Diagnosis of Broken Collarbone
Broken Collarbone Diagnosis: Book Excerpts
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SHOULDER PAIN:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there significant radiation of pain down the arm? The presence of significant radiation of pain down the arm would suggest thoracic outlet syndrome, herpes zoster, herniated cervical disk, spinal cord tumor, brachial plexus neuritis, myocardial infarction, sympathetic dystrophy, Pancoast's tumor, and aortic aneurysm.
- Is the radiation down the arm transient? The presence of transient radiation of pain down the arm would suggest coronary insufficiency.
- Are there hypoactive reflexes or significant dermatomal loss of sensation in the involved extremity? These findings would suggest spinal cord tumor, herniated cervical disk, and brachial plexus neuritis, among other disorders.
- Is there pain on active motion only? Pain on active motion only is more frequently found in subacromial bursitis, calcific tendinitis, and torn rotator cuff.
- Is there pain on both active and passive motion? This finding would suggest osteoarthritis, rheumatoid arthritis, gout, dislocation of the shoulder, adhesive capsulitis, shoulder-hand syndrome, aseptic bone necrosis, and osteomyelitis.
- Is there normal range of motion of the shoulder and normal neurologic examination? These findings would suggest that the pain is referred from gallbladder disease, pancreatitis, ruptured peptic ulcer, pleurisy, or tuberculosis.
- Are there diminished pulses in the involved extremity? These findings would suggest occlusion of the subclavian artery, thoracic outlet syndrome, or dissecting aneurysm.
DIAGNOSTIC WORKUP
The first thing to do is an x-ray of the shoulder. If this is normal, a trial of conservative therapy may be initiated before ordering an expensive diagnostic workup. If the pain persists, routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel including ANA, x-ray of the shoulder, chest x-ray, and EKG. An MRI of the shoulder may need to be done to rule out a torn rotator cuff. Shoulder arthrography can also be used to diagnose this condition. If there are abnormal neurologic findings, EMG, nerve conduction velocity studies, and MRI of the cervical spine may need to be done. A neurologist should be consulted before ordering these expensive diagnostic tests.
If there are focal trigger points in the bursa or shoulder joints, a therapeutic trial of lidocaine hydrochloride (Xylocaine®) and corticosteroid injections should be done if the x-rays of the shoulder are negative or show only calcific tendinitis. Stellate ganglion blocks may be diagnostic and therapeutic for sympathetic dystrophy. If there are abnormalities of the brachial or radial pulses, angiography may need to be done. When there is intermittent pain down the arm, an exercise tolerance test may need to be ordered. However, it may be wise to refer the patient to a cardiologist before ordering this test. A gastroenterologist may need to be consulted to rule out cholecystitis, pancreatitis, and peptic ulcer disease.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Shoulder Pain/Swelling:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Trauma and sports related injuries
–Acromioclavicular dislocation (“separated
shoulder”)
–Sternoclavicular dislocation
–Glenohumeral dislocation
–Proximal humeral fractures
- “Impingement syndrome”
–Progressive degeneration and inflammation of the subacromial contents (rotator cuff and subacromial bursa) in part due to compression between the acromion and the head of the humerus
–May result in rotator cuff tear
-
Rotator cuff strain, tear, or rupture
–May occur acutely (secondary to trauma) or, more commonly, due to a relatively mild (e.g., reaching overhead) insult to a chronically degenerative cuff
-
Degenerative joint disease
-
Tendonitis
-
Subacromion and/or subcapsular bursitis
-
AC joint inflammation
-
Calcific tendonitis
–Deposition of calcium crystals in the rotator cuff with resulting inflammation and severe pain
-
Suprascapular nerve entrapment
-
Bicipital tendonitis
-
Adhesive capsulitis
–Thickened, scarred joint capsule and “frozen shoulder” due to prolonged postinjury or postsurgery immobilization
-
Cervical disc disease and radiculopathy
-
Gout
-
Pseudogout
-
Connective tissue disease (e.g., rheumatoid arthritis, SLE)
-
Brachial plexus injury
-
Septic arthritis
-
Referred pain from MI, cholecystitis, splenic injury
-
Malignancy (e.g., apical lung)
-
Lyme disease
-
Fibromyalgia
-
Thoracic outlet syndrome
-
Reflex sympathetic dystrophy
-
Rib dislocation/rib pain
-
Acute axillary vein thrombosis
Workup and Diagnosis
-
History and physical examination
–Inspection for asymmetry, dislocation, or atrophy
–Note range of motion, strength, sensory, crepitus, pain
with passive and/or active motion
–Perform a complete neurovascular exam
-
Plain X-rays of shoulder; cervical spine films and chest X-ray may also be useful
-
X-ray or CT scan may identify chronic, degenerative arthritis
-
Shoulder MRI evaluates the anatomy of the rotator cuff and associated soft tissue; may differentiate partial from complete tears
-
EMG can help discern nerve entrapments, cervical disc disease, or brachial plexus injury
-
Diffuse shoulder or acromioclavicular pain may require workup for medical etiologies, including ESR, ANA, rheumatoid factor, and TSH
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
SHOULDER PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to ruling out various causes is most often clinical, provided x-rays of the shoulder and cervical spine have negative findings. If a torn rotator cuff is strongly suspected, an MRI or arthrogram should be done. In the classical case of subacromial bursitis, in which passive movement is much less restricted than active movement and a point of maximum tenderness can easily be located, lidocaine and steroid injections into the bursa (at the point of maximum tenderness) may be done without x-rays. Cervical root blocks, stellate ganglion blocks for shoulder–hand syndrome, and aspiration and injection of the shoulder joint with lidocaine and steroids may also be useful in establishing the cause. Adson maneuvers will help establish the diagnosis of scalenus anticus syndrome, but the clinician must bear in mind that there are many false-positives for this test and the job is not finished until tests for pectoralis minor and costoclavicular compression are done. The history will help diagnose systemic causes, but checking for dermatomal hyperalgesia or hypalgesia and other sensory changes will be most helpful in diagnosing disease of the cervical spine. Remember that a negative cervical spine x-ray does not rule out a herniated disk. If the pain is increased by pressure on the top of the head or by coughing and sneezing, then a disk must be ruled out by an MRI.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Shoulder Pain:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of the pain. What is the onset, location, radiation, severity, and duration of the pain? Is there any instability, weakness, stiffness, or locking? Are there exacerbating or alleviating maneuvers? Has there been any associated trauma? What was the mechanism of injury? Any associated neurologic or systemic symptoms? Is there a history of prior shoulder problems? Are other joints involved?
