Proximal humerus fractures

1. How much must a portion of the humerus be displaced to call it a fragment?
2. What is the most common location of humerus fractures? What are other locations?
3. What are the symptoms of proximal humerus fracture?
4. What are the surgical and non-surgical treatments?
5. What are complications of proximal humerus fracture? What nerve is often involved in surgical neck fractures?

Answers:
1. Angulated by 45 degrees or displaced >1cm.
2. Most common is the surgical neck, followed by the greater tuberosity, lesser tuberosity, and anatomical neck.
3. This fracture is common in osteoporotic elderly women after a fall and involves pain, swelling, and ecchymosis. Loss of sensation or diminished radial pulse may occur. If there's a fracture of the surgical neck, the supraspinatus causes abudction of the proximal fragment of the humerus.
4. Conservative treatment is early ROM, sling immobilization, rehab, pendulum exercises. If displaced, need ORIF.
5. Complications include brachial plexus injury, axillary artery compromise, and avascular necrosis of the humeral head. The axillary nerve is involved in surgical neck fractures.

Scapula and Clavicular fractures

1. What other significant injuries may be associated with a scapula fracture? How is it diagnosed?
2. What is the treatment for a scapula fx?
3. How are clavicular fractures classified?
4. What is the treatment of clavicular fx?

Answers:
1. Rib fx, pulmonary pathology (contusion, ptx) is associated with scapula fx. It is diagnosed by plain films (AP, lateral (scapular Y), and axillary) or CT.
2. Closed treatment for nondisplaced fx (sling, early ROM within 1-2 wks). ORIF for large displaced fragments.
3. By location: proximal, middle, or distal thirds.
4. Conservative treatment for most fxs. If >1cm displacement of lateral clavicle at AC jt, do closed reduction and figure 8 sling immobilization 3-6wks.

Adhesive capsulitis

1. What are the stages of adhesive capsulitis?
2. What conditions is adhesive capsulitis associated with?
3. What imaging is done for adhesive capsulitis?
4. What is the conservative treatment?
5. What is the surgical treatment?

Answers:
1. The first, painful stage is a progressive vague pain lasting 8 months, the second stiffening stage lasts about 8 months with decreasing ROM, and the third thawing stage results in increasing ROM with decreased pain.
2. CVA, hemorrhage, brain tumor, clinical depression, shoulder-hand syndrome, Parkinson's disease, iatrogenic disorder, cervical disc disease, IDDM, hypothyroidism.
3. Do plain films to rule out underlying tumor or calcium deposit or if there is not improvement with 3 months of treatment, arthroscopy shows decreased joint volume.
4. Restoring ROM, decrease pain, corticosteroid injection, home program, modalities.
5. Manipulation under anesthesia or arthroscopic lysis of adhesions.

Biceps tendonitis and rupture

1. Where is the most common site of biceps tendon rupture? What other shoulder condition is it associated with?
2. What are the symptoms of bicipital tendonitis? Biceps rupture.
3. What tests are done to diagnose biceps tendonitis?
4. What test is done to diagnose biceps rupture?
5. What is the treatment for biceps tendonitis/rupture?

Answers:
1. Most common site of rupture is long head of biceps proximally, often secondary to impingement syndrome or rotator cuff tears.
2. Point tenderness in bicipital groove, positive impingement signs. If there is rupture, there will be sharp pain, audible snap, ecchymosis, and visible bulge in lower arm.
3. Yergason's test (pain with supination of wrist against resistance) and Speed's test (pain with shoulder flexed, elbow extended, supination against resistance).
4. Ludington's test: deformity with flexion of biceps muscle.
5. For tendonitis, can do ROM, strengthening, modalities, or injection into tendon sheath. For rupture, reattachment isn't indicated except in young people who do heavy lifting.

Degenerative joint disease in the shoulder

1. What occurs in arthritis of the shoulder?
2. What are the symptoms and signs of shoulder arthritis?
3. What imaging should be ordered? What is seen on X-ray?
4. What is conservative treatment for shoulder arthritis?
5. What are the indications for total shoulder arthroplasty? What are the stages of recovery?
6. What is shoulder arthrodesis? What are indications for arthrodesis?

Answers:
1. Destruction of articular cartilage and narrowing of the joint space in either of the GH or AC joint.
2. Limitation and pain on AROM and PROM, worse with internal rotation, tenderness with palpation.
3. AP in internal and external rotation and 40 degrees, axillary view. Findings are irregular joint surfaces, joint space narrowing, subacromial sclerosis, osteophyte changes, flattened glenoid, cystic changes in humeral head.
4. NSAIDs, steroid injection, ROM, rotator cuff strengthening.
5. Indications for surgery are pain, avascular necrosis, neoplasm. In stage 1 (0-6 wks), avoid abduction and extension, ext rot >15 deg, NWB, sling immobilization, treat with pendulum exercises, isometrics, wall-walking. In stage 2 (6-12 wks), can start light wks, AROM. In stage 3 (>12 wks), no restrictions, start progressive resistive exercises.
6. Shoulder arthrodesis is surgical resection and fusion of shoulder joint. Indications are severe pain, loosening of arthroplasty, or joint infection.

