Upper Extremity-Shoulder Injuries

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Upper Extremity-Shoulder Injuries
2014-10-28 12:55:41
upper extremity shoulder injuries

injuries of shoulder
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  1. Clavicle Fx's-Etiology
    • MOI-
    • *FOOSH
    • *Falling on the tip of the shoulder
    • *Direct Blow
    • Majority occur in the middle 3rd from direct impact
  2. Clavicle Fx's-S&S
    • Athlete will support the arm on the injured side, with head tilted toward the injury and chin turned away
    • Injured clavicle appears lower than opposite side during observation
    • swelling, point tenderness and mild deformity
  3. Clavicle Fx's-Mgmt
    • Ice
    • Swathe and Sling
    • Refer to Dr, xray, immobilize 6-8 weeks
  4. Scapula Fx's-Etiology
    • infrequent because of bony borders and muscle cushion
    • MOI
    • *direct impact
    • *force transmitted thru humerus
    • Can occur to:
    • *body, glenoid, acromion and coracoid processes
  5. Scapula Fx's-S&S
    • pain during shoulder mvmts
    • swelling and point tenderness
  6. Scapula Fx's-Mgmt
    • sling
    • refer to dr, x ray
    • support arm for 3 weeks, overhead exercises beginning week one
  7. Humeral Fx's-Etiology
    Humeral Shaft
    • MOI
    • *direct blow or falling on arm
    • Usually a transverse fx producing a deformity
    • radial nerve likely severed
  8. Humeral Fx's-Etiology
    Proximal Humerus (Humeral Head)
    • MOI
    • *direct blow
    • *dislocation
    • *FOOSH
    • areas involved:
    • *anatomical neck, tuberosities or surgical neck (most common)
  9. Humeral Fx's-Etiology
    Epiphyseal Fx
    • More common in young athletes, 10 yrs or younger
    • MOI
    • *direct blow or any force traveling up the length of humerus
    • May show a false joint (immature cartilaginous joint)
  10. Humeral Fx's-S&S
    • pain, inability to move arm
    • swelling, severe hemorrhage
    • paralysis
    • point tenderness
  11. Humeral Fx's-Mgmt
    Humeral Shaft
    • splint
    • refer to dr., xray
    • recovery 3-4 months
  12. Humeral Fx's-Mgmt
    Proximal Humerus
    • sling
    • refer to dr, xray
    • recovery 2-6 months
  13. Humeral Fx's-Mgmt
    • splint
    • refer to dr. x ray
    • immobilize 3 wks, danger if damage is severe to growth plate
  14. Sternoclavicular Sprain-Etiology
    • relatively uncommon
    • MOI:
    • *indirect force transmitted thru humerus
    • *direct blow
    • *torsion (displacing upward and slightly anterior)
  15. Sternoclavicular Sprain-S&S
    Grade 1
    • pain and disability
    • no deformity
    • point tenderness
  16. Sternoclavicular Sprain-S&S
    Grade 2
    • subluxation of SC joint, visible deformity
    • pian, swelling, point tenderness
    • inability to abduct full ROM or perform horizontal adduction
  17. Sternoclavicular Sprain-S&S
    Grade 3
    • severe deformity
    •    *indicating a complete rupture of the SC joint and costoclavicular ligaments
    • be aware of a posterior displacement
    •    *pressure on esophagus, trachea and carotid artery
  18. Sternoclavicular Sprain-Mgmt
    • ice and compression
    • depending on severity
    •    *refer to dr., xray
    •    *immobilize for 3-5 weeks
    • High recurrence
  19. Acromioclavicular Sprain-Etiology
    • MOI
    • *direct impact to the tip of the shoulder (most common)
    • *FOOSH (causing an upward force) (grade 1 or 2)
    • Graded 1-6
    • Direct impact injuries are usually more severe
  20. Acromioclavicular Sprain-S&S
    Grade 1
    • point tenderness and discomfort with movment
    • mild stretch of AC and CC ligaments
  21. Acromioclavicular Sprain-S&S
    Grade 2
    • partial displacement
    • point tenderness
    • unable to fully abduct and horizontally adduct thru ROM
    • Rupture of AC and stretch of CC
  22. Acromioclavicular Sprain-S&S
    Grade 3
    • superior displacement of clavicle
    • rupture of AC and CC
  23. Acromioclavicular Sprain-S&S
    Grade 4
    • posterior displacement of clavicle
    • rupture of AC ligaments
    • CC ligaments may remain in tact (not likley)
  24. Acromioclavicular Sprain-S&S
    Grade 5
    • complete rupture of AC and CC
    • tearing of the trapezius and deltoid attachments
    • gross deformity, severe pain, loss of movement
    • shoulder complex becomes unstable
  25. Acromioclavicular Sprain-S&S
    Grade 6
    • very rare
    • rupture of AC and CC ligaments
    • clavicle is displaced inferior to the coracoid behind the coracobrachialis
  26. Acromioclavicular Sprain-Mgmt
    • apply a cold compress to control hemorrhaging
    • stabilizing w/ sling and swathe
    • refer to dr. to diagnose
    • grade 1: recovery 3-4 dars
    • Grade 2: recovery 10-14 days
    • Grades 4-6 req. surgical repair
  27. Glenohumeral Joint Sprain-Etiology
    • MOI
    • *arm forced into abduction (anterior capsule)
    • *forced external rotation
    • *direct blow
    • Rotator cuff muscles are usually affected with shoulder sprain
  28. Glenohumeral Joint Sprain-S&S
    • pain during movement
    • decreased ROM
  29. Glenohumeral Joint Sprain-Mgmt
    • ice and compression for 48 hrs
    • sling (depending on severity)
    • modalities
    • exercises
    •    *ROM
    •    *Strength
  30. Acute Dislocations and Subluxations-General
    • Account fo rup to 50% of all dislocations
    • Extreme ROM causes instability
    • Most common is anterior displacement
    • Once you have a dislocation, 85-90% recurrence
  31. Subluxations-General
    • excessive translation of the humeral head without a complete separation of the joint surfaces
    • can occur ant, post, or inf.
