Disclosures Update 2018 April 1-6, 2018 No relevant financial - PDF document

4/5/18 UCSF CME PRIMARY CARE MEDICINE: Disclosures Update 2018 April 1-6, 2018 No relevant financial relationship exists Common Upper Extremity Conditions You Will See in Office Practice Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine Review of Shoulder Objective Anatomy Develop strategies to diagnose and manage ■ ■ Layers common office problems including upper extremity injuries ◆ Bony articulations (4) ◆ Static stabilizers ✦ Bones, ligaments, capsule, labrum ◆ Dynamic stabilizers ✦ Scapular stabilizers/rotators ✦ Rotator cuff muscles ◆ Bursa 1

4/5/18 Shoulder Anatomy Shoulder Anatomy Bony articulations Shoulder Anatomy Shoulder Anatomy Dynamic stabilizers Static Stabilizers 2

4/5/18 Shoulder Anatomy Shoulder Anatomy Dynamic stabilizers Dynamic stabilizers ■ Rotator Cuff ◆ Supraspinatus u Teres minor ◆ Infraspinatus u Subscapularis Shoulder Anatomy Shoulder Anatomy Bursae Dynamic stabilizers ■ Rotator Cuff ◆ Subscapularis ◆ (biceps tendon) ◆ Supraspinatus ◆ Infraspinatus u Teres minor 3

4/5/18 Case #1 Based on this history, what is the least likely diagnosis? 25 yo bike messenger was ■ doored and fell off her bike, 1. Clavicle fracture landing directly on the lateral aspect of her left shoulder 2. Rotator cuff tear She was able to get back on ■ her bike but 2 hours later, 3. AC joint sprain was in too much pain to continue working 4. Subacromial bursitis/impingement 3 days later after ice and from traumatic contusion ■ NSAIDs she still had pain, difficulty lifting her arm 5. None of the above overhead or riding a bike Clavicle Fractures Based on this history, what is the least likely diagnosis? 1. Clavicle fracture 2. Rotator cuff tear 3. AC joint sprain 4. Subacromial bursitis/impingement from traumatic contusion 5% 5% 80% 80% 15% 15% 5. None of the above 4

4/5/18 Clavicle Fractures Humerus Head Fractures ◆ For any trauma with resultant loss of range of motion For any trauma with resultant loss of range of and/or weakness and/or significant pain, get Xrays ■ motion and/or weakness and/or significant pain, get Xrays ER view AC Joint Sprain Shoulder Range of Motion ◆ Deformity, crepitus, swelling, bruising of AC joint ◆ Pain with horizontal aDDuction ◆ Limited ROM and pain with resisted FF , aBDduction 5

4/5/18 Shoulder Range of Motion Shoulder Range of Motion Shoulder Impingement Syndrome Shoulder Impingement Syndrome Mechanism Symptoms Impingement of: – Subacromial bursa ■ Impingement under ■ Pain with – Rotator cuff muscles and acromion with flexion ◆ Overhead activities tendons and internal rotation of ◆ Sleep (Internal – Biceps tendon the shoulder rotation) Between ■ Rotator cuff, ◆ Putting on a jacket – Acromion subacromial bursa and – Coracoacromial ligament biceps tendon – AC joint – Coracoid process – Humeral head Rotator cuff tendinosis 6

4/5/18 Impingement Signs Impingement Signs Hawkins Sign Neer’s Sign – Arm passively ◆ Passive test forward elevated to – Arm fully pronated 90 degrees, elbow is and placed in forced flexed, then flexion shoulder forcibly – Trying to impinge internally rotated subacromial – Trying to impinge structures with subacromial humeral head structures with Sens = 83 % – Pain = Positive test Sens = 88 % humeral head Spec = 51 % Spec = 43 % – Pain = positive test PPV = 40 % PPV = 38 % NPV = 89 % NPV = 90 % MacDonald et al. J Shoulder Elbow Surg, 2000 MacDonald et al. J Shoulder Elbow Surg, 2000 Always check cervical Impingement Rotator Cuff Disease ■ Spurling � s test for ■ Tendinitis ■ Partial thickness tear cervical radiculopathy ■ Full (Complete) thickness tear ■ May be due to: ◆ Impingement ◆ Degeneration ◆ Overuse ◆ Trauma Sens = 64% Spec = 95% < 1% of shoulder injuries ■ in persons < 30 yo are PPV = 58% complete rotator cuff NPV = 96% tears 7

