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What ligaments hold atlas to axis & keep it stable?
Alar ligaments
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Light touch: Upper Neck:
C2
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Light touch: Lower Neck:
C3
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Anterior vert column:
vert bodies, disc spaces, A&P longitudinal ligaments, & annulus fibrosis
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Posterior vert column:
pedicles, facet joints, laminar spinous processes, & posterior ligament complex
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If one of the two vert columns is intact, then:
the injury is stable
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If both columns are disrupted, then:
the injury is unstable
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2 major regions of C spine:
cranio-cervical junction (occiput to C2); lower cervical spine (C3 - C7)
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Cranio-cervical jnct (occiput to C2)
50% of motion; atl-occ jnt (Yes); atl-axial jnt (No)
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Lower C spine (C3 - C7)
50% of motion divided evenly between segments
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Spine Forces:
flexion (forward & lateral), extension, axial compression, rotation, & distraction
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Anterior Marginal Line
line drawn along the anterior vertebral bodies
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Posterior Marginal Line
line drawn along the posterior vertebral bodies C2 - C7
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Spinolaminal Line
line drawn along the bases of the spinous processes C1 - C7 (marks the posterior margin of the spinal canal)
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Posterior Spinous Line
line drawn along the tips of the spinous processes C2 - C7
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Radiology: Trauma:
order lateral, AP, & odontoid view; all 7 vertebrae must be seen
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Radiology: Lateral:
4 smooth lines
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Radiology: AP:
spinous processes should be in a vertical row
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Radiology: Odontoid:
open mouth: inspect odontoid, distance between axis & dens should be equal bilateral
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Tx Jefferson fx: stable
Rigid collar (cervicothoracic) x 3 mo; regular f/u for radiographs
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Tx Jefferson fx: unstable
Cranial traction; halo x 3 months; > 5mm C1-C2 subluxation = C1-C3 fusion
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Odontoid fx types
type I (rare): avulsion fx of alar ligament; type II & III
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Burst Jefferson fx stability: determined by:
transverse ligament
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Burst Jefferson fx stability:
Usually neuro intact (fragments burst away; wide breadth of C1 canal)
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Burst Jefferson fx: 1/3 of fx assoc with:
an axis fx
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Burst Jefferson fx: 50% chance that:
some other C spine injury is present
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Odontoid fx MOA
Hyper-flexion or hyper-extension
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Odontoid fx: Blood supply (watershed area):
Neck
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Odontoid fx: assoc with:
C1 neural arch fracture or Jefferson fx
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Odontoid fx: 25% incidence of:
neurologic injury
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Odontoid fx: non-displaced fx show:
callus at 2-3 weeks
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Hangmans Fx =
Traumatic Spondylolisthesis of C2 (bilateral C2 pedicle fx)
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Hangmans Fx MOA
hyperextension & sudden violent distraction; hyperextension & axial loading; or flexion & compression (usu combination of forces)
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Hangmans Fx: Types
4 types (I, II, IIA, III = worst)
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Hangmans Fx: Immobilization:
rigid cervical orthosis or halo vest system
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Hangmans Fx: Traction:
used generally for reductions (Gardner-Wells tongs or halo vest system)
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C spine inj prevalence in football
10-15% of football players
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Sp cord injury overall incidence
4/100,000 per year
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Most recent sport SCI:
football, trampoline (gymnastic), diving
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Highest % head injuries
football; then ice hockey
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Acute Cervical Sprain =
Injury to restraining ligaments of cervical spine
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Acute C- Sprain grade I (mild):
ligaments damaged but not lengthened
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Acute C- Sprain grade II (mod):
some laxity but not total disrupt
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Acute C- Sprain grade III (severe):
ligament completely disrupt
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Acute C- Sprain can occur alone or with:
C-strain (mx), fx/ dislocation, instability
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Isolated C-sprain: S/S
- localized pain, decreased ROM, no neurologic deficits
- Acute C- Sprain: if no fx/ sublux on films, then get:
- flex/ext (assess for instability)
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Acute C- Sprain: if sig mx spasm, then:
repeat flex/ext films after spasms subside (protect neck)
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Acute C- Sprain: if poss subluxation:
pt should wear hard collar & flex/ext films repeated in 2-4 wks
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Acute C- Sprain: if instability present, may need:
6-12 wks immobilization in rigid orthosis and/or surgery
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Acute C- Sprain: if xray w/u neg:
RTP only when painless full ROM & normal neck strength
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Cervical Stenosis =
narrowing of sagittal diameter of cervical canal
