1. Musculoskeletal Blueprint
PANCE/PANRE Review

2. Disorders of the Shoulder

3. Disorders of the Shoulder
History Taking & Performing Physical Exam:
-Neer test forcibly entraps the humerus against the coracocromial arch. It is a test for impingement. It is having the patient flex their arm over their head bringing it near the patients head.
-Internal shoulder rotation is tested by having the patient reach their thumb as far behind their back while seated.
-Empty can test or supraspinatus test is when patient places both arms in a position of abduction and 30 degrees of forward flexion with thumbs down. Examiner pushes both arms down as patient resists. Weakness is consistent with rotator cuff tear.

4. Disorders of the Shoulder
-Inferior instability is tested by having the patient abduct the arm 90 degrees and the examiner push directly downward on mid humerus. This can indicate inferior subluxation of the glenohumeral joint.
-Posterior instability is assessed by having the patient flex shoulder to 90 degrees and examiner pushes posteriorly
-Hawkin’s Impingement sign is tested by having patient put arm in throwing position and flex about 30 degrees. The examiner then forcibly internally rotates the humerus. Positive test with this indicates impingement syndrome.
-Apprehension sign is assessed by having the patient place arm in throwing position, and having the examiner pull hand backward into more external rotation and extension. It is an assessment for an unstable shoulder.

5. Disorders of the Shoulder
-Sulcus sign is having the patient dangle arm at side and pull inferiorly and watch for deepening of the acrominohumeral sulcus. This test if positive is consistent with glenohumeral instability.
Using Laboratory & Diagnostic Studies:
-Plain radiographs of shoulder are used to assess integrity of joint, fractures, effusion, and for arthritis.
-Ligaments, tendons, and rotator cuff injuries best imaged by MRI.

6. Disorders of the Shoulder
Formulating Most Likely Diagnosis:
-Diagnosis is made by history and physical exam and confirmed by radiographic studies.
Health Maintenance:
-No major health maintenance issues.
Clinical Intervention:
-See below for specific injuries/disorder.
Pharmaceutical Therapeutics:
-See below of for specific injury/disorder.

7. Disorders of the Shoulder
Applying Basic Science Concepts:
-Glenohumeral joint consists of the humeral head sitting in the glenoid fossa of the scapula.
-The acromioclavicular joint consists of the acromion of the scapula and the lateral aspect of the clavicle.
-Rotator cuff consists of supraspinatus, infraspinatus, teres minor and subscapularis.

8. Fractures/Dislocation of the Shoulder
-Acromioclavicular Injuries-
History Taking & Performing Physical Exam:
-Typical mechanism for injury is falling on the tip of the shoulder with the patients arm tucked to the side. -AC separation is actually a subluxation.
-Patients with AC separation present with pain at the AC joint and lifting their arm is difficult.

9. Fracture/Dislocations of Shoulder
Using Laboratory & Diagnostic Studies:
-Diagnosis is made by plain radiographs of the AC joint. Can be done with and without weights to exaggerate injury.
Formulating Most Likely Diagnosis:
Types of AC Separation:
Type I-AC joint capsule is partially disrupted
Type II-AC joint and CC ligaments partially disrupted
Type III-AC joint capsule and CC ligaments completely disrupted
Type IV-Type III and avulsion of the CC ligament from clavicle
Type V-Type III and posterior dislocation of the clavicle behind the acromion.
Type VI-Type II and inferior dislocation of lateral end of the clavicle.

10. Fractures/Dislocation of the Shoulder
Health Maintenance:
-If injury is not treated appropriately can cause chronic shoulder pain, cosmetic deformity, decrease range of motion, and paresthesias.
Clinical Intervention:
-Type I-III AC separation can be treated conservatively usually with a sling and NSAIDS.
-Type IV and V AC separation requires surgical repair.
-Ice to area acutely helps reduce pain.

11. Fractures/Dislocations of Shoulder
Pharmaceutical Therapeutics:
-NSAIDs and analgesics should be used to manage pain and symptoms
Applying Basic Science Concepts:
-No specific scientific concepts exists.

