Sites@Duke | sites.duke.edu



Shoulder Pain and MVC caseAlison S. Clay, MD1/21/2015Objectives of this Module:Actively review the shoulder anatomy and demonstrate key provocative tests for the shoulder examAssociate key positive findings (in history and physical) that correlate with specific patterns of shoulder injuryDemonstrate clinical reasoning to rule out serious injuries that require more urgent evaluation in a trauma patientProvide anticipatory guidance to a patient with shoulder injuryPatient History:A 57 year old presents with shoulder pain after a motor vehicle collision early today. The patient was T-Boned by a car that failed to stop at a red light, going approximately 25mph in the passenger side of the vehicle. The patient was not restrained and the air bag did deploy. The patient hit his left shoulder against the side of the car and has significant shoulder pain.PMH:Diabetes MellitusHypertensionOsteoarthritisMedicationsLisinopril 20mgMetformin 1000mg BIDGlyburide 5mg QDTramadol PRNHydrochlorothiazideSH: Married with 3 grown children, works as a computer programmer for a firm, occasional red wine with dinner, scotch on the weekends.FH: NoncontributoryWhat additional history is important to you in a patient who had a motor vehicle collision?Ask about the accident—was there loss of consciousness, any other pain (pain in the neck, back, chest, abdomen, hands, feet, etc). Ask about the presence of amnesia prior to the event.Clarifying History: The patient had no loss of consciousness, and remembers the details of the accident as an argument that happened at work 15 minutes before the accident. He denies any other associated symptoms.T: 37.1 RR: 14 HR:97 BP: 165/85Gen: Well developed, well nourished middle aged manNeuro: Able to follow commands, is oriented. Eyes: Pupils reactive bilaterally, spontaneous eye openingLungs: Clear to auscultation throughout, no wheezes and normal I:E ratioChest: Clear to auscultation bilaterally, no cracklesCVS: A little bit tachycardic, regular, no murmurs, rubs or gallpsAbd: nontender, no obvious organomegalyExt: No edema, 2+ pulses, no swelling or deformity, or pain in any of his hands or feet, or any of the joints of the extremities.What are the components of the Glasgow Coma Scale?Eye response, motor response, and verbal response (look up on web)glasgow-coma-scale-score/What diagnoses do you NOT want to miss? What are their history/physical exam findings in a patient who had a MVC (not related to shoulder pain)?InjuryHistory/Physical ExamDecision rules for imagingHead InjuryPerform Glasgow Coma ScaleEvaluate for HemotympanumEvaluate for OtorrheaEvaluate for history of vomitingAsk about retrograde amnesiacanadian-ct-head-injury-trauma-rule/No imaging needed if:GCS is >15There are no skull fracturesNo signs of basilar skull fracture (raccoons eyes, hemotympanum, oto-rhinorrhea, <2 episodes of vomiting, age <65 no retrograde amnesia, and no dangerous mechanism (Ped hit, ejection, etc)C Spine InjuryEvaluate for focal neurology deficitDetermine if there is midline spinal tendernessDetermine of there is altered level of consciousnessDetermine if intoxication is presentDetermine if there is a distracting injuryCanadian C Spine RulesCan clear with films if age <35, no fall >3ft or 5 stairs, no axial load, no ejective, rollover, bicycle collision, or motorized vehicleNexus Decision rulesNo focal neurologic deficit, no midline spinal tenderness, no alteration of consciousness, no intoxication no distracting injuryWhat types Injuries related to shoulder pain do we not want to miss, and what are their history and physical exam findingsDiagnosesHistoryPhysical ExamOther TestingMyocardial infarctionChest pain (not always present in women or in diabeticsSOB/DiaphoresisNo history of traumaAcute presentationIncreased JVD or nonePainless ROM of the shoulderECGReferred PainRuptured spleen/ruptured ectopicTraumaSudden in Onset of pain inPregnancyWhile patient is laying supine, left the legs; if doing so elicits pain in the shoulder tip, you should be concerned about blood in the peritoneumPainless ROM of the shoulderUS or CTReferred PainLower lobe/RML pneumoniaFeverSOBPleuritic complaintsMalaiseExam the right axilla and anterior right chest to hear the RMLCrackles on examEgo Painless ROM of the shoulder phony on ExamCXRReferred PainBiliary Disease or pancreatitisNausea/VomitingAbdominal PainVaso-vagalNew medication, fatty meal, EtOh useAbdominal pain to palpation in the RUQ or epigastrumPainless ROM of the shoulderCMP, GGT, amylase, lipaseFracture of Humeral HeadH/O traumaPainPain over the bonePlain FilmsShoulder DislocationNeeds to be repositioned to avoid nerve injuryTraumaAcute on onsentOr h/o previous dislocationsArm Feels numbAxillary nerve complaints in 50%--evaluate sensation over the deltoidAnterior—most common; hold in external rotation; can feel head of humerus antPosterior-appear to be guarding, internally rota?Plain FilmsScapula FracturePain over the scapula to direct palpationDON’T MISS because it takes a lot of force to break the scapula and you probably need imaging of the chest if presentPain filmsCervical Spine DiseaseSensory deficits or pain along a nerve rootAfter assuring there is no direct pain over the C-spine, Have patient extend and slightly flex neck towards the affected side, then push down on the head (axial load) to see if symptoms