06 PM.png
    • Classification:
      • Important for prognostic and theraputic purposes
      • If one-part fracture: usually sling
        • 80% are one-part (fragments held in place by periosteum, rotator cuff, joint capsule).
        • Sling and early mobility important
        • Early Codman exercises!! (bend down, do pendulum motions with arm, or rottional - passive)
          • Active exercises later on...
          • Screen shot 2013-08-07 at 10.31.08 PM.png
      • Two/three/four part fractures
        • Require reduction, could be unstable after.
        • Three/Four part fractures associated with dislocation.
        • May require prosthesis if significant fracture
      • Fracture through articular surface not included in Neers classification - treated differently
      • Successful treatment of proximal humeral fractures is dependent on early mobility.  A compromise in anatomic reduction may be accepted as long as prolongued mobilization is avoided.
      • Surgical neck fractures usually present adducted.  A patient who presents with surgical neck fracture with arm abducted.  Must immobilize in same position before radiographs.  Adducting can cause neurovascular damage.
      • Surgical Neck Fracture

      • Screen shot 2013-08-07 at 10.21.24 PM.png
      •  
        • Ensure angle btwn humeral head and shaft is 135°.  If <90 or >135 needs reduction depending on age.
        • Neurovascular compromise and axillary nerve damage COMMON.  Esp if comminuted.
        • Treatment depends on parts:
        • One-part fracture:Screen shot 2013-08-07 at 10.31.08 PM.png
          • Sling
          • Ice, elevate, analgesics.
          • Circumduction exercises as soon as tolerated (see figure - circles, sideways pendulum etc.) followed by elbow and shoulder passive exercises at 2-3 weeks.       
        • Two-part
          • sling immobilization
          • Ice, analgesics
          • Emergent referral
          • Closed reduction under regional or GA preferred.
          • Screen shot 2013-08-08 at 12.41.14 AM.png
      • Complications
        • Joint stiffness (avoid by early mobilization)
        • Malunion
        • Myositis ossificans.
      • Anatomic Neck Fractures

        • Rare, more common in kids.

        • High complication of avascular necrosis  - consult ortho

      • Greater Tuberosity Fractures

        • Upward displacement common due to rotator cuff attachment (supra, infra, teres minor)

        • Exception to Neers: only 0.5cm displacement enough for operative management.

        • Neurovascular injuries uncommon

        • Often anterior shoudler dislocations, and rotator cuff tears.

        • Tx:

          • Nondisplaced: Ice, analgesics, sling, early referral (high incidence of complications

          • Displaced (>0.5cm): 

            • If dislocated, then reduce (often corrects displacement).  Then manage as nondisplaced.

            • If displacement remains or non-dislocated:

              • Young: internal fixation + rotator cuff repair.

              • Elderly: ice, immobilization with sling.  EARLY MOBILIZATION is key.

        • Complications:

          • Often impingement (long head of biceps) = chronic tenosynovitis.

          • Nonunion

          • Myositis ossificans.

      • Lesser Tuberosity Fractures

        • Uncommon, often with posterior shoulder dislocations.

        • Usually intense contraction of subscab avulses lesser tuberosity

        • Neurovascular injuries rare, associated with surgical neck fractures, often posterior dislocations.

        • Tx:

          • Ice, analgesics, sling immobilization, ortho consult.

          • If nondisplaced: treat non-operatively

          • If two-part (>1cm displaced): require surgical repair.

      • Three/Four part fractures

        • Often intense trauma (fall on arm)

        •  

          Tx: ice, analgesics, sling, emergent referral + admission.

          •  

            All require surgery (four-part require prosthesis)

            High risk of neurovascular injury and avascular necrosis

      •  

         

         

         

        Articular Surface Fractures

     

    • Generally "impression fracture" (Humeral head compressed and "impression" made on surface)
    • <40% of articular involvement: immobilize in ext. rotation.
    • >40% - surgical repair or insertion of prosthesis
    • comminuted - surgical repair or insertion of prosthesis.