Shoulder impingement: imaging and treatment

1. What is seen on plain film with impingement? Chronic rotator cuff tear?
2. What is the gold standard for rotator cuff tears? For labral tears?
3. What is the utility of arthrogram for rotator cuff tears?
4. What is the conservative treatment for rotator cuff injury in the acute phase (first 4 weeks)?
5. What is the conservative treatment for the first 6 months? After the first 6 months?
6. What are the indications for surgery?

Answers:
1. With impingement, there are cystic changes in the greater tuberosity. In chronic rotator cuff tear, there is superior migration of the proximal humerus, flattening of the greater tuberosity, and subacromial sclerosis.
2. MRI for rotator cuff, add gadolinium for labral assessment.
3. Can assess full thickness tears but can't tell size of tear or partial thickness tear.
4. Relative rest, pain management, modalities, reestablish nonpainful ROM, retard muscle atrophy.
5. In first 6 months, improve ROM, improve rotator cuff strength and scapular stabilizers. After the first 6 months, continue strengthening, do activity-specific training, conticosteroid injections.
6. Surgical indications include tears that fail conservative treatment. In athletes, surgical repair may be done within first 3 weeks for better return of function.

Impingement syndrome

1. What is impingement syndrome?
2. What are the three different acromion shapes? Which kinds are associated with higher risk of rotator cuff tears?
3. What are symptoms of rotator cuff tear?
4. What is the range of the painful arc?
5. What is the supraspinatus test?
6. What physical exam test indicates a complete tear of the rotator cuff?

Answers:
1. Narrowing of subacromial space causing compresion and inflammation of the subacromial bursa, biceps tendon, and rotator cuff tendons. These tendons then get inpinged upon under the acromion and greater tuberosity with arm abduction and internal rotation.
2. Type I is flat, type II is curved, type III is hooked. Curved and hooked have higher risk of tear.
3. Pain with repetitive overhead activities or sports (throwing ball, swimming), crepitus, clicking, weakness, nocturnal pain (sleeping on affected side), tenderness over greater tuberosity or inferior to acromion, atrophy (with tears).
4. 60-120 degrees.
5. Pain and weakness with arm in flexion, abduction, and internal rotation.
6. Drop arm test: passively abduct arm to 90 degrees and internally rotated --> positive is if patient is unable to maintain arm in abduction.

Glenoid labrum tears

1. What are common causes of labral tears?
2. What is a SLAP lesion?
3. What are the symptoms of glenoid labral tears?
4. What is a physical exam finding in a glenoid labral tear?

Answers:
1. Repetitive overhead sports or trauma.
2. Superior glenoid Labral tear in the Anterior to Posterior direction, which encompasses entire glenoid labrum.
3. Symptoms similar to shoulder instability (clicking, locking, pain).
4. Load and shift test: grasp humeral head and push into glenoid while applying anterior and posterior force. Positive test is excess translation.

Treatment of glenohumeral instability

1. What is the conservative treatment for anterior GH instability?
2. When should surgery be considered for anterior GH instability?
3. What is the conservative treatment for posterior GH instability?
4. How successful is rehab for multidirectional GH instability?

Answers:
1. Sling immobilization, strengthening and ROM of shoulder girdle complex, PROM (Pendulum-Codman's exercises).
2. After 3 dislocations or in a very active patient.
3. Immobilize in a neutral position for 3 weeks, strengthening of posterior shoulder-scapula musculature (infraspinatus, post deltoid, teres minor), rehab usually curative.
4. 80% success.

Work-up of glenohumeral instability

1. What are the symptoms of shoulder instability? How is laxity measured?
2. What are three tests for anterior GH instability?
3. What are two tests for posterior GH instability?
4. What is a test for multidirectional GH instability?
5. What imaging is done to assess GH instability? What special views are used for Bankart and Hill-Sachs lesions?

