atc 222 chapter 21 the shoulder complex anatomy n n bones – –clavicle – –humerus –...
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Ligaments Sternoclavicular Sternoclavicular Acromioclavicular Acromioclavicular GlenohumeralGlenohumeral
MusclesMuscles Rotator CuffRotator Cuff
– S.I.T.S.S.I.T.S.– surrounding musculaturesurrounding musculature
Blood SupplyBlood Supply
Subclavian ArterySubclavian Artery Axillary ArteryAxillary Artery Brachial ArteryBrachial Artery
Shoulder Shoulder AssessmentAssessment
H.O.P.S.H.O.P.S.– HistoryHistory– ObservationObservation– PalpationPalpation– Special TestsSpecial Tests
FracturesFractures ClavicularClavicular HumerusHumerus
– ShaftShaft– ProximalProximal– EpiphysealEpiphyseal
Clavicular Clavicular FracturesFractures
EtiologyEtiology– fall on outstretched arm or tip of fall on outstretched arm or tip of
shouldershoulder– direct impactdirect impact
Signs and SymptomsSigns and Symptoms– supports the arm on the injured supports the arm on the injured
side tilting the head toward that side tilting the head toward that side and the chin oppositeside and the chin opposite
ManagementManagement– apply sling and swatheapply sling and swathe– refer for x-rayrefer for x-ray– immobilize 6-8weeksimmobilize 6-8weeks
Clavicular Clavicular FracturesFractures
Humeral Humeral Fractures-ShaftFractures-Shaft EtiologyEtiology
– direct blow or fall on the armdirect blow or fall on the arm Signs and SymptomsSigns and Symptoms
– probable deformityprobable deformity– wrist drop and inability to wrist drop and inability to
supinate the wristsupinate the wrist
Humeral Humeral Fractures-ShaftFractures-Shaft ManagementManagement
– splint and referral to a physiciansplint and referral to a physician– 3-4 months3-4 months
Humeral Humeral Fractures-Fractures-ProximalProximal
EtiologyEtiology– direct blow, fall on outstretched direct blow, fall on outstretched
arm, or dislocationarm, or dislocation Signs and SymptomsSigns and Symptoms
– often mistaken for a shoulder often mistaken for a shoulder dislocationdislocation
– possible severe hemorrhagingpossible severe hemorrhaging
Humeral Humeral Fractures-ProximalFractures-Proximal
ManagementManagement– sling and swathe and referralsling and swathe and referral– 2-6 months2-6 months
Humeral Humeral Fractures-Fractures-EpiphysealEpiphyseal
EtiologyEtiology– direct blow or indirect force along the direct blow or indirect force along the
axis of the humerusaxis of the humerus Signs and SymptomsSigns and Symptoms
– shortening of the armshortening of the arm– appearance of a false jointappearance of a false joint
ManagementManagement– splint and referralsplint and referral to a physician to a physician
– immobilization for 3 weeksimmobilization for 3 weeks
SprainsSprains SternoclavicularSternoclavicular AcromioclavicularAcromioclavicular Glenohumeral;Glenohumeral;
Sternoclavicular Sternoclavicular SprainSprain
EtiologyEtiology– indirect force transmitted through the indirect force transmitted through the
humerushumerus– twisting of an posteriorly extended armtwisting of an posteriorly extended arm
Signs and SymptomsSigns and Symptoms– Grade 1Grade 1– Grade 2: visible deformity and inability Grade 2: visible deformity and inability
to abduct armto abduct arm
Sternoclavicular Sternoclavicular SprainSprain
– Grade 3: complete dislocation, if Grade 3: complete dislocation, if posterior, it’s a MEDICAL posterior, it’s a MEDICAL EMERGENCYEMERGENCY
Sternoclavicular Sternoclavicular SprainSprain
ManagementManagement– RICERICE– reduction, immobilization 3-reduction, immobilization 3-
5weeks5weeks
AcromioclaviculaAcromioclavicular Sprainr Sprain
EtiologyEtiology– direct impact to tip of shoulderdirect impact to tip of shoulder– upward force against long axis of upward force against long axis of
humerus, falling on outstretched humerus, falling on outstretched armarm
AcromioclaviculaAcromioclavicular Sprainr Sprain
Signs and SymptomsSigns and Symptoms– Grade 1:Grade 1:– Grade 2: prominent lateral end of Grade 2: prominent lateral end of
clavicle, unable to completely abduct clavicle, unable to completely abduct or horizontally adductor horizontally adduct
– Grade 3: rupture the AC and Grade 3: rupture the AC and Coracoclavicular ligaments resulting Coracoclavicular ligaments resulting in a dislocation of clavicle, very in a dislocation of clavicle, very prominent distal clavicleprominent distal clavicle
AcromioclaviculaAcromioclavicular Sprainr Sprain
ManagementManagement– apply ice and sling and swatheapply ice and sling and swathe– referralreferral– Grade 1: 3-4 daysGrade 1: 3-4 days– Grade 2: 10-14 daysGrade 2: 10-14 days– Grade 3: 2 weeks, Operative vs. Grade 3: 2 weeks, Operative vs.