    Clavicle Fractures

    • Most common broken bone:
      • Middle third: 80% (most force, associated with thoracic injury, subclavian injury, and brachial plexus)
      • Lateral third: 15%
      • Medial third: 5%
    • Proximal fragment often pulled superiorly due to sternocleidomastoid attachment.
    • Beware of subclavian and brachial plexus injuries (lie underneath).
    • Mechanism:
      • Direct blow (if inferior force: usually neurovascular compromise and comminuted)
        • Blow from above (lateral third fracture)
      • Fall on lateral shoulder (force transmitted - middle third fracture)
        • All displaced lateral-third clavicular fractures are associated with coracoclavicular ligament rupture and should be treated similar to a AC joint dislocation.

     

     

    • Treatment
      • In general:
        • ice,
        • analgesics,
        • sling (unless non-displaced lateral third - already splinted by surrounding structures)
        • Early Motion if non-displaced. (esp with articular to prevent degen arthritis)
        • Ortho Referral (if displaced, b/c non-union high, and complications)
           
      • Middle Third
        • Non-displaced: Sling + ice (intact periosteum). Adults 6 weeks of immobilization, kids 3-5weeks.
          • Repeat radiographs in 1 week.
        • Displaced:
          • Closed reduction do not improve outcomes.
          • Immobilize with sling.
            • figure-of-eight strap can be used.  Placed behind patient, pulls shoulders back allows use of both hands such as typing, but uncomfortable and does not improve outcome). 
          • Ortho referral if completely displaced.  (15-20% non-union is high)
      • Lateral-Third
        • Non-displaced: Ice, analgesics, early motion.  No sling b/c already splinted by surrounding ligaments and muscles.
        • Displaced: ice, analgesics, SLING, ORTHO REFERRAL
        • Articular Surface: Ice, analgesics, sling for support.  Early motion required to prevent degenerative arthritis.
      • Medial-Third
        • Non-displaced: Ice, analgesics, sling for support
        • Displaced: same, but require ortho referral

     

    Fracture Type ice, analgesics Sling Ortho Referral
    Medial Third Non- Displaced + + (6 weeks) -
    Displaced + + (or strap) + if complete displaced
    Lateral Third Non-Displaced + - (early motion) -
    Displaced + + +
    Articular # + + (++ early motion!) -
    Medial Third Non-Displaced + + -
    Displaced + + +

     

    • Complications:
      • Malunion (primary in adult, uncommon in kids due to extensive remodeling).
      • Excessive callus (cosmetic defect)
      • Nonunion
      • Delayed union (esp lateral third)
      • Degenerative arthritis (if articular fractures).

    AC Dislocation

    • Types:
      • 1st Degree: Sprain of AC ligament and incomplete tear.
      • 2nd Degree: Subluxation of AC joint, disruption of AC ligament.  However coracoclavicular CC ligament is intact.
      • 3rd Degree: Disruption of both AC and CC ligaments.  (usually superior displacement)
      • Type 4: clavicle displaced posteriourly through trapezius muscle.
      • Type 5: displaced into neck.
      • Type 6: I don't even know...
    • photo (20).JPG

     

     

    • Mechanism:
      • Direct force on shoulder/arm or force from above on acromion.
    • Xray Measurements:
      • 1. AC joint width <3mm
      • 2. Clavicle-Coracoid CC distance <5mm
      • 3. Clavicle elevation (superior displacement compared to acromion)
    • First degree: normal radiographs
    • Second degree: subtle, AC joint width ≥3mm or 50% increase compared to other side).  CC distance normal <5mm.
    • Third degree: inferior border of distal clavicle is above midpoint of acromion.  CC ≥5mm compared to other side.
    • Can do stress views by hanging weight off arm to distinguish 2nd and 3rd, but not really done anymore.
    • Treatment:
      • 1st degree: rest, ice, sling, early ROM
      • 2nd degree: same as 1st, but keep sling for 2 weeks (or until sx resolve) and no heavy lifting for 3 weeks.  (otherwise conver to 3rd degree)
        • early ROM is key to prevent adhesive capsulitis.
      • 3rd degree: same as others, but early referral.
        • Operative tx controversial (maybe in heavy labourers and younger pts).  Surgery can cause impingement or neurovascular compromise.  Based on degree of displacement (>2cm = treat?)
    • Complications
      • Pain syndromes due to degenerative joint disease are common (8-42%).  Some people have clavicle resections due to pain syndromes.