Answers:
1. Symptoms are early shoulder fatigue, pain, numbness, paresthesias. The shoulder slips out of place when in a "throwing" position. Joints are considered lax if the patient can touch the thumb against the flexor surface of the forearm.
2. The apprehension test (feeling of instability with 90 deg shoulder abduction and ext rotation), relocation test (relief of Apprehension with posterior directed force), anterior draw (passive anterior displacement).
3. The jerk test (arm in 90 flexion and int rot with elbow flexed 90 degrees --> patient jerks away when arm is passively adducted while pushing humerus posteriorly), posterior draw (posterior displacement of humerus).
4. The sulcus sign involves pulling down on the patient's arm while stabilizing scapula --> indentation between the acromion and the humeral head is a positive.
5. Routine AP, scapular Y view, axillary lateral view. The West Point lateral axillary is used for Bankart lesions and the Stryker notch view is used for Hill-Sachs.

Glenohumeral instability

1. What is the difference between shoulder instability, subluxation, and dislocation?
2. What is the most common direction of instability? What is the mechanism and complications?
3. What is the presentation and mechanism of posterior GH instability?
4. What is a Bankart lesion? What sort of instability results from this?
5. What is a Hill-Sachs lesion? What sort of instability is associated with this lesion?

Answers:
1. Instability is translation of humeral head on glenoid fossa without separation. Subluxation is separation of humeral head from glenoid fossa with immediate reduction. Dislocation is separation of humeral head from glenoid fossa without immediate reduction.
2. Most common direction is anterior inferior, via arm abduction and external rotation. Complications include axillary nerve injury.
3. Mechanism is landing on a forward flexed adducted arm or as a result of seizure. The patient presents with an adducted, internally rotated arm.
4. Bankart lesion is a tear of the glenoid labrum off the front of the glenoid, allowing the humeral head to slip anteriorly --> anterior instability.
5. A Hill-Sachs lesion is a compression fracture of the posterolateral aspect of the humeral head caused by abutment against the anterior rim of the glenoid fossa due to recurring anterior shoulder dislocation.

Acromioclavicular joint sprains

1. What are the 3 ligaments surrounding the AC joint?
2. How do AC joint sprains usually occur?
3. What are the 6 types of AC joint sprain?
4. What sort of X-ray should be obtained for AC joint separation? What is seen?
5. What is the treatment of Type I and II AC injury?
6. What is the treatment for Type III AC injury?
7. What is the treatment for Type IV-VI AC injury?
8. What is the treatment for chronic AC joint pain?

Answers:
1. AC ligament, coracoclavicular (CC) ligament, coracoacromial ligament.
2. Direct impact to shoulder, falling on outstretched arm.
3. Type I is a partial sprain of the AC ligament with intact CC ligament. Type II involves a complete tear of the AC ligament and a partial tear of the CC ligament. Types III-VI involve complete tear of the AC and CC ligaments with varying displacement.
4. Weighted (10lb) radiographs of shoulder should be obtained. Type III injury shows 25-100% widening of clavicular-coracoid area. Type V injury may show widening >100%.
5. Rest, ice, NSAIDs, sling (comfort), avoid heavy lifting, shoulder girdle strengthening, return to play if asymptomatic with full ROM for 2 weeks if Type I, 6 weeks if Type II.
6. Controversial: surgery vs. conservative, based on need.
7. ORIF or distal clavicular resection with reconstruction of CC ligament.
8. Corticosteroid injection vs. surgery.

Glenohumeral joint

1. What is the labrum? What attaches at the labrum?
2. What is the purpose of the glenohumeral ligaments?
3. What are the three glenohumeral ligaments?
4. What are the muscles that surround the humeral head and provide dynamic stabilization?

Answers:
1. The labrum is a fibrocartilaginous fold of capsular tissue that surrounds the glenoid fossa, increasing contact between the humeral head and the glenoid. The labrum is where the glenohumeral ligaments and tendons attach and prevents humeral head dislocation.
2. To provide stability and keep the head of the humerus in the glenoid fossa.
3. Superior, middle, and inferior ligaments.
4. Rotator cuff muscles (SITS), long head of biceps tendon, deltoid, teres major.

Shoulder movement

1. What are the 4 muscles responsible for shoulder flexion?
2. What are 5 muscles responsible for shoulder extension?
3. What are 2 muscles responsible for shoulder abduction?
4. What are 7 muscles responsible for shoulder adduction?
5. What are 5 muscles responsible for internal rotation of the shoulder?
6. What are 4 muscles responsible for external rotation of the shoulder?

Answers:
1. Deltoid, pectoralis major, biceps brachii, coracobrachialis.
2. Deltoid, triceps, latissimus dorsi, teres major, pectoralis major.
3. Supraspinatus and deltoid.
4. Pectoralis major, triceps, coracobrachialis, infraspinatus, teres major, latissimus dorsi, deltoid.
5. Subscapularis, pectoralis major, latissimus dorsi, anterior deltoid, teres major. (SPLAT)
6. Infraspinatus, teres minor, deltoid, supraspinatus.