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C-stenosis often asymptomatic until:
acute hyperflexion/ extension or axial loading of C-spine produces neuro signs
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C-stenosis: segments most commonly involved
C5 and C6 segments
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Cervical Stenosis Types
Congenital; Developmental; Acquired
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C-stenosis: Congenital =
short pedicles, funnel shape of cervical canal
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C-stenosis: Developmental =
bone size due to stress in weight training
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C-stenosis: Acquired =
spondylosis, spurs, disc bulge or space narrowing
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Fx & Dislocation: Injury MOA
axial load w/ slight neck flexion (spearing)
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Downed Player: initial x-rays s/b obtained:
on spine board with helmet on
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Cervical Spondylosis =
Chronic disc degeneration (arthritis)
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Cervical Spondylosis: Represents:
nerve root compression
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Cervical Spondylosis S/S:
neck pain, radicular pain radiating from neck to upper extremity
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Cervical Spondylosis Rx:
supportive, facet injections, operative decompression
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Brachial Plexus Neuropraxia include:
Burners, stingers, hot shots (football, wrestlers, hockey)
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Brachial Plexus =
C5, C6, C7, C8, T1
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Brachial Plexus Neuropraxia: Blow to head:
lateral flexion to contra side of shoulder being depressed results in traction on nerves
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Brachial Plexus Neuropraxia S/S
Sudden burning pain, numbness in lateral arm, thumb, & index finger, lasts 1-2 min
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Brachial Plexus Neuropraxia: if S/S persist/ repeated:
MRI is indicated
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Brachial Plexus Neuropraxia RX:
- ROM, strengthening, protection
- Atlas: superior surface of lateral masses articulates with:
- the occipital condyles forming the occipito-atlantal joints
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Atlas: inf surface of lateral masses articulate with:
the superior articular facets of C2 forming the C1 - C2 apophyseal joints
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R/O C Spine Fx
Pt not c/o neck pain; no neck tenderness on palp; no hx LOC; no mental status changes fr trauma, etc; no S/S referable to neck inj (paralysis, sensory changes); no other distracting inj
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C Spine injuries
Occ- atl Dislocn; Occ Condyle Fx; Atlas fx (C1); Odontoid fx; Atl-Axl (C1-C2) instability; C2 Lateral Mass fx; traumatic Spondylolisthesis of C2 (Hangmans fx)
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Burst Jefferson fx MOA
Axial blow to head, force transmitted thru occ condyles; forces C1 lateral masses outward
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Burst Jefferson fx Radiology:
C1 lat masses not line up vertly w/ C2 sup articular facets; distance btw dens & C1 lat masses is asymmetric
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Odontoid fx: tx
Reduce fx & hold in halo immobilization (3 months); C1-C2 fusion if severely displaced or non-union; Few advocate acute ORIF dens
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Hangmans Fx: alignment:
vert body of C2 is normally aligned w/ C1 & dens; post elements of C2 are normally aligned w/ C3
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Hangmans Fx: Stability:
unstable; neuro deficit is surprisingly rare unless C2 - C3 subluxation is severe
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Hangmans Fx: Tx
will usually stabilize with halo fixation; anterior fusion may be needed due to delayed instability
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Hangmans Fx: Operative Tx:
occipitocervical fusion; atl-axial fusion; transarticular screw fixation; ant. screw fixation of dens; internal fixation w/ posterior plating of occiput to C2
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Evaluation of cervical instability (White & Punjabi )
Vert malalignment; >3.5mm translational displacement; 1.7 mm or greater disk widening
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C-Cord Neurapraxia & Transient Quadriplegia: S&M recovery usu occurs in:
10-15 minutes (up to 24-36h in some)
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C-Cord Neurapraxia & Transient Quadriplegia may involve:
both legs, both arms, or ipsilateral arm & leg
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C-Cord Neurapraxia & Transient Quadriplegia Initial evaluation:
routine c-spine films & poss CT scan (flex/ext films if routine films normal); consider MRI
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Fx & Dislocation: forces transmitted:
directly to spinal structures; energy first absorbed by discs with compressive deformation; continued energy: angular deformation & buckling w/ failure of discs, lig structures & bony elements
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On Field Eval (Downed Player)
- 1: Assess ABCs;
- 2: initial neuro;
- 3: turning the athlete;
- 4: immobilization;
- 5: evacuation
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Downed Player: turning athlete
Doc at head grasp player shoulders & cradle head w/ forearms (if use hands alone, avoid flexing neck). Avoid cervical traction
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Downed Player: immobilization
Leave helmet & shoulder pads on; fasten torso to spine board w/ straps; sandbags/ blankets on either side of head and taped with helmet to board
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Downed Player: immobilization: C-collar =
NOT an alternative to proper head immobilization on the board & may compromise the airway
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C Spine injuries: Tx
Philadelphia collar immobilization (stable); Halo immobilization (stable); Occipito-cervical fusion (unstable)
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Trapezial strain:
localized pain posterior C-Spine; Pain reproducible with palpation of trapezius; Wry neck or torticollis; Rx: Supportive
