Shoulder Pain and MVC caseAlison S. Clay, MD

1/21/2015

Objectives of this Module:1) Actively review the shoulder anatomy and demonstrate key provocative tests for

the shoulder exam2) Associate key positive findings (in history and physical) that correlate with

specific patterns of shoulder injury3) Demonstrate clinical reasoning to rule out serious injuries that require more

urgent evaluation in a trauma patient4) Provide anticipatory guidance to a patient with shoulder injury

Patient 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:1. Diabetes Mellitus2. Hypertension3. Osteoarthritis

Medications1. Lisinopril 20mg2. Metformin 1000mg BID3. Glyburide 5mg QD4. Tramadol PRN5. Hydrochlorothiazide

SH: Married with 3 grown children, works as a computer programmer for a firm, occasional red wine with dinner, scotch on the weekends.

FH: Noncontributory

What 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)www.mdcalc.com/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)?Injury History/Physical Exam Decision rules for imagingHead Injury Perform Glasgow Coma Scale

Evaluate for HemotympanumEvaluate for OtorrheaEvaluate for history of vomitingAsk about retrograde amnesia

www.mdcalc.com/canadian-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 Injury Evaluate 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 injury

Canadian 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 vehicle

Nexus Decision rulesNo focal neurologic deficit, no midline spinal tenderness, no alteration of consciousness, no intoxication no distracting injury

What types Injuries related to shoulder pain do we not want to miss, and what are their history and physical exam findingsDiagnoses History Physical Exam Other

TestingMyocardial infarction

Chest pain (not always present in women or in diabeticsSOB/DiaphoresisNo history of traumaAcute presentation

Increased JVD or nonePainless ROM of the shoulder

ECG

Referred PainRuptured spleen/ruptured ectopic

TraumaSudden in Onset of pain inPregnancy

While 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 shoulder

US or CT

Referred PainLower lobe/RML pneumonia

FeverSOBPleuritic complaintsMalaise

Exam the right axilla and anterior right chest to hear the RMLCrackles on examEgo PainlessROM of the shoulder phony on Exam

CXR

Referred PainBiliary Disease or pancreatitis

Nausea/VomitingAbdominal PainVaso-vagalNew medication, fatty meal, EtOh use

Abdominal pain to palpation in the RUQ or epigastrumPainless ROM of the shoulder

CMP, GGT, amylase, lipase

Fracture of Humeral Head

H/O traumaPain

Pain over the bone Plain Films

Shoulder DislocationNeeds to be repositioned to avoid nerve injury

TraumaAcute on onsentOr h/o previous dislocationsArm Feels numb

Axillary 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 Films

Scapula Fracture

Pain over the scapula to direct palpation

DON’T MISS because it takes a lot of force to break the scapula and you probably need imaging of the chest if present

Pain films

Cervical Spine Disease

Sensory deficits or pain along a nerve root

After 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)

MRI

What specific shoulder injuries are most common after trauma?Fracture of clavicle, proximal humerus fracture, damage to AC joint, and displacements from the glenohumeral joint

Keys to shoulder problems on history: History of seizures (posterior shoulder dislocation) History of falling on outstretched hand—rotator cuff or AC separation Recent viral illness—look for scapular winging or consider Parsonage-Turner

syndrome Night time pain: impingement Shoulder pain in someone who throws: impingement/ glenohumeral instability Pain or clunking: labral tear

Review of Anatomyhttps://www.youtube.com/watch?v=D3GVKjeY1FM

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 Palpationhttps://www.youtube.com/watch?v=WV1DJBpg2tc (excellent and short—shows a patient with markers on key muscle/anatomical locations

External rotation and abduction, with head of humerus anterior: Anterior dislocation

Patient guarding, with internal rotation and adduction (rare)Posterior dislocation

Winging of the scapula: Trapezius dysfunction, can be viral; suprascapular nerve entrapment

Wasting 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 a

laterally over the deltoid)

Specific examination techniques: (animated images of muscles and bones during key maneuvers)https://www.youtube.com/watch?v=xn-c2goYzLE

Injury Manuever ManueverRotator Cuff tear (weakness) or pain/tendinits (pain), pain also with impingement

Apleys—scratch tests for internal rotation and external rotation

Hawkins

Drop Arm Test-Passively Abduct the arm to 90 degrees, then have patient slowly lower arm; if cannot do so, may have rotator cuff injury

Impingement Neers-with arm flexed to 90 degrees and pronated, forcefully flex arm (to 170 degrees)

Hawkins

AC joint Cross arm test See below for when AC joints are a problem

Biceps tendinitis

Speed Test-Resist arm flexion while patient performs a biceps curl (flexes bicep)

Yergason’s Test-pin with resisted

supinationGlenohumeral instability

Apprehension Test- with arm abducted and externally rotated, place pressure on the humerus

Sulcus Test- drop in humeral head near acromoclavicula joint with downward pressure

InfraspinatusTeres minor

Resistance to External rotation:

Supraspinatus

Drop Can test—With arm pronated and flexed to 90 degrees (with elbow extended), have patient try to elevate arms against resistance

From Up To DateProblem Issue on history and physical examRotator Cuff Tendinopathy/Impingement Problems with external rotation and

reaching overheadAdhesive Capsulitis Age > 40, diabetes, diminished range of

motionRotator Cuff Tear Unable to perform maneuvers/weak

When 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 Injury What to do

I Mild swelling pain over the AC joint, no deformity

Place in Sling and starts ROM when the patient can do it; ice and analgesia

II Complete 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 exercise

III Complete 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 downward

IV-VI SHOULD NOT BE IN OUR CLINIC Surgical management necessary-Concern over neurovascular bundle.Marked deformity, tenting of skin, sever displacement

How 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 exercises Going 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.