Diagnostic Tests for Broken Collarbone
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Broken Collarbone Diagnosis: Book Excerpts
Diagnostic Tests for Broken Collarbone: Online Medical Books
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SHOULDER PAIN:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Shoulder Pain:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Laboratory tests. A complete blood count (CBC) and analysis of synovial or bursal aspirate for cell count, Gram’s stain, and culture are obtained for suspected infectious arthritis or bursitis. Obtain an erythrocyte sedimentation rate (ESR), rheumatoid factor, antinuclear antibody, and aspirate for crystals for inflammatory arthritis.
B. Radiographic study. Routine shoulder views are obtained for a history of acute trauma or chronic injury not responsive to conservative management. Special axillary or scapular Y views are needed if posterior dislocation is suspected. Views with and without weights may better assess for AC joint separation.
C. Diagnostic injection. Anesthetic infiltration of the involved area may relieve symptoms and establish the diagnosis. Injection sites include the subacromial and intraarticular spaces, AC joint, and biceps tendon sheath (2).
D. Other imaging studies. Computed tomography (CT) scan, magnetic resonance imaging (MRI), ultrasound, arthrography, fluoroscopy, and bone scan can be used when diagnosis is unclear or surgery is considered. MRI is superior for soft tissue pathology. Arthrography is useful for rotator cuff tears if MRI is unavailable or the patient is claustrophobic. A CT scan is useful to evaluate bony structures. Ultrasonography can identify moderate and full-thickness tears, but accuracy is operator-dependent. Bone scan can identify areas of bone remodeling (e.g., metastatic tumors, nonunion of fractures). Fluoroscopy allows dynamic assessment of fracture stability and can detect loose bodies or impingement (1).
Diagnostic assessment (3,4)
A. Nonshoulder origin. Painless ROM without localized tenderness suggests referred pain. Muscular sprain or strain presents with pain on active, but not passive, ROM and muscle tenderness or spasm; cervical disc herniation with radicular symptoms, neurologic findings, and an abnormal CT or MRI scan. Thoracic outlet symptoms include pain and numbness in the shoulder or arm (especially with head turning) and a positive Adson test.
B. Shoulder origin, nontraumatic. Both inflammatory and infectious arthritis may present with a joint effusion and inflammatory signs on examination. Serologic testing may be positive in the former; joint aspirate analysis and culture will help differentiate the two. An x-ray study or bone scan can help to rule out osteomyelitis. Tumor presents with localized pain and a positive imaging study.
C. Shoulder origin, acute traumatic
1. Fractures and contusions have point tenderness on examination. An associated pneumothorax should be ruled out with a clavicular fracture. Scapular fractures are infrequent, and usually occur with other severe thoracic injury. Contusions present with point tenderness on examination, but have no evidence of ligament injury and an x-ray study is negative.
2. Shoulder separation is more common at the AC joint. An AC dislocation may occur secondary to a fall on an outstretched hand or the lateral shoulder. Pain and swelling are seen at the joint, and a crossover test is positive. An x-ray study can be negative. Sternoclavicular separation is usually associated with other severe injuries.
3. Glenohumeral instability can develop with trauma. In anterior dislocation, the patient uses the other hand to hold the injured arm in abduction and external rotation. Visually, the acromion will be prominent. In the less-common posterior dislocation, the arm is held across the chest. Only an axillary or scapular x-ray view may show the displaced head.
D. Shoulder origin, chronic traumatic
1. An AC joint sprain is usually caused by overuse, degenerative joint disease, or incorrect weightlifting. On examination, tenderness is found over the AC joint.
2. Chronic glenohumeral instability occurs when recurrent trauma causes small labral or capsular tears. The patient presents with chronic or subacute pain and may report that the shoulder “pops” in and out. On examination, mild instability signs may be seen (Table 12.12).
3. Impingement syndrome is a common cause of shoulder pain.
a. Rotator cuff tendinitis most often involves the supraspinatus tendon and is secondary to overuse of the joint. It presents with diffuse pain in the anterior or lateral shoulder. The patient cannot sleep on the affected side. The shoulder is tender in the upper deltoid region or below the acromion. Seen are decreased ROM and pain, especially between 70° and 120° abduction; impingement signs are positive. The x-ray study is normal or shows calcific tendinitis or a prominent acromial spur.
b. Subacromial bursitis is usually secondary to tendinitis and presents with the same findings. Inflammatory, infectious, or crystalline causes may need to be ruled out by joint fluid aspiration.
c. A rotator cuff tear develops with overuse or trauma in the presence of an underlying abnormality. On examination, supraspinatus weakness and positive impingement signs may be seen.
d. Bicipital tendinitis is another overuse injury. Pain in the anterior shoulder radiates to the biceps and forearm. Examination findings include limited abduction, positive impingement signs, biceps tendon tenderness, and pain on resisted elbow flexion or wrist supination.
4. Adhesive capsulitis presents with chronic pain and stiffness, often following a period of prolonged immobility. It is especially common in elders. Decreased active and passive ROM occurs in all planes.
References
1. Howard TM, O’Connor FG. The injured shoulder: primary care assessment. Arch Fam Med 1997;6:376–384.
2. Larson HM, O’Connor FG, Nirschl RP. Shoulder pain: the role of diagnostic injections. Am Fam Phys 1996;53:1637–1643.
3. Glockner SM. Shoulder pain: a diagnostic dilemma. Am Fam Phys 1995;51:1677–1687.
4. Diagneault J, Cooney LM. Shoulder pain in older people. J Am Geriatr Soc 1998;46:
1144–1151.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Shoulder Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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
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