  32. Dislocations/Subluxations-Etiology
    • direct impact to posterior or posterolateral aspect of the shoulder
    • most common MOI
    • *forced abduction, external rotation and extension
    • The humerus is forced out of the articulation anteriorly passed the labrum then downward under the coracoid process
    • may cause a tear or detachment of the glenoid labrum causing instability
    • **Bankhart Lesion: permanent detachment (tear) on the anterior labrum
    • **Hill-Sachs deformity (lesion): defet on the posteriolateral aspect of the humeral head against the anterior glenoid rim, creating a divot in the bone
    • **SLAP lesion: on the superior aspect of the labrum, beginning posteriorly extending anteriorly affecting the attachment of the long head of the biceps to the labrum
  33. Dislocations/Subluxations-Etiology
    Posterior dislocations
    • MOI
    • *forced adduction and internal rotation, or fall on an extended and internally rotated arm
    • tears to posterior labrum are common (sometimes known as reverse bankart lesion)
    • Reverse Hill-Sachs deformity (lesion) may occur on the anteromedial portion of the humeral head
  34. Dislocations/Subluxations-S&S
    • flattened deltoid contour (sulcus sign)
    • humeral head is palpable in the axilla
    • patient carries arm in slight abduction and internal rotation
    • moderate pain and disability
  35. Dislocations/Subluxations-S&S
    • severe pain and disability
    • arm held in adduction and external rotation
    • anterior deltoid is flattened
    • acromion and coracoid are prominent
    • head of humerus may seem posterior
  36. Dislocations/Subluxations-Mgmt
    • immediate immobilization in comfortable position
    • immediate reduction by dr.
    • control hemorrhage w/ Ice
    • should NOT be done by AT
    • xrays should be taken prior to reduction
    •   *immobilization 3 wks
    •   *reconditioning should be initiated ASAP
    •   *may perform isometric internal/external rotation while immobilized
    •   *strengthening program should progress as quickly as pain will allow
    • ROM extremely important
  37. Shoulder Impingement-Etiology
    • Caused by a mechanical compression of the supraspinatus tendon or subacromial bursa and long head of biceps
    • repeated compression thru overhead activities causes irritation and inflammation
    •   *these individuals often have hypermobility which can contribute
    • prolonged inflammation causes decreased muscular efficiency, which progressively gets worse
    •   *can progress to rotator cuff tears rupture near the insertion (nearly always)
    • Primary MOI: acute trauma or impingement
    • Mostly likely involves the supraspinatus
    •   *tear of the other rotator cuff muscles are extremely rare
    • Postural malalignment may decrease the space under the coracoacromial arch
    •   *foreward head, rounded shoulders, increased kyphotic curve
    • also having a hook-shaped acromion=more likely to have impingement
  38. Shoulder Impingement-S&S
    • pain around acromion but not stiffness
    • increased pain with palpation of the subacromial space and over head activities
    • swimmers and throwers may have increase in external rotation and decrease with internal rotation
    • + signs with hawkins-kennedy and neers special tests
    •   *empty can and drop arm tests will show supraspinatus weakness
    • Neers 4 stages
  39. Shoulder Impingement-Mgmt
    • initial Ice and e-stim (pain)
    • ultrasound and anti inflammatories
    • modify activities, gradual progression with return
    • strengthening exercises of the rotator cuff
    •   *also movements of abduction, elevation and upward rotation
    • Stage 3 & 4
    •   *immobilization
    •   *could req. surgery
    •         *sub acromial decompression
  40. Scapular Dyskinesis-Etiology
    • Abnormal mvmt of scapula
    • SICK scapula
    • *Scapular malposition
    • *Inferior medial scapular winging
    • *Coracoid tenderness
    • *Kinesis Abnormalities
    • Because of adaptive changes from repetitive use
    •    *particularly throwing athletes
    • Detrimental to normal function
  41. Scapular Dyskinesis-S&S
    • patient will hold the shoulder in slouched position
    • inferior medial border will be prominent in the cocking phase
    • tightness
    •   *pec major and minor
    • weakness
    •   *lower trapezius and serratus anterior
  42. Scapular Dyskinesis-Mgmt
    • stretching of
    •   *posterior capusle
    •    *pec minor, coracobrachialis and short head of biceps