4/5/18 Rotator Cuff Disease Rotator Cuff Disease Etiology ■ ◆ Overhead overuse ■ Painful Arc activities ◆ Trauma ◆ Pain with abduction ◆ Instabililty starting around ◆ Degenerative joint 70 � to 120 � disease ✦ Maximal at 90 � Pain radiates antlat and ◆ Pain with forward ■ superior flexion at 90-120 � ◆ Often to deltoid insertion Can also be positive ◆ Often with night pain ■ in impingement Associated symptoms ■ ◆ Giving way feeling ◆ Clicking, catching, grinding ◆ Weakness Subscapularis Tests Rotator Cuff Tendonitis/Tears ■ Lift-Off Test ■ Subscapularis ◆ Lift-off test, Belly ◆ Lift arm off the back press ◆ If unable to maintain position ■ Supraspinatus ✦ Positive lift-off sign ◆ Empty can (Jobe test) ◆ Make sure pt is not extending elbow ◆ Drop Arm Test ◆ Can then also test strength ■ Infraspinatus, Teres Minor For tendonitis: ◆ Dropping sign Sens = 50 % ◆ Hornblower’s sign Spec = 84 % For tears: Sens = 50 % Spec = 95 % Naredo et al. Ann Rheum Dis, 2002 8

4/5/18 Subscapularis Tests Supraspinatus Tests ■ Belly-Press Test ◆ If unable to internally rotate arm to their back: ■ Jobe Test ✦ Palms on belly ✦ Bring both elbows forward ◆ 30 deg anterior to ✦ Resisted elbow forward flexion coronal plane ✦ Not good to isolate superior fibers ◆ Abduction 90 deg ◆ Thumbs up ◆ Isolate supraspinatus muscle activity ◆ Resisted abduction Supraspinatus Tests Infraspinatus/Teres Minor Tests Drop Arm Test Arms at the side ■ Abducted arm slowly Elbows flexed lowered ■ Resisted external rotation ■ – May be able to lower arm slowly to 90 � (deltoid function) For tendonitis: – Arm will drop to side if rotator cuff tear Sens = 57 % Positive test Spec = 71 % – patient unable to For tears: lower arm further Sens = 36 % with control – If able to hold at 90º, Spec = 95 % pressure on wrist will cause arm to fall Naredo et al. Ann Rheum Dis, 2002 – 9

4/5/18 Infraspinatus/Teres Minor Tests Case #2 ■ Dropping sign 55 yo female with onset of right shoulder pain one ■ ◆ Infraspinatus year ago when playing tennis ◆ Forearm is placed in 45 � ◆ she is RHD of external rotation Had been “getting along” with it and controlling ◆ Resist examiner’s hand ■ symptoms but began to notice gradual loss of ◆ If falls back to 0 � of ER, then + test motion despite ice and NSAIDs ■ Hornblower’s sign Now presenting with pain all the time, including ■ night pain, with inability to sleep on shoulder due Teres minor and IS ■ If unable to stay ER when to pain ■ placed in 90/90 ER She has had to buy new bras that clasp in front position, + test ■ Elbow rises above hand ■ level when hand raised to mouth What is your next step with What is your next step with this patient? this patient? 1. Refer to PT if her ROM doesn’t improve with an 1. Refer to PT if her ROM doesn’t improve with an aggressive HEP at 1 mo F/U aggressive HEP at 1 mo F/U 2. Control other comorbid conditions like HTN and 2. Control other comorbid conditions like HTN and hyperlipidemia that predispose her to this problem hyperlipidemia that predispose her to this problem 1. Refer her to ortho for surgical manipulation under 3. Refer her to ortho for surgical manipulation under anesthesia anesthesia 2. None of the above 4. None of the above 10

4/5/18 Adhesive Capsulitis Adhesive Capsulitis ■ IR/ADDuction first Spontaneous, gradual ■ onset of shoulder to go and last to stiffness and pain caused come back by tightening of joint capsule ■ Scapular 70% female, 40-60 yoa substitution ■ Comorbid conditions ■ ■ End range pain include diabetes, hypothyroid dz, RA ■ Disuse atrophy Usually occurs after ■ shoulder immobilized or subconscious restricted motion after minor injury Natural History Treatment ■ Pain management (+/- sling) ■ 0-3 months � gradual onset � - painful ■ Education and reassurance ■ 2-9 months � freezing � ■ Active home stretching ■ 4-12 months � frozen � program “ The The art of of medicine ■ 5-26 months � thawing � ■ Physical Therapy co consists ts of amusing th the ■ Oral NSAIDs (or steroids) pa patient whi hile natur ure ■ Usually self-limited ■ Glenohumeral injection- cu cure res th the disease. ” capsular distension ■ Rarely needs surgery -Vo Voltaire (examination/manipulation under anesthesia or arthroscopic lysis of adhesions) Hannafin & Chiaia, Clin Orthop Rel Res, 2000 11