Shoulder

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)
  • 
• 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

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

• 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...
• 

• 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
• 
• 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.
    • 

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.
• 

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)
  • 
• Three types of anterior dislocations: (depending on where head of humerus ends up)
  • Subclavicular
  • Subcoracoid
  • Subglenoid
  • 
• 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.
  • 
• 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.
• 
• 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