     

    Sternoclavicular Dislocation

    • Two ligaments:
      • Sternoclavicular
      • Costoclavicular
    • Joint moves if arm elevated past 110 degrees
    • Dislocations can be anterior (more common) or posterior
    • Screen shot 2013-08-09 at 12.25.28 AM.png
    • Mechanism:
      • Huge force that thrusts shoulder forward. (MVA or sports)
    • On Exam:
      • Tenderness over joint
      • Mild sprain: Pain by elevating arm above 110 degrees.
      • Complete tear: Pain with any shoulder motion.
      • On inspection: obvious deformity.
    • Complications
      • Anterior dislocations rarely have complications
      • Posterior dislocations (25% complication rate):
        • Tracheal compression (SOB)
        • Tracheal rupture
        • Pneumothorax
        • Venous congestion (subclavian vein)
        • Esophageal compression (dysphagia)
    • Treatment
      • Mild: ice 3-4x/day, sling for 3-4 days.
      • Moderate: figure-of-eight clavicle strap and a sling (to keep clavicle in normal position to allow ligament healing)
        • Continue strap + sling for 6 weeks, and advise that problems may develop that require surgery.
        • Reductions:
          • Patient supine, folded sheet between shoulders.
          • Abduct arm, and apply traction + push anterior clavicle back into position or grab posterior clavicle and move forward.
          • Posterior dislocations are difficult, often need sedation and use of towel clip to grab the clavicle.  
          • Place compression bandage over clavicle to prevent recurrence.
        • Notes:
          • If reduced: keep figure-of-eight sling for 6 weeks, and protected motion x2 weeks.  
          • Anterior dislocations are unstable, and can dislocate.  No benefit from surgery.
        • Screen shot 2013-08-09 at 12.25.40 AM.png

    Scapular Fractures

    • Overview:
      • Triceps inserts on inferior rim of glenoid (can displace)
      • Short head of biceps, coracobrachialis, and pectoralis minor insert on coracoid process.
      • Need ORIF if scapula and clavicle injured together.
    • Types of fractures:
      • Body or spine fractures
        • Direct blow (little displacement)
        • R/O thoracic aortic injury (1%), pneumothorax etc..
        • Tx: sling, ice, analgesics, refer if displaced or functional impairment (ORIF)
      • Acromion fractures
        • Direct blow
        • Nondisplaced: sling, early ROM exercises (to avoid restricted ROM)
        • Displaced: ortho referral, b/c often compromises ROM.
        • R/O brachial plexus injuries, AC join injuries.  Often bursitis.
      • Glenoid Neck fractures 
        • Uncommon
        • Often with humerus #
        • non-displaced: sling, ice, analgesics.  Passive ROM at 48hrs as tolerated.
        • Displaced: require surgery (If >40° angulation, and 1-2cm displacement) High malunion incidence.
      • Glenoid rim fractures (glenoid rim with dislocations)
        • Often with dislocation
        • Rim: ortho referral.  Will operate if >25% of glenoid surface or more than 5mm steop-off.
        • Comminuted articular: ice, sling, analgesics, surgery.
      • Coracoid process fractures
        • Muscles: short head of biceps, coracobriachialis, pectoralis minor.
        • Ligaments: coracoacromial, coracoclavicular, coracohumeral.
        • Usually direct blow or violent contraction 
        • Tx: symptomatic: ice, sling, analgesics, early ROM as tolerated. 
        • R/O: clavicular #, AC injury, brachial plexus injury.
    • photo (19).JPG