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Stingers & Burners =
transient shooting/ burning pain or paresthesia in one arm related to neck or shoulder trauma
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Stingers & Burners: due to:
stretch injury on brachial plexus or compression on nerve root (neural foramen)
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Stingers & Burners: If S/S longer than 15 min:
consider w/u (if compression type injuries, image for foraminal stenosis or herniated disk)
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Shoulder: 4 joints:
SC, AC, GH, Scapulothoracic
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Acromion process Type I:
Flat, smooth acromion at clavicular joint; normal subacromial space
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Acromion process Type II:
Hooked acromion; subacromial space mildly decreased
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Acromion process Type III:
Hooked acromion with spur; subacromial space significantly decreased
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Shoulder Hx: unusual aspects
hand dominance; Night pain; Clunks, pops; Neck pathology
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Night pain: may indicate
rotator cuff injury
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Scapular winging/trauma =
Serratus or Trapezius dysfxn
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Unable to externally rotate =
Posterior dislocation
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Supra/infraspinatus wasting =
RCT or suprascapular n. palsy
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Dec. cervical ROM, pain below elbow =
Cervical disc disease
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Throwing athletes/ ant. Pain =
Instability
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Pain or “clunk” w/ motion =
Labral tear
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Night pain =
Impingement, Frozen
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Generalized laxity =
Multidirectional instability
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Shoulder Exam: significant:
Asymmetry; Atrophy; Apley scratch test
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Rotator cuff: tests for impingement
Neer; Hawkins (both passive)
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Test of AC joint
crossover (passive)
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Tests for biceps tendonitis
Speeds; Yergason (both active)
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Tests for anterior shoulder instability
Sulcus; apprehension & relocation (both passive)
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Tests for labral tears
Obrien; anterior slide; crank
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Circulation tests
Adson; Allen; Roos
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Shoulder imaging: Standard views:
AP and axillary
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Imaging: Can get Y view if:
suspected dislocation or scapular fx (trauma)
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On shoulder imaging: may see:
bony bankhart, Hill-Sachs (uncommonly), or spur; tumor or fx; elevated humeral head (RCT); AC separation or DJD
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Best imaging for RCT
CT arthrogram good, but MRI is better (invasive)
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CT is good for:
bone abnormality; tumors
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MRI for RCT
95% sensitivity & specificity in detecting RCT
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MRI good for:
RCT; SLAP lesions (Arthrogram); Soft tissue
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Ultrasound: Positives
Non-invasive; Cost; Portable
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Ultrasound: Negatives
Quality; User dependent
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Shoulder Injections
Depo medrol w/ lidocaine & bupivacaine HCl (total of 10 mL); 25 gauge 1.25-1.5 needle
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Common Injection Solutions
Depo Medrol, Celestone; Dexamethasone; Kenalog
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Depo Medrol, Celestone =
shorter acting, less irritating
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Dexamethasone =
Medium (duration)
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Kenalog =
Long acting, slightly more painful initially; mix with lidocaine & Marcaine
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5% of all fractures seen by FP =
Clavicle Fx
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Clavicle Fx: MOA
FOOSH, onto shoulder, direct trauma
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Clavicle Imaging
AP, 45 degree cephalic tilt
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Grades of AC Separations:
6 different grades
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AC Separation: MOA
Usually direct blow to shoulder
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AC Separation: PE:
step deformity, TTP AC joint, (+) crossover sign
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AC Separation: Radiographs:
AP, Zanca (100 cephalic tilt), axillary
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AC Separation: Grade 3 & above:
Refer for poss surgical fixation, otherwise conservative care (sling)
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AC Separation: RTP when:
pain-free with abduction, crossover
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Anterior SC Dislocation: MOA
Anterior usually MVA
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Anterior SC Dislocation: PE:
TTP SC joint, deformity
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Anterior SC Dislocation: Radiographs:
AP, 40 degree cephalic view
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Anterior SC Dislocation: Mgmt
Usually conservative; Sling, ROM
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Posterior SC Dislocations: MOA
Usually fall on flexed and adducted shoulder
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Posterior SC Dislocations: Concern
Can be life-threatening; immediate referral and CT
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Posterior SC Dislocations: Mgmt
Closed reduction or surgical reduction
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95% of dislocations =
Anterior Shoulder Dislocations
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Anterior Shoulder Dislocations: usually held in:
ext. rotation and abduction