Non-operativeNon-operative
Glenohumeral Glenohumeral Joint SprainJoint Sprain
EtiologyEtiology– forceful abduction and ERforceful abduction and ER– forceful movement posteriorly forceful movement posteriorly
with flexion of armwith flexion of arm Signs and SymptomsSigns and Symptoms
– decreased ROMdecreased ROM– pain with reproduction of pain with reproduction of
mechanismmechanism
Glenohumeral Joint Glenohumeral Joint SprainSprain
ManagementManagement– ice and sling for comfortice and sling for comfort– initiate active and passive ROM initiate active and passive ROM
after 1-3 daysafter 1-3 days
Acute Acute Subluxations & Subluxations &
DislocationsDislocations accounts for up to 50% of all accounts for up to 50% of all
dislocationsdislocations only 1-4% are posterioronly 1-4% are posterior 85-90% recur85-90% recur
Glenohumeral Glenohumeral Dislocations-Dislocations-
AnteriorAnterior EtiologyEtiology
– direct impact on posterolateral direct impact on posterolateral or posterior aspect of shoulderor posterior aspect of shoulder
– forced abduction and ERforced abduction and ER
Glenohumeral Glenohumeral Disloccations-Disloccations-
AnteriorAnterior
Signs and SymptomsSigns and Symptoms– flattened deltoid contourflattened deltoid contour– humeral head in the axillahumeral head in the axilla– arm carried in slight abduction and ERarm carried in slight abduction and ER
Glenohumeral Glenohumeral Dislocations-Dislocations-
AnteriorAnterior ManagementManagement
– immobilize in sling and immobilize in sling and application of iceapplication of ice
– referral to a physician for referral to a physician for reduction and x-rayreduction and x-ray
– DO NOT attempt to reduceDO NOT attempt to reduce
Glenohumeral Glenohumeral Dislocation-Dislocation-
PosteriorPosterior EtiologyEtiology
– forced adduction and IRforced adduction and IR– fall on extended and internally fall on extended and internally
rotated armrotated arm Signs and SymptomsSigns and Symptoms
– arm held in adduction and arm held in adduction and internal rotationinternal rotation
– head of humerus may be seen head of humerus may be seen posteriorlyposteriorly
Chronic Shoulder Chronic Shoulder InstabilitiesInstabilities
EtiologyEtiology– traumatic (micro vs. macro), traumatic (micro vs. macro),
atraumatic, congenital, and atraumatic, congenital, and neuromuscularneuromuscular
Signs and SymptomsSigns and Symptoms– AnteriorAnterior– PosteriorPosterior– GlobalGlobal
Chronic Shoulder Chronic Shoulder InstabilitiesInstabilities
ManagementManagement– Conservative vs. SurgicalConservative vs. Surgical– shoulder harnessshoulder harness
Shoulder Shoulder Impingement Impingement
SyndromeSyndrome EtiologyEtiology
– repetitive overhead activities repetitive overhead activities – capsular laxity leading to capsular laxity leading to
inflammationinflammation– forward head and rounded forward head and rounded
shoulders shoulders – hooked shaped acromion processhooked shaped acromion process
Rotator Cuff TearsRotator Cuff Tears
partial thickness vs. complete partial thickness vs. complete thickness tearsthickness tears
acute trauma or impingementacute trauma or impingement nearly always involves the nearly always involves the
supraspinatus musclesupraspinatus muscle
Shoulder Shoulder Impingement Impingement
