ATC 222 Chapter 21 The Shoulder Complex

Anatomy n n Bones – –clavicle – –humerus – –scapula

Ligaments n Sternoclavicular n Acromioclavicular n Glenohumeral

Muscles n Rotator Cuff –S.I.T.S. –surrounding musculature

Nerve Supply nBnBnBnBrachial Plexus C5-T1

Blood Supply n Subclavian Artery n Axillary Artery n Brachial Artery

Shoulder Assessment n H.O.P.S. –History –Observation –Palpation –Special Tests

Recognition & Management of Specific Injuries

Fractures n Clavicular n Humerus –Shaft –Proximal –Epiphyseal

Clavicular Fractures n Etiology –fall on outstretched arm or tip of shoulder –direct impact n Signs and Symptoms –supports the arm on the injured side tilting the head toward that side and the chin opposite

n Management –apply sling and swathe –refer for x-ray –immobilize 6-8weeks Clavicular Fractures

Humeral Fractures- Shaft n Etiology –direct blow or fall on the arm n Signs and Symptoms –probable deformity –wrist drop and inability to supinate the wrist

Humeral Fractures- Shaft n Management –splint and referral to a physician –3-4 months

Humeral Fractures- Proximal n Etiology –direct blow, fall on outstretched arm, or dislocation n Signs and Symptoms –often mistaken for a shoulder dislocation –possible severe hemorrhaging

Humeral Fractures- Proximal n Management –sling –sling and swathe and referral –2-6 –2-6 months

Humeral Fractures- Epiphyseal n Etiology –direct blow or indirect force along the axis of the humerus n Signs and Symptoms –shortening of the arm –appearance of a false joint n Management –splint and referral to a physician –immobilization for 3 weeks

Sprains n Sternoclavicular n Acromioclavicular n Glenohumeral;

Sternoclavicular Sprain n Etiology –indirect force transmitted through the humerus –twisting of an posteriorly extended arm n Signs and Symptoms –Grade 1 –Grade 2: visible deformity and inability to abduct arm

Sternoclavicular Sprain –Grade 3: complete dislocation, if posterior, it’s a MEDICAL EMERGENCY

Sternoclavicular Sprain n Management –RICE –reduction, –reduction, immobilization 3-5weeks

Acromioclavicular Sprain n Etiology –direct impact to tip of shoulder –upward force against long axis of humerus, falling on outstretched arm

Acromioclavicular Sprain n Signs and Symptoms –Grade 1: –Grade 2: prominent lateral end of clavicle, unable to completely abduct or horizontally adduct –Grade 3: rupture the AC and Coracoclavicular ligaments resulting in a dislocation of clavicle, very prominent distal clavicle

Acromioclavicular Sprain n Management –apply ice and sling and swathe –referral –Grade 1: 3-4 days –Grade 2: days –Grade 3: 2 weeks, Operative vs. Non- operative

Glenohumeral Joint Sprain n Etiology –forceful abduction and ER –forceful movement posteriorly with flexion of arm n Signs and Symptoms –decreased ROM –pain with reproduction of mechanism

Glenohumeral Joint Sprain nMnMnMnManagement –i–i–i–ice and sling for comfort –i–i–i–initiate active and passive ROM after 1-3 days

Acute Subluxations & Dislocations n accounts for up to 50% of all dislocations n only 1-4% are posterior n 85-90% recur

Glenohumeral Dislocations-Anterior Glenohumeral Dislocations-Anterior n Etiology –direct impact on posterolateral or posterior aspect of shoulder –forced abduction and ER

Glenohumeral Disloccations-Anterior n Signs and Symptoms –flattened deltoid contour –humeral head in the axilla –arm carried in slight abduction and ER

Glenohumeral Dislocations-Anterior n Management –immobilize in sling and application of ice –referral to a physician for reduction and x-ray –DO NOT attempt to reduce

Glenohumeral Dislocation-Posterior n Etiology –forced adduction and IR –fall on extended and internally rotated arm n Signs and Symptoms –arm held in adduction and internal rotation –head of humerus may be seen posteriorly

Chronic Shoulder Instabilities n Etiology –traumatic (micro vs. macro), atraumatic, congenital, and neuromuscular n Signs and Symptoms –Anterior –Posterior –Global

Chronic Shoulder Instabilities Chronic Shoulder Instabilities n Management –Conservative vs. Surgical –shoulder harness

Shoulder Impingement Syndrome n Etiology –repetitive overhead activities –capsular laxity leading to inflammation –forward head and rounded shoulders –hooked shaped acromion process

Rotator Cuff Tears n partial thickness vs. complete thickness tears n acute trauma or impingement n nearly always involves the supraspinatus muscle

Shoulder Impingement Syndrome n Signs n Signs and Symptoms –diffuse –diffuse pain around the acromion –pain –pain with overhead activities –weak –weak external rotators

Shoulder Impingement Syndrome n Stage I –aching after activity –pain with abduction that becomes worst at 90 degrees –pain with flexion and resisted supination and external rotation n Stage II –aching during activity that becomes worst at night, restricted movement

Shoulder Impingement Syndrome n Stage III (25-40) –pain during activity with increase pain at night –possible muscle tear and permanent thickening of rotator cuff & bursa –scar tissue

Shoulder Impingement Syndrome Stage IV (40+) Stage IV (40+) –infraspinatus and supraspinatus wasting –a lot of pain with abduction to 90 –limited AROM and PROM –weakness during abduction and ER

Shoulder Impingement Syndrome n Management –RICE –Modification of activity –Strengthening of ER and Scapular Stabilizers –Surgery vs. Injection

Shoulder Bursitis n Etiology –fall on tip of shoulder –direct impact or shoulder impingement n Signs and Symptoms –pain with abduction, flexion and IR n Management –cold, antiinflammatory medications

Bicipital Tenosynovitis

Biceps Brachii Rupture

Peripheral Nerve Injuries n Etiology –blunt trauma or stretch n Signs and Symptoms –constant “burning” pain, muscle weakness and atrophy –paralysis

Peripheral Nerve Injuries n Management –ice –resume play when symptoms subside –referral to a physician is ESSENTIAL if symptoms persist

Thoracic Outlet Compression Syndrome n Etiology –compression of brachial plexus, subclavian artery and vein (neurovascular bundle) –compression by the scalene and pectoralis mucles

Thoracic Outlet Compression Syndrome n Signs and Symptoms –paresthesia and pain –impaired circulation in the fingers –muscle weakness and atrophy

Thoracic Outlet Compression Syndrome n Management –stretching of pectorals and scalenes –strengthening of the traps, rhomboids, serratus anterior