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ATC 222 Chapter 21 The Shoulder Complex Anatomy Bones – clavicle – humerus – scapula Ligaments Sternoclavicular Acromioclavicular Glenohumeral Muscles Rotator Cuff – S.I.T.S. – surrounding musculature Nerve Supply Brachial Plexus C5-T1 Blood Supply Subclavian Artery Axillary Artery Brachial Artery Shoulder Assessment H.O.P.S. – History – Observation – Palpation – Special Tests Recognition & Management of Specific Injuries Fractures Clavicular Humerus – Shaft – Proximal – Epiphyseal Clavicular Fractures Etiology – fall on outstretched arm or tip of shoulder – direct impact Signs and Symptoms – supports the arm on the injured side tilting the head toward that side and the chin opposite Clavicular Fractures Management – apply sling and swathe – refer for x-ray – immobilize 6-8weeks Humeral FracturesShaft Etiology – direct blow or fall on the arm Signs and Symptoms – probable deformity – wrist drop and inability to supinate the wrist Humeral FracturesShaft Management – splint and referral to a physician – 3-4 months Humeral FracturesProximal Etiology – direct blow, fall on outstretched arm, or dislocation Signs and Symptoms – often mistaken for a shoulder dislocation – possible severe hemorrhaging Humeral FracturesProximal Management – sling and swathe and referral – 2-6 months Humeral FracturesEpiphyseal Etiology – direct blow or indirect force along the axis of the humerus Signs and Symptoms – shortening of the arm – appearance of a false joint Management – splint and referral to a physician Sprains Sternoclavicular Acromioclavicular Glenohumeral; Sternoclavicular Sprain Etiology – indirect force transmitted through the humerus – twisting of an posteriorly extended arm 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 Management – RICE – reduction, immobilization 3-5weeks Acromioclavicular Sprain Etiology – direct impact to tip of shoulder – upward force against long axis of humerus, falling on outstretched arm Acromioclavicular Sprain 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 Management – apply ice and sling and swathe – referral – Grade 1: 3-4 days – Grade 2: 10-14 days – Grade 3: 2 weeks, Operative vs. Nonoperative Glenohumeral Joint Sprain Etiology – forceful abduction and ER – forceful movement posteriorly with flexion of arm Signs and Symptoms – decreased ROM – pain with reproduction of mechanism Glenohumeral Joint Sprain Management – ice and sling for comfort – initiate active and passive ROM after 1-3 days Acute Subluxations & Dislocations accounts for up to 50% of all dislocations only 1-4% are posterior 85-90% recur Glenohumeral Dislocations-Anterior Etiology – direct impact on posterolateral or posterior aspect of shoulder – forced abduction and ER Glenohumeral Disloccations-Anterior Signs and Symptoms – flattened deltoid contour – humeral head in the axilla – arm carried in slight abduction and ER Glenohumeral Dislocations-Anterior 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 Etiology – forced adduction and IR – fall on extended and internally rotated arm Signs and Symptoms – arm held in adduction and internal rotation – head of humerus may be seen posteriorly Chronic Shoulder Instabilities Etiology – traumatic (micro vs. macro), atraumatic, congenital, and neuromuscular Signs and Symptoms – Anterior – Posterior – Global Chronic Shoulder Instabilities Management – Conservative vs. Surgical – shoulder harness Shoulder Impingement Syndrome Etiology – repetitive overhead activities – capsular laxity leading to inflammation – forward head and rounded shoulders – hooked shaped acromion process Rotator Cuff Tears partial thickness vs. complete thickness tears acute trauma or impingement nearly always involves the supraspinatus muscle Shoulder Impingement Syndrome Signs and Symptoms – diffuse pain around the acromion – pain with overhead activities – weak external rotators Shoulder Impingement Syndrome Stage I – aching after activity – pain with abduction that becomes worst at 90 degrees – pain with flexion and resisted supination and external rotation Stage II – aching during activity that becomes worst at night, restricted movement Shoulder Impingement Syndrome 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+) – infraspinatus and supraspinatus wasting – a lot of pain with abduction to 90 – limited AROM and PROM – weakness during abduction and ER Shoulder Impingement Syndrome Management – RICE – Modification of activity – Strengthening of ER and Scapular Stabilizers – Surgery vs. Injection Shoulder Bursitis Etiology – fall on tip of shoulder – direct impact or shoulder impingement Signs and Symptoms – pain with abduction, flexion and IR Management – cold, antiinflammatory medications Bicipital Tenosynovitis Biceps Brachii Rupture Peripheral Nerve Injuries Etiology – blunt trauma or stretch Signs and Symptoms – constant “burning” pain, muscle weakness and atrophy – paralysis Peripheral Nerve Injuries Management – ice – resume play when symptoms subside – referral to a physician is ESSENTIAL if symptoms persist Thoracic Outlet Compression Syndrome Etiology – compression of brachial plexus, subclavian artery and vein (neurovascular bundle) – compression by the scalene and pectoralis mucles Thoracic Outlet Compression Syndrome Signs and Symptoms – paresthesia and pain – impaired circulation in the fingers – muscle weakness and atrophy Thoracic Outlet Compression Syndrome Management – stretching of pectorals and scalenes – strengthening of the traps, rhomboids, serratus anterior