12. Clavicle Fracture History Taking & Performing Physical Exam:
-Mechanism of injury usually involves the patient falling on the shoulder or being hit on the shoulder with an object.
-On physical exam patients have difficulty raising their arm
Using Laboratory & Diagnostic Studies:
-Diagnosis is confirmed by plain x rays of the clavicle

13. Clavicle Fracture Formulating Most Likely Diagnosis:
-Other differentials include AC separation and dislocation or separation of the sternoclavicular joint.
Health Maintenance:
-Health maintenance would focus on fall prevention for elderly and children.
Clinical Intervention:
-Most clavicle fractures can be immobilized with a sling. Children usually heal in 3-4 weeks where adults may take 4-6 weeks.
-Usually after 3 weeks can start exercising shoulder and strengthen shoulder.
-Ice to sore areas acutely can help with swelling and pain.

14. Clavicle Fracture Pharmaceutical Therapeutics:
-Patients should be treated with NSAIDS and/or analgesics as needed.
Applying Basic Science Concepts:
-Children will heal faster because of more ossification centers in the clavicle.

15. Proximal Humerus Fracture
History Taking & Performing Physical Exam:
-Typical mechanism of injury is falling directly onto shoulder or struck in the shoulder with blunt force.
-On exam patients have pain and swelling. Patients typically have exquisite pain with any movement of shoulder.
-Patients can rarely get a loss of feeling in the arm and this should raise the suspicion for a brachial plexus injury.

16. Proximal Humerus Fracture
-Patients with mid shaft humerus fractures can be associated radial nerve injury. Can cause wrist drop.
-Patients rarely can injure the axillary artery and lead to vascular compromise of the upper extremity. The radial and ulnar pulses must be assessed.
Using Laboratory & Diagnostic Studies:
-Plain films of the shoulder or humerus are the imaging study of choice for diagnosing shoulder fractures.
-Patients with suspect brachial plexus injury may need an EMG and an MRI of that area.
-Patients with vascular compromise need either arterial dopplers, CTA of the upper extremity, or angiogram of the site.
Formulating Most Likely Diagnosis:
-Differential diagnosis includes: rotator cuff tear, shoulder dislocation, AC separation, or biceps tendon tear.

17. Proximal Humerus Fracture
Health Maintenance:
-Health maintenance focuses on fall prevention and screening/treating osteoporosis in the target populations.
Clinical Intervention:
-Minimally displaced humerus fractures that are less than 1 cm can be treated with a sling.
-Usually after the first week, the patient will begin exercises as pain permits.
-After 3 weeks, the patient can go to wearing the splint as needed.
-Proximal humerus fractures that are displaced greater than 1 cm likely will require surgical repair.
-Ice to fracture site can help pain and swelling in the acute phases.

18. Proximal Humerus Fracture
Pharmaceutical Therapeutics:
-Patients should be managed with opiate analgesics as needed for pain.
Applying Basic Science Concepts:
-Early screening/treatment for osteoporosis can reduce fracture risk in elderly patients.

19. Fracture of Scapula History Taking & Performing Physical Exam:
-Scapular fractures usually come as result of a high energy trauma.
-It is unusual to have an isolated scapula fracture. Most are associated with other fractures.
-Pain in the posterior shoulder is the most common complaint along with pain with movement.

20. Fracture of Scapula Using Laboratory & Diagnostic Studies:
-A scapular diagnosis can usually be confirmed from plain films of the shoulder or a chest x ray.
-CT scan should be performed if the fracture of the scapula involves the glenoid.
Formulating Most Likely Diagnosis:
-Diagnosis can be confirmed by physical examination and by plain films of the scapula or chest x ray.
Health Maintenance:
-Patients can have loss of range of motion or chronic pain if not treated appropriately.

21. Fracture of Scapula Clinical Intervention:
-Immobilization for 1-2 weeks with a sling is initial treatment, then range of motion exercises and physical therapy can be initiated.
Pharmaceutical Therapeutics:
Patients pain can be managed with opiate analgesics.
Applying Basic Science Concepts:
-There can be suprascapular nerve impingement with these injuries.

