Morning Report-ish Shoulders

Adam Ware PGY-3

18 year old presents after crash on mountain bike.
• Helmeted mountain bike rider describes this:
– http://www.youtube.com/watch?v=0WzBLmW2kc

• Unable to move right shoulder since crash

Physical Exam

Physical Exam

Shoulder anatomy

AC Joint Sprain/Separation
• Six classifications of injury:

AC Joint Sprain/Separation
• Physical Exam:
– Well-localized swelling & tenderness over AC joint – Painful active & passive range of motion – Crossover testing (scarf sign) increases pain – Type II, III, V may have high riding clavicle – May have tenderness to palpation over clavicle shaft, SC joint & clavicular attachments of trapezius & deltoids

AC joint:
Crossover Test

• Patient raises affected arm to 90° • Actively adducts arm across body • Forces acromion into distal end of clavicle • Isolates AC joint & painful if positive

AC Joint Sprain
• Treatment:
– Type I, II, III:
• Conservative treatment • Ice, Rest, NSAIDS • Begin ROM exercise as soon as tolerated

– Type IV and higher:
• May require further intervention

18 year old with shoulder pain
• Skateboarding accident – Fell forward after jumping from stairs – Like this: http://www.youtube.com/watch?v=NoPBevhP blo • Presented via EMS with pain over mid-clavicle

Clavicle Fracture

Clavicle Fracture
• Physical Exam:
– Visible & palpable deformity – Local pain & swelling – Pain may radiate into trapezius & neck – Complete neuro exam important to detect brachial plexus injury

Clavicle Fracture
• Treatment:
– Conservative – Sling for 2 to 4 weeks – Displaced fractures may need referral for further evaluation

Risk Factors for Nonunion of Midshaft Clavicle Fractures • • • • • • Clavicle shortening > 15–20 mm Female sex Fracture comminution Fracture displacement Greater extent of initial trauma Older age

16 year old
• Wrestling practice described being thrown like this:
– http://www.youtube.com/watch?v=Avo88766Ek0

• Unable to move shoulder. No prior history of shoulder injury.

Anterior Shoulder Subluxation/Dislocation
• Dislocation:
– Complete separation of articular surfaces

• Subluxation:
– Abnormal translation of humeral head on glenoid without complete separation of articular surfaces

• Humeral head can dislocate anteriorly, posteriorly or inferiorly • Anterior dislocation most common

Anterior Shoulder Subluxation/Dislocation
• Mechanism:
– Forced extension, abduction, external rotation – Direct blow to posterior or posterolateral shoulder – Repeated episodes of overuse (subluxation)

Anterior Shoulder Subluxation/Dislocation
• Physical Exam:
– Intense pain – Arm held in abduction & external rotation – Humeral head palpable anteriorly – Unable to completely internally rotate or abduct the shoulder – Thorough neuro exam (close relation of axillary nerve)

Anterior Shoulder Dislocation
• Prompt reduction • Many different methods of reduction

Tractioncountertraction

Anterior Shoulder Dislocation
• Stimson maneuver

• Kocher Maneuver
– http://www.youtube .com/watch?v=jD0 eAuctHoo

Anterior Shoulder Subluxation/Dislocation
• Treatment:
– Sling – few days to 2 weeks – Ice – NSAIDS – Protected range of motion – Rotator cuff strengthening after acute pain resolves – Return to sport when normal strength & motion regained

12 year old with shoulder pain
• No recent trauma • Participates as pitcher on competitive baseball team. • Physical exam shows pain with passive and active ROM of shoulder, minimal swelling, and pain to palpation over proximal humerus.

Little League shoulder
• • • • • • Stress fracture through the prox humeral physis Commonly in throwers Overload/overstress injury Dx: clinical Tx: rest for 4-6wks, followed by rehabilitation Return to full activity when full, pain free ROM, improved stability, normal strength present

Impingement/Rotator cuff tendonitis
• Overuse injury • Repetitive subacromial impingement, compression of rotator cuff and/or biceps tendon btw head of humerus and coraco-acromial arch • Swimmers, baseball, volleyball, tennis

Shoulder Impingement Treatment
• Phase 1: pain control
– Ice, NSAIDs, limit overhead activity

• Phase 2: therapeutic exercise
– Strengthen interscapular mm with rowing type exercise – Use elastic tubing to strengthen external rotators of shoulder

• Phase 3: maintain fitness
– General conditioning, running, cycling

Strengthening exercises
Figure 1. Strengthening inter-scapular muscles with elastic tubing

Figure 2. Shoulder protraction exercise (balance with one arm on wobble board or deflated ball)

Strengthening Exercises

PE: Range of Motion
• Flexion/Extension • Abduction/Adduction • Internal/External Rotation

PE: Muscle Testing
Supraspinatus

• • • •

Empty Can Test 90° abduction 30° forward flexion Thumbs pointing downward • Patient attempts elevation against examiner’s resistance

PE: Muscle testing
Subscapularis
• “Lift-off test”

• Internally rotate shoulder • Dorsum of hand against lower back • Patient attempts to push away examiner’s hand • Modified: Place hand on abdomen and resist internal rotation

PE: Muscle Testing
Infraspinatus/Teres Minor

• Patient’s arms adducted at sides • Elbows flexed to 90° • Patient attempts external rotation against examiner’s resistance

Impingement Signs:
Neer’s Test

• Scapula stabilized • Arm fully pronated • Examiner brings shoulder into maximal forward flexion • Pain  subacromial impingement