Shoulder Problems ================= þ The Gerber test was the only maneuver good enough to rule out bursitis (negative LR = 0.1) and was only modestly good at ruling it in (positive LR = 3.3). Basically, none of the tests for shoulder impingement are any good at detecting impingement and only so-so for bursitis. [Silva L, Andréu JL, Muñoz P, et al. Accuracy of physical examination in subacromial impingement syndrome. Rheumatology (Oxford). 2008;47:679- 683.] þ The following clinical tests, if positive, may indicate bursitis (Wikipedia): * The patient actively abducts the arm and a painful arc occurs between 80° and 120°. This is due to the compression of the supraspinatus tendon or subacromial bursa between the anterior acromial arch and humeral head. When lowering from full abduction there is often a painful “catch” at midrange. If the patient can achieve adequate muscle relaxation, passive motion tends to be less painful (Starr & Harbhajan, 2001). * The patient performs an isometric flexion contraction against resistance of the therapist (Speed’s Test). When the therapist’s resistance is removed, a sudden jerking motion results and latent pain indicates a positive test for bursitis (Buschbacher & Braddom, 1994). * Neer’s Sign: If pain occurs during forward elevation of the internally rotated arm above 90°. This will identify impingement of the rotator cuff but is also sensitive for subacromial bursitis (Starr & Harbhajan, 2001). þ In 2005, Park et al. published their findings which concluded that a combination of clinical tests were more useful than a single physical examination test. For the diagnosis of impingement disease, the best combination of tests were “ any degree (of) a positive Hawkins-Kennedy impingement sign, a positive painful arc sign, and weakness in external rotation with the arm at the side,” to diagnose a full thickness rotator cuff tear, the best combination of tests, when all three are positive, were the: “the painful arc, the drop-arm sign, and weakness in external rotation” [] þ Dislocations - a Hill-Sachs lesion is damage to the posterosuperior (or posterior) humeral head due to repeated (anterior) shoulder dislocation (no big deal). - It is often accompanied by a Bankart lesion, an injury of the anterior (or anteroinferior) glenoid labrum: bad, leads to chronic dislocations. - May combine external rotation with Milch - May combine Stimson with scapular manipulation þ AC Sprains þ Recurrence of Shoulder Dislocation: - 90% of patients whose first dislocation occurs at age 20 will have a recurrent dislocation, while only 14% of those whose first dislocation occurs at age 40 will have a recurrent dislocation. [Price DD, Wilson SR, Keany J (ed) in EMedicine by Plantz and Adler (eds). http://www.emedicine.com/emerg/topic148.htm] - See also: for methods of reduction. þ Neer's and Hawkins' impingement tests - Neer's: move the patient's straightened arm into full abduction. - Hawkins': rotate the patient's arm across the body while held in 90 degrees of abduction and 90 degrees of elbow flexion. These tests signify the presence of impingement syndrome if the pain is reproduced. Ref: Tintinalli 4th ed. p 1289 Date sent: Wed, 29 May 1996 10:56:02 -0500 Send reply to: Harvey Louzon From: Harvey Louzon Subject: Re: Shoulder dislocations To: Multiple recipients of list EMED-L On Wed, 29 May 1996, Jim Squires wrote: ............. > >This little anecdote may serve little benefit. Although I do get > prereduction xrays on my own patients this is usually done only to CMA and > not necessarily in the interest of cost effective and good patient care. If > there has been a substantial delay in getting to the ER (and there usually > will be) it is likely that patients will thank you if you provide expedient > analgesia. Are there any clinical predictors of an associated # in the > patient with an obvious dislocation??? (BTW - don't believe for a second > "agony" is specific for a complicating fracture!) Harvey? I don't know of any physical findings that would predict the absence of an associated fracture, although I agree with previous observations that an 'atraumatic' mechanism of injury would probably qualify. As far as obtaining pre-reduction films, I would continue to get them in all cases. Several reports of shoulder dislocations asscoiated with fracture of the anotomical neck of the humerous with subsequent avascular necrosis of the humeral head have been described which would contraindicate attempts at closed reduction (1,2,3). H. Louzon MD (1) Hersche O, Gerber C Iatrogenic displacement of fracture-dislocations of the shoulder. A report of seven cases. J Bone Joint Surg Br 1994 Jan;76(1):30-3 We report seven cases in which open or closed reduction of a shoulder dislocation associated with a fracture of the humeral neck led to displacement of the neck fracture. Avascular necrosis of the humeral head developed in all six patients with anatomical neck fractures. All five anterior dislocations also had a fracture of the greater tuberosity and both posterior dislocations had a fracture of the lesser tuberosity. The neck fracture had not initially been recognised in three of the seven cases. In five cases attempted shoulder reduction led to complete displacement of the head segment, which was treated by open reduction and minimal internal fixation. In the other two cases, shoulder reduction caused only mild to moderate displacement which was accepted and the fracture was treated conservatively. We conclude that biplane radiography is essential before reduction of a shoulder dislocation. Neck fractures must always be ruled out, especially where there are tuberosity fractures. In our series, careful closed reduction under general anaesthesia with optimal relaxation and fluoroscopic control did not prevent iatrogenic displacement. Prophylactic stabilisation of the neck fracture should be considered before reduction of such a fracture-dislocation. It may be, however, that the prevention of displacement by prophylactic stabilisation does not always prevent late avascular necrosis; we observed this in one case. (2) Ferkel RD, Hedley AK, Eckardt JJ Anterior fracture-dislocations of the shoulder: pitfalls in treatment. J Trauma 1984 Apr;24(4):363-7 Fracture-dislocations of the shoulder can present difficulties in treatment. Two cases are described to illustrate the complications that can occur when an inexperienced examiner attempts a closed reduction of a two-part anterior fracture-dislocation of the shoulder. Careful clinical and radiologic evaluation (A-P and transcapular or axillary lateral X-rays) followed by appropriate management can help to prevent these problems from occurring. If there is evidence that the fracture is displaced by manipulation, immediate open reduction and internal fixation are recommended. (3) Suso S, Peidro L, Ramon R Avascular necrosis of the humeral head after dislocation with fracture of the greater tuberosity. Acta Orthop Belg 1992;58(4):457-9 A case of posttraumatic avascular necrosis of the humeral head in a young patient was detected 3 years after an anterior dislocation with a nondisplaced greater tuberosity fracture. The evolution to degenerative joint disease is described.