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 > 1520 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 examiners resistance

PE: Muscle testing

Subscapularis
Lift-off test

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

PE: Muscle Testing

Infraspinatus/Teres Minor

Patients arms adducted at sides Elbows flexed to 90 Patient attempts external rotation against examiners resistance

Impingement Signs:
Neers Test

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