get worse (Spurlings test)MRIWhat specific shoulder injuries are most common after trauma?Fracture of clavicle, proximal humerus fracture, damage to AC joint, and displacements from the glenohumeral jointKeys to shoulder problems on history:History of seizures (posterior shoulder dislocation)History of falling on outstretched hand—rotator cuff or AC separationRecent viral illness—look for scapular winging or consider Parsonage-Turner syndromeNight time pain: impingement Shoulder pain in someone who throws: impingement/ glenohumeral instabilityPain or clunking: labral tearReview of Anatomy Ask students to Identify landmarks on a patient or if acceptable to another student, a student (the AC joint, the subacromial space, the coracoid, the biceps groove, etc)What specific examination do you want to perform of the shoulder?Inspection and Palpation (excellent and short—shows a patient with markers on key muscle/anatomical locationsExternal rotation and abduction, with head of humerus anterior: Anterior dislocationPatient guarding, with internal rotation and adduction (rare)Posterior dislocationWinging of the scapula: Trapezius dysfunction, can be viral; suprascapular nerve entrapmentWasting of the supra and infraspinatus: common in rotator cuff injuriesSwelling of the glenohumerol joint anteriorly: hard to seeSwelling at the acromclavicular and coracoclavicular jointsDeltoid muscle wasting (shoulder appears square)Palpate all joints, and for the bursa (have arm extended and palpate anteriorly alaterally over the deltoid)Specific examination techniques: (animated images of muscles and bones during key maneuvers) Cuff tear (weakness) or pain/tendinits (pain), pain also with impingementApleys—scratch tests for internal rotation and external rotationHawkinsDrop Arm Test-Passively Abduct the arm to 90 degrees, then have patient slowly lower arm; if cannot do so, may have rotator cuff injuryImpingementNeers-with arm flexed to 90 degrees and pronated, forcefully flex arm (to 170 degrees)HawkinsAC jointCross arm testSee below for when AC joints are a problemBiceps tendinitisSpeed Test-Resist arm flexion while patient performs a biceps curl (flexes bicep)Yergason’s Test-pin with resisted supinationGlenohumeral instabilityApprehension Test- with arm abducted and externally rotated, place pressure on the humerusSulcus Test- drop in humeral head near acromoclavicula joint with downward pressureInfraspinatusTeres minorResistance to External rotation:SupraspinatusDrop Can test—With arm pronated and flexed to 90 degrees (with elbow extended), have patient try to elevate arms against resistanceFrom Up To DateProblemIssue on history and physical examRotator Cuff Tendinopathy/ImpingementProblems with external rotation and reaching overheadAdhesive CapsulitisAge > 40, diabetes, diminished range of motionRotator Cuff TearUnable to perform maneuvers/weakWhen to inject lidocaine into subacromial bursa-In a patient with pain to determine if there is a complete tear of the rotator cuff or whether limited range of motion is related pain only (tendinitis)If concerned about AC joint, INSPECT THE NEUROVASCULAR BUNDLEDescription of InjuryWhat to doIMild swelling pain over the AC joint, no deformityPlace in Sling and starts ROM when the patient can do it; ice and analgesiaIIComplete tear of the AC joint; more Pain and swelling than in II Minimal tenderness of the coracoclavicular (CC) space Place in Sling, ice and anesthesia and starts ROM when the patient can do it—recovery can take as long as 4 -6weeks1-3 weeks, ROM3-5 weeks: strengthening>5 weeks, increase strengthening exerciseIIIComplete disruption of the AC and CC; palpable posterior fullness or deformity of AC joint; significant swelling; increased CC space Shoulder deformity reduces when you push on it downwardIV-VISHOULD NOT BE IN OUR CLINICSurgical management necessary-Concern over neurovascular bundle.Marked deformity, tenting of skin, sever displacementHow do you manage rotator cuff injuries?Generally, conservatively! -with pain management and physical therapy. Hard to demonstrate improvement, unless patient is <50, the injury is acute (and not chronic) and there is near complete rupture of the rotator cuff (partial tears usually heal on their own, unless the person is an elite athlete). (see next page) should this be here?When referring to PT, what are some things to consider discussing with patient:Without insurance, the charge to patients for PT is $150. (per visit?)With insurance the co-pay can still be as high as $50 (that adds up if multiple visits a week, etc).PT very helpful in determining which execises to focus on, particularly as pain begins to subside and focus plan needs to narrow to individual muscle exercisesGoing to PT without doing the exercises they show you at the session (even though it doesn’t take much time), can impeded recovery and is costly!PT can often perform therapies that help reduce pain –such as release techniques/focused massage on trigger points, passive stretching, etc.How do you advise patients about resting injured shoulders?A short period of rest may help, but prolonged rest (without ROM) fosters adhesive capsculitis---in the end, you have to use it, or you lose it.References:Videos, as displayedMD CalcUptoDateAAFP Shoulder pain part I and II, AAFP, 2000. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download