Acute Orthopaedic Injuries Developing a Diagnostic Approach to the Shoulder

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Primrose Marshall
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1 Acute Orthopaedic Injuries Developing a Diagnostic Approach to the Shoulder

2 Overview To be able to quickly categorize shoulder injuries To take appropriate history and conduct proper exam of shoulder and related structures Begin immediate treatment plan Advise regarding recovery and return to play

3 Shoulder Injuries Fracture AC joint Injury Instability/Dislocation Referred pain Rotator Cuff Injury

4 Usually very easy to determine from clinical point of view Look for deformity and feel for crepitus although you only get one chance at the crepitus Start at SC joint and work out laterally Fractures

$complex multipart fractures MRI$

5 Fractures Trauma x-rays include AP and axillary view CT useful for complex multipart fractures MRI has no role in fracture diagnosis or care

6 Glenohumeral Dislocations Most common dislocated joint in the body Most often abduction and external rotation 1.7% of adult population Large male:female ratio 9:1, most frequently in 21 to 30 age group Redislocation rates from 30% to 100% Classified as acute or recurrent Anterior, posterior, inferior or multidirectional instability

7 Glenohumeral Dislocations Complications include axillary nerve palsy recurrence of subluxation/dislocation in the young tear of the rotator cuff in the older(over age 30)((ouch)) Must be aware of possibility of posterior dislocation, often missed

8 Glenohumeral Dislocations Diagnosed with history and AP, axillary or Y view Document normal neurological status pre reduction Post reduction x-ray

9 Glenohumeral Dislocations Recurrent dislocations tested by : apprehension/ relocation test Load and shift test Sulcus sign Jerk test

10 Glenohumeral Dislocations Treatment protocols range from prolonged immobilization to rapid return to sports Use of a brace has been used to allow return to sports and complete the season Buss et al AJSM Vol. 32 No 6 Recent evidence shows immobilization in external rotation may help to reduce recurrence

11 Rotator Cuff Injuries Can vary from contusion to complete tears Often present with impingement and are acute on chronic injuries

12 Impingement Can occur from external(primary or secondary) or internal causes Secondary external from inadequate muscular stabilization of scapula or weakness of cuff leads to instability of humeral head Internal occurs mainly in overhead athletes at late cocking stage of throwing

13 Impingement Tested by Hawkin s or Neer s tests

14 Rotator Cuff Contusion Bradley et al AJSM Vol. 35 No 3 Result of traumatic insult, most frequently direct blow to shoulder in football or fall on elbow jamming shoulder Account for almost 50% of shoulder injuries in football

15 Rotator Cuff Contusion Exam shows decreased active ROM especially abduction with normal passive ROM Weakness of affected muscle Investigation with MRI arthrogram is recommended Treament protocol includes pain meds and cryotherapy with pasive ROM for 3 days At day 3 if MRI consistent and still dysfunction then subacromial steroids

16 Rotator Cuff Contusion Average return was at 4 days, return to practice/play judged by full ROM and full strength 11.4% went on to full rotator cuff tears and required surgical intervention Authors felt MRI important to avoid under treatment of injury

17 Rotator Cuff Tears Occur primarily of the supraspinatus tendon Weakness and pain especially at night are common as are weakness, catching and grating

18 Rotator Cuff Tears Examination Look for wasting of muscles Passive range of motion usually normal Test supraspinatus with Empty can sign

19 Rotator Cuff Tears Infraspinatus tested by resisted external fixation

20 Rotator Cuff Tears Subscapularis tested by lift off test Napoleon test

21 Rotator Cuff Tears Ultrasound is very good and inexpensive for evaluating cuff tears Operator dependant and in many areas more difficult to obtain than MRI MRI +/- arthogram most useful for evaluating soft tissue injury

22 Rotator Cuff Tears Treatment should be adapted to the patient Nonoperative rehabilitation in the elderly Trial of nonoperative in non labourer, operative for pain control Aggressive surgical for labourer/athlete including for first time dislocator Open or arthroscopic options exist and results are equal

23 AC Joint Injury Often missed as source of shoulder pain Most frequently fall on point of shoulder Diagnose with cross body motion and often use of injection to localize pain to AC joint

24 AC Joint Classification of injuries to AC joint In grade 1 or 2 treatment non operative Grade 3 controversial Grade 4, 5 or 6 operative

25 Referred Pain Shoulder very common site for referred pain from: Cervical spine Thoracic spine Soft tissues of upper back Biceps injury Nerve entrapments Look for trigger points Palpate spine and perform neurological exam if suspicious Nerve conduction studies may be required

26 Referred Pain Don t forget shoulder pain can be the presentation of myocardial infarction, rupture of spleen, perforated ulcer, diaphragm injury or cholecystisis Don t miss the proximal humeral tumor in young and older patients

27 Summary Don t forget about past history of injury or shoulder problems Should be able to categorize problem fairly quickly by history Special tests should crystallize diagnosis Imaging studies should only be done to confirm diagnosis or plan for treatment

2015 OPSC Annual Convention. syllabus. February 4-8, 2015 Hyatt Regency Mission Bay San Diego, California

2015 OPSC Annual Convention. syllabus. February 4-8, 2015 Hyatt Regency Mission Bay San Diego, California 2015 OPSC Annual Convention syllabus February 4-8, 2015 Hyatt Regency Mission Bay San Diego, California THURSDAY, FEBRUARY 5, 2015: 3:30pm - 4:30pm The Shoulder: 2 View or Not 2 View * Presented by Alexandra