     

     

    Shoulder Dislocations

    • Anterior (95%) vs posterior (5%)
    • 50% of all dislocations
    • 25% of time there are concominant fractures.
    • Xray views:
      • AP
      • Scapular Y view (see image)
      • WATER_CORDT01-06-001.jpg
    • Three types of anterior dislocations: (depending on where head of humerus ends up)
      • Subclavicular
      • Subcoracoid
      • Subglenoid
      • Screen shot 2013-08-09 at 12.25.53 AM.png
    • Mechanism:
      • Abduction and external rotation.
      • Subglenoid: often hyper-abduction
      • Subcoracoid: often hyper-ext rotation.
    • On exam:
      • Acromion prominent in absence of humeral head.
      • Axillary nerve injury common! (12%)  [abduction is best test, sensation unreliable]
      • Absence of humeral head in the glenoid fossa.
    • Associated injuries:
      • R/O Hill-Sachs fracture where the soft base of the humeral head impacts against anteroir glenoid. (40% of anterior dislocations).  Can see internal rotation views post-reduction
      • R/O Bankart lesion - fracture of anterior glenoid rim. (can be soft-tissue if labral fracture)
      • ALWAYS CHECK TEARS (good outcome if treated early).  in 50% of young pts and 80% old.
        • Rotator cuff tear: ask to abduct (can be either tear or axillary nerve injury)
        • Biceps tendon tear.
      • photo (21)b.jpg
    • Treatment:
      • Analgesia is key.  Pt must relax muscles.
        • Can do procedural sedation (i.e. fentanyl + prophofol)
        • If contraindicated: intraarticular injection 20mL of 1% lidocaine using 20G needle. Inject 1cm inferior to lateral edge of acromion.  Direct needle medial+inferior to depth of 2.5-3cm
          • Intra-articular analgesia is better if presents 6h post-dislocation
      • Reduction:
        • Scapular Manipulation (simple, 80-100% success)
          • pt lies prone on table with affected arm hanging down with 5-10lb weight. (similar to Stimson).  Physician rotates scapula with tip medial and spine lateral.  
        • External Rotation: (80-90% success, and 81% w/o analgesia)
          • Adduct arm (elbow to torso), and externally rotate.
          • External rotation overcomes internal rotator spasm and unwind join capsule.  allowing external rotators to pull humerus in position.  Can allow shoulder muscles reduce dislocation with no analgesia. 
          • If discomfort during ext rotation, wait, allow muscles to relax and proceed slowly.
        • Milch Technique (86-100%)
          • Abduction (elevation), and if it does not do it alone, can elevate humeral head direct into glenoid.
        • Spaso Technique
          • Gentle vertical traction and external rotation.
        • Stimson (70-90%)
          • patient prone with affected arm hanging down off the table.  10-15lb weight applied to hand for 20-30min.  
          • Hard to sedate, can use intra-articular lidocaine. 
        • Traction-countertraction
          • Use sheet to pull under affected axilla, and person #2 pulls on arm in opposite direction.
          • if fails, can use a third sheet and pull humerus (from under axilla) up towards head.  BE CAREFUL...slow traction, otherwise can fracture glenoid rim. 
      • Reduced?
        • Fullness under acromion.
        • Can put hand on opposite shoulder.
      • After reduction
        • Put pt in sling (adduction + int. rotation).
          • In young pts <30yo: 3 weeks of immobilization.  
          • In older pts >30yo: immobilize 7-10 days + circumduction (Codman) exercises 4-5 days post-injury.
        • All exercise within pain-free ROM.
        • Caution against abduction and ext rotation.
        • After 2months: strengthen internal rotator (subscapularis) to prevent re-dislocation.  Can also do some ext. rotators to help further stabilize.
        • Warn 60% recurrence, 
      • Surgery if:
        • # of greater tuberosity >5mm displacement
        • Glenoid rim (Bankard) # w/ >5mm 
        • Recurrent: >3 dislocations (90% Bankart lesions).
        • Anterior glenohumeral instability: if subluxation on ant. apprehension test.
    • Posterior Dislocation:
      • Uncommon, but missed up to 60-70% of time
      • Suspect if Block of ext. rotation, and limitation of abduction. (~100% sensitivity)
      • Radiology:
        • Rim sign - Superimposition of medial humeral head and ant. glenoid rim. (not in socket but superimposed posteriorly)
        • Light bulb sign - interally rotated humerus
        • Trough line sign: Reverse hill-sachs lesion (impaction site)
      • NOTE; Isolated fracture of lesser tuberosity = post dislocation until proven otherwise
      • Consult ortho for reduction.  Surgery if significant lesser tub. fracture.
    • Inferior Dislocation (aka Luxatio erecta) - arm abducted.
      • Uncommon
      • Hyperabduction injury, cannot abduct.
      • Always detachment + tear of rotator cuff (inferior).

