Shoulder Dislocations:
- Most common shoulder dislocation? Anterior (arm is abducted + externally rotated, squared-off shoulders)
- Most commonly missed shoulder dislocation? Posterior (arm is adducted + internally rotated)
- Most important X-ray to diagnose shoulder dislocation? Axillary view
- If you do MRI -> will show bankart lesion (anterior inferior labrum tear)
- Positive apprehension test -> needs surgery
- Age is #1 factor to tell if the pt will re-dislocate
- Treatment for first dislocation: traction + counter-traction
- Treatment for recurrent dislocations: physiotherapy, then arthroscopy repair of teared labrum
- Most common complication in young? Re–dislocation and axillary N injury
- Most common complication in elderly? Rotator cuff tear
Rotator Cuff injury:
- First stage is bursitis -> then tear
- Pt will complain of pain, can’t lay on his\her side, stiffness, weakness
- First action lost -> internal rotation
- Know the different tests done in physical examination:
- Impingement
- Painful arc: active abduction will cause pain after 90-120°
- Neer sign: shoulder IR + passively forward flex the arm
- Hawkin’s test: flex elbow and shoulder 90° + internally rotate the shoulder
- Supraspinatus: empty can test: jobe’s test
- Subscapularis: lift off test
- Infraspinatus: resisted ER w\ arm by side
- Teres minor: Hornblower’s sign: 90° shoulder abduction, elbow 90° flexion + resist ER
- Biceps:
- Speed’s test: forward flex shoulder 90°, supinate forearm, resisted downward force
- Yergason’s test: arm by side, elbow 90° flex, resist supination
- AC joint: cross arm test: FF shoulder 90, adduct arm horizontally
- Impingement
- Dx: MRI
- First line treatment: physio, NSAIDs, steroid injection, US shockwaves -> if not working (3-12 mo) -> surgical decompression
- If young patient with acute tear -> cuff repair w\in 6 wks
- Left untreated; will lead to rotator cuff arthopathy:
- Arthritis due to rotator cuff dysfunx -> proximal humerus migration
- Swelling, atrophy SS\IS, fluid sign (GHJ fluid in soft tissue)
- Tx is hemiarthropathy (reverse shoulder)
Frozen Shoulder; Adhesive Capsulitis:
- “Essential lesion” is CHL contracture of the rotator interval
- Diabetes, cervical spondylosis, hypothyroid, female
- Stages:
- Inflammation: hot, painful, some dec ROM -> injections, NSAIDs
- Frozen stage: dec pain, more loss of ROM
- Thawing stage: slow improvement
- First line is conservative: blah, blah
- If left untreated, it will disappear in 12-18 months, but the pt will end up w\ stiffness, so prompt treatment is important!
Avascular Necrosis:
- Less common, better prognosis than hip AVN
- Anterolateral branch = arcuate artery = artery of Laing
- Causes: ASEPTIC: Anemia, Sickle cell, EtOH, Pancreatitis, Thyroid\Trauma, Idiopathic\Iatrogenic, Caisson’s
- Stages:
- Stage 1: normal
- Stage 2: sclerosis
- Stage 3: crescent
- Stage 4: collapse
- Stage 5: glenoid involvement
- First line treatment: conservative
- If the head is not collapsed -> decompression
- If the head is collapsed -> replace
Osteoarthritis:
- Can be primary OA, or not (after trauma)
- First line: conservative
- If unresponsive: total shoulder replacement (bc both the head and glenoid are affected)
Tendinopathies:
- Most common side of overuse tendon injury? Osteotendinous junction
- Conservative: rest, analgesia, physio, US shockwave, brace -> for 3-6 mo
- If failed -> surgery (debride the tendon)
- Most common is epicondylitis (Tennis elbow) -> ECRB
De Quervain’s Tenosynovitis:
- Inflammation of first extensor compartment of the hand (EPB, APL)
- Finkelstein’s test
- Conservative, if failed; surgical release
Carpal Tunnel Syndrome:
- MCC is idiopathic
- Risk factors: female, obese, pregnant, hypothyroid, RA, age, CRF, alcohol, DM, repetitive motion
- Most sensitive test -> carpal tunnel compression test
- Most reliable test -> nerve conduction studies
- Conservative (NSAIDs, night splints), if failed; surgical decompression
Download the PDF version: here
References:
- Dr. Wazzan AlJuhani’s lecture
