8/12/2011 Shoulder Joint Basic Structures: . Clavicle . Scapula . AC joint . Proximal humerus . Greater tuberosity . Rotator cuff muscles http://commons.wikimedia.org/wiki/File:Shoulderjoint.PNG UMDNJ PANCE/PANRE Review Course Acromioclavicular Injury Young, active person with direct fall onto shoulder S/S::--painpain at top of shoulder, radiates to neck -tender, swollen AC joint, decreased ROM -positive crossover test Dx::--clinical,clinical, x-x-raysrays if unsure Tx::--ice,ice, sling 22--44 wks, NSAIDs, early ROM --gradesgrades IVIV--VIVI f/u with orthopedic surgeon UMDNJ PANCE/PANRE Review Course Grading Scale for AC Injury II-- contusion/sprain of AC joint IIII-- rupture of AC ligament III- minor displacement of clavicle IVIV--VIVI-- coracoclavicular ligament rupture, significant displacement of clavicle UMDNJ PANCE/PANRE Review Course 1 8/12/2011 http://commons.wikimedia.org/wiki/File:Shoulder_joint_anatomy_quiz.jpg UMDNJ PANCE/PANRE Review Course Clavicle Fracture Most common bone fractured in children, due to direct trauma (sporting events) or fall on outstretched hand S/S: -pain over clavicle, possible deformity or tenting of skin --decreaseddecreased shoulder ROM --documentdocument pulses, sensation, strength --mostmost fractured at middle 1/3 UMDNJ PANCE/PANRE Review Course Clavicle Fracture cont’d Dx::--clavicleclavicle xx--ray,ray, if medial 1/3 fractured, study for subclavian artery or intrathoracic injjyury Tx::--slingsling or figure of 8 splint, 33--44 wks --afterafter 33--44 wks start range of motion UMDNJ PANCE/PANRE Review Course 2 8/12/2011 http://commons.wikimedia.org/wiki/File:Claviculafraktur_median_tangential.jpg UMDNJ PANCE/PANRE Review Course Rotator Cuff SITS Muscles Supraspinatus (most commonly injured) Infraspinatus Teres Minor Subscapularis Top 3 insert on the greater tuberosity http://upload.wikimedia.org/wikipedia/commons/9/90/Shoulderjoint.PNG UMDNJ PANCE/PANRE Review Course Rotator Cuff Disorders Chronic, overhead work or fall on hand. Pain begins as inflammation, then becomes impingement then progresses to tear S/S::--painpain at greater tuberosity, lateral shoulder -pain and difficulty abducting arm -positive Neer impingement sign Dx::--MRIMRI Tx::--rest,rest, ice, NSAIDs, PT, steroid injection --ifif no better after 66--1212 wks, consider surgery UMDNJ PANCE/PANRE Review Course 3 8/12/2011 Biceps Tendonitis Caused by overuse of the biceps muscles, usually heavy or excessive lifting S/S::--presentspresents as anterior shoulder pain -bicipital groove tenderness --painpain with resisted supination of forearm Dx::--clinical,clinical, x-x-rayray to r/o other injury Tx::--rest,rest, ice, sling, NSAINSAIDs,Ds, steroid injectioninjection-- not into tendon sheath UMDNJ PANCE/PANRE Review Course http://upload.wikimedia.org/wikipedia/commons/9/90/Shoulderjoint.PNG UMDNJ PANCE/PANRE Review Course Proximal Humerus Fracture Fall onto outstretched hand, common in elderly women with osteoporosis S/S::--pain,pain, swelling proximal humerus with decreased shoulder ROM --evaluateevaluate axillary artery/nerve Dx::--xx--rayray (Y(Y--viewview to r/o dislocation) Tx::--slingsling and swath 4 wks, early ROM -surgery if head displaced or compound fx UMDNJ PANCE/PANRE Review Course 4 8/12/2011 Proximal Humerus Fracture Impacted, stable fracture http://upload.wikimedia.org/wikipedia/commons/2/20/Surgical_neck_fracture_of_humerus.jpg UMDNJ PANCE/PANRE Review Course Shoulder Dislocations Fall on externally rotated, abducted arm (trying to catch self while falling) S/S::--presentpresent with arm abducted and in ER --shouldershoulder appears “squared off” --evaluateevaluate axillary nerve and artery UMDNJ PANCE/PANRE Review Course Shoulder Dislocations cont’d Dx::--xx--rayray (A/P, lateral, Y-Y-view)view) -97% are anterior dislocations, posterior RARE (usually due to electric shock or seizure) Tx::--immediate closed reduction with postpost--reductionreduction xx--rayray --sling/swathsling/swath 4 wks, start ROM at 2 wks UMDNJ PANCE/PANRE Review Course 5 8/12/2011 http://upload.wikimedia.org/wikipedia/commons/e/ea/Luxation_epaule.PNG UMDNJ PANCE/PANRE Review Course A patient c/o right shoulder pain after a fall. He has no weakness but a + crossover test. What is the most likely diagnosis? 