Physical examination
Observe the shoulder for symmetry, motion, and signs of injury. Palpate all bony structures [including the acromioclavicular (AC) joint and bicipital groove]; check cervical spine range of motion (ROM) and the neurovascular status of the affected arm. If fracture is suspected, obtain an x-ray study. If finding on the x-ray is negative, proceed with passive and active ROM testing of the shoulder. Assess muscle strength and perform provocative tests for specific suspected pathology (Table 12.12) (1).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Shoulder Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Rotator cuff tendinitis
❑ Bicipital tendinitis
❑ Acromioclavicular joint inflammation
❑ Acromioclavicular joint separation
❑ Cervical spondylosis
❑ Impingement syndrome
❑ Rotator cuff tear
❑ Adhesive capsulitis
❑ Glenohumeral joint instability
❑ Referred pain
❑ Shoulder dislocation
❑ Humeral neck fracture
❑ Glenohumeral joint arthritis
❑ Reflex sympathetic dystrophy
❑ Aseptic necrosis of the humeral head
Diagnostic Approach
Beware referred pain, which can be the seemingly innocuous presentation of a life-threatening condition. The patient will often try to link the pain to a musculoskeletal explanation, inadvertently providing false clues leading away from the correct diagnosis. Consider this explanation if there is no pain with movement of the shoulder.
Pain aggrevated with reaching is due to rotator cuff tendinitis or impingement in 80%, most commonly supraspinatus tendinitis. Pain with motion usually signifies periarticular pathology. Pain with isometric resistence in midarc abduction and external rotation of the shoulder is found in supraspinatus tendinitis, whereas with impingement this manuver is not painful. Pain with resisted external rotation occurs with infraspinatus and teres minor inflammation, and pain with resisted internal rotation occurs with subscapularis inflammation.
Apprehension test: With the shoulder at 90 degrees abduction, and the elbow at 90 degrees flexion, the examiner applies forward pressure to the posterior aspect of the humerus. A positive test occurs if the patient expresses pain or apprehension. Relocation test: With the arm in the same position and the patient lying supine, the examiner applies backwards pressure on the anterior aspect of the humerus and the patient expresses relief. Anterior release: After performing the relocation test, the examiner releases pressure, and the patient expresses apprehension or pain. Biceps load: With the patient supine, and the elbow at 90 degrees and maximally externally rotated, the shoulder is placed at 90 degrees of abduction (biceps load I). While the examiner pulls laterally on the forearm, the patient resists. A positive test is indicated by increased pain. The biceps load II test is performed at 120 degrees.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
SHOULDER PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to ruling out various causes is most often clinical,
provided x-rays of the shoulder and cervical spine have negative findings.
If a torn rotator cuff is strongly suspected, an MRI or arthrogram should be
done. In the classical case of subacromial bursitis, in which passive
movement is much less restricted than active movement and a point of maximum
tenderness can easily be located, lidocaine and steroid injections into the
bursa (at the point of maximum tenderness) may be done without x-rays.
Cervical root blocks, stellate ganglion blocks for shoulder–hand syndrome,
and aspiration and injection of the shoulder joint with lidocaine and
steroids may also be useful in establishing the cause. Adson maneuvers will
help to establish the diagnosis of scalenus anticus syndrome, but the
clinician must bear in mind that there are many false-positives for this
test and the job is not finished until tests for pectoralis minor and
costoclavicular compression are done. The history will help to diagnose
systemic causes, but checking for dermatomal hyperalgesia or hypalgesia and
other sensory changes will be most helpful in diagnosing disease of the
cervical spine. Remember that a negative cervical spine x-ray does not rule
out a herniated disc. If the pain is increased by pressure on the top of the
head or by coughing and sneezing, then a herniated disc must be ruled out by
an MRI.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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