SyndromeSyndrome Signs and SymptomsSigns and Symptoms
– diffuse pain around the acromiondiffuse pain around the acromion– pain with overhead activitiespain with overhead activities– weak external rotatorsweak external rotators
Shoulder Shoulder Impingement Impingement
SyndromeSyndrome Stage IStage I
– aching after activityaching after activity– pain with abduction that becomes worst pain with abduction that becomes worst
at 90 degreesat 90 degrees– pain with flexion and resisted pain with flexion and resisted
supination and external rotationsupination and external rotation Stage IIStage II
– aching during activity that becomes aching during activity that becomes worst at night, restricted movementworst at night, restricted movement
Shoulder Shoulder Impingement Impingement
SyndromeSyndrome Stage III (25-40)Stage III (25-40)
– pain during activity with increase pain during activity with increase pain at nightpain at night
– possible muscle tear and possible muscle tear and permanent thickening of rotator permanent thickening of rotator cuff & bursacuff & bursa
– scar tissuescar tissue
Shoulder Shoulder Impingement Impingement
SyndromeSyndrome Stage IV (40+)Stage IV (40+)
– infraspinatus and supraspinatus infraspinatus and supraspinatus wastingwasting
– a lot of pain with abduction to 90a lot of pain with abduction to 90– limited AROM and PROMlimited AROM and PROM– weakness during abduction and ERweakness during abduction and ER
Shoulder Shoulder Impingement Impingement
SyndromeSyndrome ManagementManagement
– RICERICE– Modification of activityModification of activity– Strengthening of ER and Strengthening of ER and
Scapular StabilizersScapular Stabilizers– Surgery vs. InjectionSurgery vs. Injection
Shoulder BursitisShoulder Bursitis EtiologyEtiology
– fall on tip of shoulderfall on tip of shoulder– direct impact or shoulder direct impact or shoulder
impingementimpingement Signs and SymptomsSigns and Symptoms
– pain with abduction, flexion and IRpain with abduction, flexion and IR ManagementManagement
– cold, antiinflammatory medicationscold, antiinflammatory medications
Peripheral Nerve Peripheral Nerve InjuriesInjuries
EtiologyEtiology– blunt trauma or stretchblunt trauma or stretch
Signs and SymptomsSigns and Symptoms– constant “burning” pain, muscle constant “burning” pain, muscle
weakness and atrophyweakness and atrophy– paralysisparalysis
Peripheral Nerve Peripheral Nerve InjuriesInjuries
ManagementManagement– iceice– resume play when symptoms resume play when symptoms
subsidesubside– referral to a physician is referral to a physician is
ESSENTIAL if symptoms persistESSENTIAL if symptoms persist
Thoracic Outlet Thoracic Outlet Compression Compression
SyndromeSyndrome EtiologyEtiology
– compression of brachial plexus, compression of brachial plexus, subclavian artery and vein subclavian artery and vein (neurovascular bundle)(neurovascular bundle)
– compression by the scalene and compression by the scalene and pectoralis muclespectoralis mucles
Thoracic Outlet Thoracic Outlet Compression Compression
SyndromeSyndrome
Signs and SymptomsSigns and Symptoms– paresthesia and painparesthesia and pain– impaired circulation in the fingersimpaired circulation in the fingers– muscle weakness and atrophymuscle weakness and atrophy