    Impingement Syndrome

    • Compression ofrotator cuff tendons as they pass between the acromion, rigid coracoacromial ligament and humerus.
    • photo (22).JPGphoto (23).JPG
    • Acutely: inflammation, edema, hemorrhage
    • Chronic: fibrosis, tendonitis, eventually tearing of rotator tendons.
    • Supraspinatus most common: b/c close to coracoacromial arch and poor blood supply.
    • Worse if bad posture: shoulders anterior, closes the subacromial space.
    • Mechanism:
      • Commonly: athletes with overhead motion (tennis, swimming, etc.), also whiplash injury.
      • Others: hooked acromion, osteophyte formation, subacromial bursal fibrosis, and coracoacromial ligament thickening.
      • Fibrosing tendon thickens, calcifies, can cause overlying subacromial bursitis, = worsening impingement.
    • History:
      • Pain referred to lateral aspect of joint, worse at night, 
      • Worse with overhead activities (abduction = outlet narrows)
      • Painful arch: 60-120° abduction = acromial pathology.  NOTE: If pain increases >120° abduction = AC disorder.
    • Exam:
      • Worse when shoulder in fwd flexion and int. rotation, and better w ext. rot. (Hawkin sign)
      • Worse when passive fwd flexion of pronated arm to 180° (Neer sign).
    • Diagnose:
      • High resolution U/S
      • MRI
      • steroid or lidocaine injection = immediate relief.  (needle under acromion into coracoacromial ligament).
    • Treatment:   (stabilize and balance shoulder and improve posture.  )
      • Strengthen back muscles (esp trap, rhoboids) b/c helps pull shoudlers back = better posture, open the subacromial space = less impingement.
      • strengthen pectoralis muscles (these are int. rotators), evidence shows may be even more important than back muscles.

    Supraspinatus Tendonitis + Subacromial Bursitis

    • Supraspinatus tendon passes under acromion and coracoacromial arch in close proximity to the subacromion bursa (separates supraspinatus tendon and deltoid)
    • Tendonitis can occur in any rotator cuff tendons, but most common in supraspinatus.
    • Tendon gets injured (overuse, impingement, bad posture etc..), fibroses, calcifies, = worseining impingement.
    • Inflammation in supraspin. tendon can cause inflammation of subacromial bursa.
      • Inability to abduct >30deg --> chronic bursitis ---> eventually adhesive pericapsulitis or bursitis.
      • Pain can radiate down entire limb.
      • Point tenderness at "critical point" btwn acromion and greater tuberosity.
    • Treatment:
      • Avoid inciting activity
      • NSAIDs, ice prevent pain/inflam/atrophy.
      • ROM exercises: Codman (circumduction).
      • NEVER IMMOBILIZE SHOULDER (if eldelry = adhesive capsulitis)
      • Steroid/anesthetic injections.  (move needle back/forth along tendon sheat for max analgesia).
        • Methylprednisolone (40mg, 1mL) and bupivicaine (5-10mL) effective.

