ࡱ> XZW@ | bjbjFF ,R,,w6666tBF+F+F+F+4z+lB(5+++++,,,44444446Rl84.,,..466++4111.6l++41.411'4,s4++ ]FF+.?4440(5G4,88.L8s4BB66668s4X,>-,1;-$_-,,,44BB'F+1BBF+The Shoulder Anatomy Complex interplay of 4 joints Synovial Joints Gleno-humeral Sterno-clavicular Acromio-clavicular Gliding Joint Scapulo-Thoracic Bony Anatomy Clavicle Humerus Head Shaft Greater Tuberosity Lesser Tuberosity Scapula Glenoid Acromion Body Spine Ligaments Gleno-humeral Acromio-clavicular Coraco-acromial Coraco-clavicular Bursa Subacromial Subdeltoid Muscles Inner sleeve-Rotator cuff Subscapularis- Internal rotator Supraspinatus- abductor Infraspinatus- external rotator; abductor Teres minor- external rotator Biceps (long head) Outer sleeve-Deltoid Pectoralis major Latissimus dorsi Teres major Scapula muscles Nerves Brachial plexus Axillary nerve- major nerve to the shoulder Musculocutaneous nerve- innervates the biceps Biomechanics Stability Function of the Rotator Cuff Delto-supraspinatus force couple Motion Gleno-humeral: scapula-thoracic Clavicle rotation Shoulder Exam History Trauma- mechanism of injury Pain- where, when, how long Function Physical exam Inspection Palpation Range of motion- active Strength Abduction- Supraspinatus/deltoid Internal rotation- Pectoralis major/Subscapularis/Latissimus dorsi External rotation- teres minor, Infraspinatus Sensation Axillary nerve-deltoid Median nerve- middle finger, palm side Ulnar nerve- 5th digit Radial nerve- first web space dorsal side Mucocutaneous nerve-top of forearm Special tests Apprehension Impingement sign Abduction sign Adduction sign Roentgenographic exam Trauma series- AP, Y view( a 40 degree lateral view for the shoulder) Axillary view- shot with arm up Stress views Arthrogram- contrast in the joint; MRI used more often now MRI- Can show tears of rotator cuff Clavicle Fractures The clavicle is the only bony structure that suspends the scapula and the arm from the axial skeleton (most commonly fractured bone in the body) Mechanism of injury Falls Outstretched arms Falling on side Classification Mid-third- 80% Distal-15% Inner third- 5% Signs and symptoms Arm held against chest Tender at fracture site Palpable deformity X-rays Treatment Sling (swathe) Figure of eight Shoulder spica cast Surgery- O.R.I.F Complications Neurovascular- can injure brachial plexus Malunion Nonunion Post-traumatic arthritis Injuries to the acromioclavicular joint (separated shoulder) A-C joint Acromioclavicular ligament Coracoclavicular ligament Mechanism of injury Classification- measures displacement on clavicle and acromion Type I- all ligaments function with no displacement Type II- ac ligaments torn but Coracoclavicular ligaments intact Type III- everything is torn Type IV, V, VI Signs and symptoms Joint tenderness Joint swelling Deformity X-rays Stress views-upright Treatment Shoulder harness (Kenny Howard Type) Sling Surgery Complications Chronic instability- small percentage never heal properly A-C joint arthritis Injuries to the Sternoclavicular joint Uncommon injury Large force, direct or indirect, to the shoulder Commonly in MVAs Classification Anterior dislocation Posterior dislocation- uncommon Traumatic vs. atraumatic Signs and symptoms Pain Deformity Posterior dislocation may have SOB, choking sensation X-rays Special views C-T scan, tomograms Treatment Posterior dislocation requires treatment immediately Closed reduction- anesthesia Towel clip reduction Figure of eight cast Sling Glenohumeral dislocation- traumatic Anterior shoulder dislocation-97% Subcoracoid Subglenoid Subclavicular and intrathoracic- very rare Mechanism Direct force Indirect force- abduction-external rotation Signs and symptoms Severe pain Arm slightly abducted and externally rotated Squared off appearance of shoulder Anterior shoulder fullness Positive apprehension signs- recurrent dislocation X-rays AP Y view Axillary view Hill-Sachs lesion- Glenoid makes impaction fracture in humeral head Seen in patients with multiple dislocations Bankart lesion- Ligaments tears a piece of bone off of the glenoid during a dislocation Pathognomonic of dislocations Treatment Closed reduction IV sedation Shoulder immobilization Rehab Complications Recurrence- especially with young people Nerve injury- axillary nerve Fracture Posterior Shoulder dislocation- 1-3%- very rare Mechanism of injury Direct force Indirect force Electric shock Seizure- must be aware of posterior dislocations It is more common to have an anterior shoulder dislocation during a seizure Signs and symptoms Over 60% missed on initial exam Arm in fixed adduction and internal rotation External rotation is blocked Anterior aspect of shoulder flat Coracoid process prominent X-rays Treatment Closed reduction Open reduction Sling Orthosis/cast Complication Missed diagnosis- very common to miss Fractures Impingement Syndrome- most common shoulder complaint; shoulder pain with arm elevation Other names/causes Painful arc syndrome Bursitis Tendonitis Rotator Cuff Tears Biceps Tendon Ruptures Stages Stage 1- Acute inflammation (overuse type; younger person) Stage 2- Chronic (fibrosis, collagen failure; over 40) Stage 3- Rupture of biceps and rotator cuff Failure of rotator cuff; extension of stage 2 Stress fracture Stage 4- Cuff tear arthropathy Mechanism Related to repetitive overhead activities Acute injury to rotator cuff Bony changes Signs and symptoms Pain with overhead activities Night pain Decreased function in elevation Positive impingement sign, abduction test Impingement test- inject lidocaine into subacromial space Relief of pain is indicative of impingement X-rays Arthrogram MRI Treatment NSAIDs Activity modification Physical therapy- strengthen rotator cuff Sub-acromial injection-cortisone Surgery Acromioplasty Rotator cuff repair Adhesive Capsulitis- frozen shoulder Women 40s Nondominate arm +/- history of trauma Neck pain Insidious onset Signs and symptoms Limited ROM in all planes Pain at the end of ROM X-rays Normal Arthrogram Treatment NSAIDs Physical therapy Time Manipulation under anesthesia Arthritis Wear and tear-osteoarthritis Rheumatoid arthritis Uncommon in the shoulder (G-H joint) Usually affecting the A-C joint Signs and symptoms Inflammation of the joint Swelling Pain Stiffness Treatment Resection of clavicle- for AC joint Anti-inflammatory agents Shoulder replacement- For G-H joint arthritis 34CDERSdewxy         ' ( : ; 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L^`LhH. ^`hH. ^`hH. PLP^P`LhH.T= p]]YAB,)Jd     3 ]'zDX0ax8in%9yVy5mPR!1UjC8@|@@UnknownGz Times New Roman5Symbol3& z Arial;|i0Batang"h;Fj& , ,!hr4dkk3QH ?5m The ShoulderNicholas M. RiniNicholas M. Rini Oh+'0 , H T `lt| The Shoulderohe Nicholas M. Rinidichich Normal.dot Nicholas M. Rinid4chMicrosoft Word 10.0@^в@;,@nJF՜.+,0 hp|   h, k  The Shoulder Title  !"#$%&'()+,-./0123456789:;<=>?@ABCDEFHIJKLMNPQRSTUVYRoot Entry Fp]F[1Table*8WordDocument,RSummaryInformation(GDocumentSummaryInformation8OCompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q