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Cf to anterior, posterior shoulder dislocations have:
limited external rotation
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Anterior Shoulder Dislocations: Radiographs:
AP and axillary or Y
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Anterior Shoulder Dislocations: Mgmt
Acute: reduction (Stimpson or Kocher)
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Anterior Shoulder Dislocations: Complications:
recurrent dislocations, bony injury (Hill Sachs, or Bankhart), RCT , NV injury, arthropathy (later)
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Anterior Shoulder Dislocation: Tx
once reduced, sling w/ mobilization in 2 wks
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Rotator cuff disorder: age of most pt
usually > 40 y.o. unless traumatic
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Rotator cuff disorder: S/S
Insidious onset, worse w/ overhead activity, night pain
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Rotator cuff disorder: PE:
ROM, RC strength, Hawkins/Neer, Jobe
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Rotator cuff disorder: Tx & CI
Injections contraindicated if there is a partial tear
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Rotator cuff disorder: Tx (conservative)
NSAIDs, ice, avoid painful activity, PT, injections
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Rotator cuff disorder: Tx (surgical)
arthroscopy vs open
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Biceps Tendonitis: usu assoc with:
other pathology (RCT, SLAP tear); may rupture if RCT worsens
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Biceps Tendonitis: PE:
TTP Bicipital groove, Speeds, Yergasons
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Biceps Tendonitis: Tx
NSAIDs, corticosteroid injection, PT
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Biceps Rupture: age of pt
Usually > 50 yrs old
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Biceps Rupture: usually involves:
long head of biceps (short head rupture rare)
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Biceps Rupture: S/S
pop, ecchymosis
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Adhesive Capsulitis =
Contraction of capsule (Frozen Shoulder )
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Adhesive Capsulitis: Usually secondary to:
immobilization after injury
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Clin dx of Adhesive Capsulitis: what is key?
ROM (usually lose external rotation first)
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Adhesive Capsulitis: mgmt
PT, NSAIDs, injections; may need surgical lysis of adhesions
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3 Stages of Adhesive Capsulitis
Painful; Adhesive; Recovery
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SLAP Lesions =
Superior Labral Anterior Posterior
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SLAP Lesions S/S
Painful shoulder with clicks, pops with motion
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SLAP Lesions: PE
Pos clunk test, crank test, OBriens, sometimes instability or biceps tendonitis; MRI
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SLAP Lesions: tx
Conservative tx (NSAIDs, PT, rest); arthroscopy vs open repair
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Tests for posterior shoulder instability
Pt supine, elbow flexed 90, arm abducted to 90; push postly, pos test = pt apprehension & laxity
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Posterior shoulder dislocations cf to anterior:
Posterior will have limited external rotation cf to anterior dislocations
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Clavicle Fractures: most common geography
middle third (followed by distal third); most common place at jnct btw middle & distal 1/3
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Clavicle Fx: PE:
edema & pt tenderness over fx site; assess ROM of neck, shoulder; motor strength, sensation; SC dislocations
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Clavicle fx: Tx
Sling; Figure of 8 (sig displacement, use of arms for ADLs); Periodic ROM; No contact sports for 6 wks
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Clavicle Fx: When to Refer?
NV compromise; open fx; symptomatic non-union at 12 wk; Cosmesis; Distal third (? physeal injury, AC injury); Proximal third (SC joint dislocation)
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Rotator cuff disorder: DDX:
Instability; SLAP; Bursitis; Referred pain ; Calcific tendonitis; Thoracic outlet syndrome; Adhesive capsulitis
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Ant Shoulder Dislocation: may need surgical repair
Thermal capsular shift (subluxations); arthroscopy vs open repair
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Biceps Rupture: Mgmt
Conservative: Proximal (most); MRI if dx uncertain; Tenodesis within 3-4 wks prn (Distal)
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Adhesive Capsulitis: epidemiology
assoc w/ other illnesses (DM, thyroid, recent chemo/ rad); F >> M (increased estrogen receptors around shoulders)
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Adhesive Capsulitis: Painful stage
(0-3 months); pain w/ movement; genl ache; mx spasm; inc noc/ rest pain
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Adhesive Capsulitis: Adhesive stage
(3-6 months); Less pain; inc stiffness & restricted movement; less noc pain; pain at extreme ranges of movement
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Adhesive Capsulitis: Recovery stage
(>6 months); dec pain; restrictn w/ slow, gradual inc ROM; recovery spontaneous, often incomplete
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Ulnar n. symptoms
numbness, paresthesia, thenar wasting
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Carrying angle (M/F)
Men 5 degrees, women 10-15 degrees
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Elbow Radiographs: Order:
AP, lateral, oblique
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Elbow Radiographs: Inspect for:
Cortical defects; Radiocapitellar line; Ant. humeral line; fat pad sign
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Anterior fat pad =
Usually normal (Sail sign)
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Posterior fat pad =
Always pathologic
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Posterior fat pad sign in adults may indicate:
radial head fx
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Posterior fat pad sign in kids =
supracondylar fx
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