Shoulder
Shoulder Dislocation (glenohumeral luxation)
- AP x-ray to r/o fracture with axillary and Y-view x-ray to distinguish anterior from posterior dislocation
Anterior (MC)
MOI: Abducted, externally rotated - FOOSH
SSX: Pt keeps arm externally rotated and abducted
Deltoid squared off (not contoured)
Check for axillary nerve damage
Sergeant's patch (lateral deltoid) sensory deficit
Hill-Sachs: Impact of humeral head against glenoid rim ➔ notch in humeral head
Bankart lesion: Stripping of glenoid labrum with bone fragment
James Heilman, MD, CC BY-SA 4.0, via Wikimedia Commons
James Heilman, MD, CC BY-SA 4.0, via Wikimedia Commons
Posterior
MOI: ADducted, internally rotated
Weird MOI is why uncommon
Blow to anterior shoulder
Seizures
Electrocution
SSX: Pt keeps arm internally rotated
Anterior shoulder looks flat
Can have Reverse Hill-Sachs
Notch in anteromedial humeral head
Light bulb sign on AP
Hellerhoff, CC BY-SA 3.0, via Wikimedia Commons (Right - post reduction)
Shoulder dislocation TX
Closed reduction then immobilize (sling and swathe)
Check axillary nerve damage before and after reduction
Get imaging (above and below) before and after reduction
Surgery if large Bankhart/Hill-Sachs, neurovascular ssx
Anterior dislocation
First, try upright scapular manipulation
Push scapula medial while someone pulls flexed arm downward
If not reduced, try external rotation
Put pt supine, elbow flexed across ABD, externally rotate w/elbow flexed
If not reduced with external rotation, move into Milch technique
With arm externally rotated
Bring pt's arm overhead and apply pressure to humeral head
Posterior dislocation
Apply downward traction at flexed elbow then adduct arm (bring toward ABD)
Acromio-Clavicular Separation
MOI: Direct shoulder blow
MC types: 1-3
Type 1: AC ligament sprain
Type 2: AC rupture ➔ widened AC joint
Type 3: AC AND CC ligaments rupture
SSX: Pain and/or unable to lift the arm
DX: 3-view x-ray both shoulders (for comparison)
± weighted to show displacement
TX: Types 1, 2, 3 - conservative (RICE)
Types 4-6 - surgical reattachment
Clavicle Fracture
MOI: Landing on shoulder (fall from bike, direct blow)
MC in kids
SSX: Pain and/or unable to lift the arm with hx of trauma
Tenting/bulge, ecchymoses
No mechanism ➔ think underlying pathology
DX: AP view to assess displacement
PA chest can help to compare length with uninjured clavicle
Allman group I (MC): middle third fx
Allman group II: distal third fx
Allman group III: proximal third fx
Usually with multisystem trauma
TX: 3-6 weeks of sling (kids), 6-12 weeks in adults
Ortho referral:
Group I if complete displacement, shortened, comminuted
Group II if ligament detachment ➔ displacement
Group III... probably seeing the pt for the other injuries
Rotator Cuff
Athlete ➔ acute tear (pitcher tears infraspinatus)
Repetitive overhead movements ➔ degenerative tear
SSX: Pain (classically over lateral deltoid) that ↑ with overhead movements
± weakness
DX: Pt's hx and PE ➔ clinical dx
Significant RC tear likely if all 3 are positive:
Active painful arc test
Drop arm test
Weak external rotation (infraspinatus)
X-ray can show superior displacement of humeral head
High riding humeral head is present in chronic RC tear, RA, and pseudogout
MRI: full thickness and some partial tears; Arthrography with CT or MRI better for partial tears
TX: 6wks of PT then intra-articular steroid injection if pain still present
If no improvement at 3 month f/u "maximize nonoperative tx" or surgery referral
Acute trauma ➔ full-thickness tears in healthy pt ➔ immediate surgery
Subacromial Impingement Syndrome
Forward head/rounded shoulder posture or RC injury ➔ RC tendons & subacromial bursa pinched in subacromial space
SSX: Pain with overhead movements/sleeping/internal rotation
↓ active ROM (2° to pain) but can have preserved passive ROM
Neer test (passive painful arc)
Abduct pt's arm in neutral plane to 20°, push scapula to prevent shoulder shrugging, then lift (like you're raising their hand)
Hawkins test (flexion with internal rotation)
Grade I: inflammation of bursa and tendons
Grade II: fibrosing of bursa
Grade III: rotator cuff degeneration ➔ RC tears
TX: PT, ice, NSAIDs
Surgery: arthroscopic decompression or if acromion narrowing ➔ open acromioplasty
Adhesive Capsulitis (frozen shoulder)
40-65yo ♀ endocrine (DM, thyroid), mastectomy
Inflammation ➔ fibrosis of joint capsule
SSX: Dull shoulder pain, worse at night
↓ active and ↓ passive ROM
Inflammatory: 4-6 months, pain WITHOUT signs of trauma/rotator cuff tear
Freezing phase: 4-6 months, ↓ pain but ↑ stiffness
Thawing phase: slowly regain ROM over 1-2 years
TX: PT ➔ ↑ ROM
NSAIDs, chronic gets intra-articular steroid injections
Shoulder Physical Exam (Special Tests)
Pain with weakness (significant tendon tear) - Pain without weakness (tendinopathy or minor tendon tear)
Supraspinatus - abduction
Supraspinatus isometric strength
Pt abducts arm in neutral plane to 20° then resists against adduction for 30 secs
Active painful arc (not the Neer - Neer is passive)
Pt abducts arm in neutral plane to 20° then raises their hand
Drop arm test
Pt lowers arm from fully abducted position (positive if pt can't lower arm smoothly)
Empty can (Jobe's)
Arm in 90° of abduction, 30° of forward flexion, internally rotate arm (thumb pointing down)
Pt resists adduction
Infraspinatus - external rotation
Infraspinatus isometric strength
Pt externally rotates adducted arm against resistance
Subscapularis - internal rotation
Push off (Gerber's lift-off)
Pt's hand behind back and push posteriorly against resistance
Check out StartRadiology X-shoulder