22. Shoulder Dislocation History Taking & Performing Physical Exam:
-Injury mechanism usually involves patient falling onto shoulder.
-Most common dislocation of the shoulder is anterior dislocation.
-Patients present usually with the arm held straight down and have marked decrease range of motion.
-There may be a gap noted up near the shoulder joint on physical examination.

23. Shoulder Dislocation
-Can assess for axillary nerve injury by assessing for sensation over the deltoid.
Using Laboratory & Diagnostic Studies:
-Diagnosis is made with plain films and by physical examination.
Formulating Most Likely Diagnosis:
Health Maintenance:
-Subsequent dislocations of the shoulder can happen easier because of injury/loosening of the ligaments.

24. Shoulder Dislocation Clinical Intervention:
-The patient must have their shoulder reduced. This is usually requires conscious sedation to manage.
-Reduction can be accomplished by multiple techniques. Most common is traction/counter traction technique and Stimson technique.
-Traction counter traction technique involves pulling on the affected shoulder with elbow bent 90 degrees and other assistant hold traction with bed sheet.

25. Shoulder Dislocation
-Stimson technique involves the patient laying prone with their shoulder over the table holding a weight.
-After reduction need to get post reduction radiographs to asses successful reduction.
-Patients should be placed in a sling and swathe after reduction.
Pharmaceutical Therapeutics:
-Patients need conscious sedation to successfully reduce shoulder in most instances.
-Patients pain can be managed with NSAIDS and/or opiate analgesics.
Applying Basic Science Concepts:
-Axillary nerve injury is possible with shoulder dislocations.

26. Soft Tissue Injuries of the Shoulder
History Taking & Performing Physical Exam:
-Anteriorolateral shoulder pain that is aggravated by overhead reaching is often associated with impingement syndrome or rotator cuff tendonitis.
-Adhesive capsulitis (frozen shoulder) is when the anterior lateral shoulder pain is accompanied by stiffness or decreased external rotation or abduction.
-Labral tears do present with anterior lateral pain but pain is associated with instability or catching sensation.

27. Soft Tissue Injuries of the Shoulder
-Rotator cuff pain involving the external rotators such as teres minor and infraspinatus muscle can cause localized posterior shoulder pain.
-Pain in the posterior shoulder commonly comes from superior trapezius or cervical nerve root radiculopathy.
-Poorly localized shoulder pain is usually extrinsic from the cervical radiculopathy or even elbow pathology.
-Biceps tendonitis/rupture-biceps tendonitis comes from inflammation of the long head of the biceps tendon as it passes the anterior bicipital groove of the anterior humerus. Lifting or usual activity can cause a chronically inflamed tendon to spontaneously rupture.
-Multidirectional instability of the shoulder is consistent with subluxation, partial dislocation, or loose shoulder. Typically comes from excessive range of motion with internal and external rotation.

28. Soft Tissue Injuries of the Shoulder
Using Laboratory & Diagnostic Studies:
-Plain films can be obtained but are often of little value in patients with soft tissue injuries of the shoulder.
-MRI of the shoulder is often most useful test for definitive diagnosis.
Formulating Most Likely Diagnosis:
-History and physical exam coupled with diagnostic studies support definitive diagnosis of soft tissue shoulder pathology.

29. Soft Tissue Injuries of the Shoulder
Health Maintenance:
-Physical therapy and strengthening exercises can be useful in treating and preventing soft tissue shoulder injuries.
Clinical Intervention:
-Lidocaine injection tests can help confirm the diagnosis of a specific disorder if the patients pain and symptoms improve after injection.
-Some injures such as rotator cuff tears and labral tears need to be corrected surgically. Other injuries can be treated medically with physical therapy, NSAIDS, and/or immobilization.
Pharmaceutical Therapeutics:
-NSAIDs or opiate analgesics may be helpful to control patients pain and symptoms.
Applying Basic Science Concepts:
-No specific scientific concepts exists for this section.