87% 1. Acromioclavicular injury 2. Adhesive capsulitis 10% 3. Biceps tendonitis 1% 3% 4. Rotator cuff is is e it ulit injury s on ptur p rupture a f ru c f tend u s c ive p e or c t ta Bi o Adhes R Acromioclavicular UMDNJ PANCE/PANRE Review Course Of the SITS muscles, which is most likely to be torn? 95% 1. Infraspinatus 2. Subscapularis 3. Supraspinatus 4. Teres minor 1% 3% 1% s r inatus mino p pularis s a e aspinatu r fras r n Te I Subsc Sup UMDNJ PANCE/PANRE Review Course 6 8/12/2011 Elbow Joint Basic Structures: . Proximal ulna . Proximal radius . Distal humerus . Radial nerve . Ulnar nerve http://upload.wikimedia.org/wikipedia/commons/7/73/Gray331.png UMDNJ PANCE/PANRE Review Course Lateral Epicondylitis (Tennis Elbow) OveruseOveruse--repetitiverepetitive supination and wrist extension S/S::--pointpoint tenderness over lateral epicondyle, pain on resisted wrist extension Dx::--clinical,clinical, x-x-rayray to r/o arthritis or loose body Tx::--rest,rest, ice, NSAIDs, counter force strap, steroid injection UMDNJ PANCE/PANRE Review Course Medial Epicondylitis (Golfer’s Elbow, Pitcher’s Elbow) OveruseOveruse--repetitiverepetitive wrist flexion and pronation S/S::--pointpoint tenderness over medial epicondyle, pain on resisted wrist flexion Dx::--clinical,clinical, x-x-rayray to r/o arthritis or loose body Tx::--rest,rest, ice, NSAIDs, steroid injection, stretching exercises UMDNJ PANCE/PANRE Review Course 7 8/12/2011 Supracondylar Fracture Common in children, caused by direct blow or fall on outstretched hand S/S::--painpain and swelling over distal humerus -evaluate radial/ulnar nerve and artery Dx::--xx--ray,ray, look for posterior fat pad sign --bilateralbilateral x-x-raysrays helpful Tx::--nonnon--displaceddisplaced--longlong arm cast --displaceddisplaced-- refer to surgeon UMDNJ PANCE/PANRE Review Course http://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Healing_supracondylar_fracture.jpg/485pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Healing_supracondylar_fracture.jpg/485px--Healing_supracondylar_fractureHealing_supracondylar_fracture.jpg.jpg UMDNJ PANCE/PANRE Review Course Radial Head Fracture Result of a fall on outstretched hand S/S::--presentpresent splinting in flexion --swellingswelling and diffuse elbow pain over lateral elbow Dx::--xx--ray,ray, look for posterior fat pad sign (demonstrates blood in joint) Tx::--nonnon--displaceddisplaced or occultoccult--slingsling 22--44 wks UMDNJ PANCE/PANRE Review Course 8 8/12/2011 http://upload.wikimedia.org/wikipedia/commons/thumb/8/89/Fettpolsterzeichen_pathologisch_Ellenbogen.png/585pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/8/89/Fettpolsterzeichen_pathologisch_Ellenbogen.png/585px--FettpolsterzeichenFettpolsterzeichen_pathologisch_Ellenbogen.png_pathologisch_Ellenbogen.png UMDNJ PANCE/PANRE Review Course Wrist and Hand Basic Structures: . Distal radius . Distal ulna . Carpals . Metacarpals . Phalanges http://upload.wikimedia.org/wikipedia/commons/1/1c/Gray1237.png UMDNJ PANCE/PANRE Review Course Colles Fracture (distal radius fracture) Elderly person, fall on an outstretched hand S/S::--swelling,swelling, tenderness and contusion over distal radius/ulna --appearanceappearance often called a “silverfork” deformity UMDNJ PANCE/PANRE Review Course 9 8/12/2011 Colles Fracture cont’d Dx::--xx--ray,ray, distal radius fracturefracture with dorsal angulation (Smith’s fxfx-- distal radius fracture with volar angg)ulation) Tx::--closedclosed reduction and cast 66--88 wks --ifif intraintra--articulararticular requires surgery UMDNJ PANCE/PANRE Review Course http://upload.wikimedia.org/wikipedia/commons/thumb/4/4a/Displaced_distal_radius_fracture.jpg/592pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/4/4a/Displaced_distal_radius_fracture.jpg/592px--Displaced_distal_radius_fracDisplaced_distal_radius_fracture.jpgture.jpg UMDNJ PANCE/PANRE Review Course http://upload.wikimedia.org/wikipedia/commons/0/02/DistUArm2.png UMDNJ PANCE/PANRE Review Course 10 8/12/2011 http://upload.wikimedia.org/wikipedia/commons/thumb/0/0f/DistUArm1.png/800pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/0/0f/DistUArm1.png/800px--DistUArm1.pngDistUArm1.png UMDNJ PANCE/PANRE Review Course Gamekeeper’s Thumb Thumb forced into radial deviation, stresses ulnar collateral ligament (ski pole) S/S::--painpain with radial stress of thumb Dx::--radialradial deviation > than opposite side Tx::--partialpartial lig. rupture-rupture- thumb spica cast --completecomplete lig. rupture-rupture-ORIFORIF UMDNJ PANCE/PANRE Review Course Scaphoid Fracture Most common carpal fracture, due to fall on outstretched hand S/SS::--snuff box tenderness,,p pain with ulnar deviation of the wrist --highhigh index of suspicion with negative xx--raysrays Dx::--xx--ray,ray, all views may be negative --bonebone scan will confirm diagnosis UMDNJ PANCE/PANRE Review Course 11 8/12/2011 Scaphoid Fracture cont’d Tx::--nonnon--displaceddisplaced-- thumb spica cast 66--2020 wks -if suspect - immobilize and repeat x-ray in 1 wk or r/o with bone scan High nonnon--unionunion rate with waist and proximal fractures UMDNJ PANCE/PANRE Review Course http://upload.wikimedia.org/wikipedia/commons/thumb/2/22/Scaphoid_waist_fracture.gif/478pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/2/22/Scaphoid_waist_fracture.gif/478px--Scaphoid_waist_fracture.gifScaphoid_waist_fracture.gif