    • strengthen scapular stabilizers
    • throwing athletes shouldn't begin throwing w/ any improper scapular positioning
  43. Shoulder Bursitis-Etiology
    • chronic inflammatory conditions resulting from trauma or overuse
    •    *direct impact
    •    *falling on tip of shoulder
    •    *shoulder impingement
    • subacromial bursa
    • can develop fibrous build up and fluid accumulation from a constant inflammatory state
  44. Shoulder Bursitis-S&S
    • pain w/ movment
    •   *adduction, abduction, flexion, internal rotation
    • tenderness w/ palpation
    • impingement tests are positive
  45. Shoulder Bursitis-Mgmt
    • ice, ultrasound, and antinflammatory meds
    • exercises that will maintain full ROM
  46. Adhesive Capsulitis (Frozen Shoulder)-Etiology
    • older people
    • exact cause is unclear
    • involves contracted and thickened joint capsule
    •   *rotator cuff muscle usually involved
    •   *lack of synovial fluid
    • resist joint movement because of pain
  47. Adhesive Capsulitis (Frozen Shoulder)-S&S
    • pain w/all shoulder movement
    • restrictions w/ passive and active movement
  48. Adhesive Capsulitis (Frozen Shoulder)-Mgmt
    • aggressive joint mobilization and muscle stretching
    • e-stim to decrease pain
    • ultrasound for deep heat
    • possible surgical intervention
  49. Thoracic Outlet Compression Syndromes-Etiology
    • compression of brachial plexus, subclavian artery and vein
    • can occur from:
    •   *compression in the narrow space between 1st rib and clavicle (costoclavicular syndrome)
    •   *compression between the anterior and middle scalene muscles
    •   *compression be the pec. minor as it passes beneath the coracoid process or between the clavicle and first rib
    •   *presence of a cervical rib (an abnormal rib originating from a cervical vertebrae and the thoracic rib)
  50. Thoracic Outlet Compression Syndromes-S&S
    • pain
    • parasthesia
    • sensation of cold
    • impaired circulation
    • radial nerve palsy
    • muscle weakness and atrophy
  51. Thoracic Outlet Compression Syndromes-Mgmt
    • conservative approach
    •   *correcting any anatomical condition responsible
    •   *strengthening exercises
    •       **trapezius, rhomboids, serratus anterior and erector muscles of the spine
    •   *stretching exercises
    •       **pec. minor and scalene muscles
    • surgical release of the anterior scalenes or possible removal of first rib
  52. Biceps Brachii Rupture-Etiology
    • MOI: performing a powerful concentric or eccentric contraction
    • commonly occurs near the origin of the muscle in the bicepital groove
  53. Biceps Brachii Rupture-S&S
    • will hear a snap and have a sudden increase of intense pain at the point of injury
    • may have a bulge in the middle of the biceps
    • elbow flexion and supination will be weak
  54. Biceps Brachii Rupture-Mgmt
    • immediate ice to control hemorrhaging
    • sling
    • refer to dr
    •   *most cases require surgery
    •   *older people may opt out of surgery
  55. Bicepital Tenosynovitis-Etiology
    • common w/ overhead activities
    • high ballistic activities cause irritation
    •   *tendon
    •   *synovial sheath
    • complete rupture of the transverse ligament may occur
    • constant inflammation
    •   *degenerative scarring
    •   *subluxated tendon
  56. Bicepital Tenosynovitis-S&S
    • tenderness over biceptical groove
    • swelling, warmth and crepitus
  57. Bicepital Tenosynovitis-Mgmt
    • complete rest
    • cryotherapy, ultrasound, NSAIDs
    • gradual strengthening and stretching program
  58. Contusions of upper arm-Etiology
    • area mostly affected
    •   *lateral aspect
    •       **brachialis and portions of biceps and triceps
    • can lead to myositis ossificans
    • AKA: linebackers arm, blockers exostosis
  59. Contusions of upper arm-S&S
    • can be disabling
    • if radial nerve is contused
    •   *transitory paralysis
    •   *inability to use the extensor muscles
  60. Contusions of upper arm-Mgmt
    • ice and rest for 24 hrs
    • protect the area to prevent repeated trauma
    • maintain full ROM
  61. Peripheral Nerve Injuries-Etiology
    • MOI:
    •   *blunt truama
    •   *stretch
    • Must be considered when there is:
    •   *constant pain
    •   *paralysis
    •   *muscle weakness and atrophy
  62. Peripheral Nerve Injuries-S&S
    • pain
    • muscle weakness
  63. Peripheral Nerve Injuries-Mgmt
    RICE immediately