    Rotator Cuff Tears

    • Common with advancing age.  Many asymptomatic (25%), many undetected (28% in >60yo).
    • Any part of rotator cuff can be distrupted, but most common at supraspin. tendon.
      • impingement --> chronic tears, intrinsic degeneration, overuse, overload.
    • >30% tear required to produce decr in strength.
      • No correlation btwn pain/disability and size of tear.
    • full tear = cannot initiate abduction. 
    • Drop arm test - abduct arms to 90°, and examiner pushes down.  If drops = positive = significant tear.
    • Physical exam poorly predictive of degree of tear.
    • Radiology:
      • Cuff view: degenerative changes (erosion, periosteal reaction of greater tuberosity)
      • MRI: 100% sensitivity and 95% spec.  
      • High-Res Ultrasound: also high sensitivity/spec (comparable to MRI)
    • Treatment:
      • Conservative (good outcome in 50%)
        • Passive ROM important to decr stiffness.
        • Initially Rest, Ice, NSAID.
        • Surgery if:
          • If young + complete tear (arthroscopic repair 90% good results).
            • In study: moderate tears better for arthroscopic repair, massive tears better with open repair.
            • Anterior tear is better candidate
          • NO SURGERY if elderly, and sedentary.

     

    Bicipital Tendonitis

    • Long head of biceps passes within bicipital groove and inserts into glenoid rim. (constant trauma and irritation).
    • History
      • Pain in biceps region, and anterior shoulder radiates down forearm.
      • Abduction and external rotation are most painful (compared to abd + int rot in supraspin tendonitis)
    • On Exam:
      • Tenderness in bicipital groove
      • Yergason Test: Eblow at 90° flexion, resist patient supanation.  Positive if pain in intertubercular groove.
    • Treatment:
      • Immobilize with sling, NSAIDs.
      • Injection of bicipital canal. (see pictures on web). do not inject tendon, inject along the tendon sliding needle.

     

    Bicipital Tendon Dislocation

    • Tendon subluxates and dislocates out of groove between greater and lesser tuberosities.
    • Congenital shallow bicipital groove = predisposes to this.
    • Sharp, acute pain in anterior shoulder.  Tendon can slip back and fourth
    • Do Yergason Test (See Bicipital Tendonitis)
      • Any supanation against resitance will move tendon in/out of groove =-> pain.
    • Tx:
      • Operative: anchor tendon to bone (Tenodesis) and release (tenotomy) are possibilities.

     

    Frozen Shoulder - Adhesive Capsulitis

    • Usually pts >40yo, onset can be insidious.
    • history
      • Pain in anterolateral aspect of shoulder. rad to arm.
      • Worse at night, severe, interferes w sleep.
      • RF's: diaetes, trauma, hypertriglyceridemia, and thyroid disease.
    • Mechanism:
      • Unclear.  Calcific tendonitis of rotator cuff and bicipital tendon complexes implicated.
    • Treatment:
      • Physical therapy - intense, start with ROM in painless arc.
      • NSAIDs
      • Steroid injections - need multiple, helps ROM exercises.
      • Surgery (remove calcific parts, or arthroscopically punch through calcific areas)

     

    Cervical Disease

    • Presents with shoulder pain, typically pain radiates down arm past elbow.
    • Exacerbated by neck movements (esp rotation + extension on affected side). 

     

    Other

    Long Thoracid Nerve Palsy (Winged Scapula)

    • Injured due to length and superficial course.
    • Paralyzes ant. serratus muscle.
    • On exam: prominence of inferior and medial border of scapula "Winged Scapula"
    • Mech:
      • Overuse, improper using of crutches, trauma, idiopathic.
    • Treatment:
      • Conservative (analgesics, physio)
      • Recovery long - 12-18mo
      • Surgery if do not recover.
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