Trunk And Shouder Regions

TRUNK AND SHOUDER REGIONS

EXAMINATION OF THE TRUNK

PAIN       

What caused the pain? (acute or chronic) Where is the pain? Radiation? (to & from) Character Abnormal sensation Exacerbation and relief? Course (progressive, regressive , stationary)

IMPORTANT POINTS  Patients occupation  Faulty postural habits?  Abnormal gait?  Medications?  Sphincter & sex abnormalities

PAST HISTORY - SYSTEMIC DISEASE - MEDICATION - SURGERY FAMILY HISTORY

Examination of the Dorso lumbar Spine

Attitude:

+ PAIN

Patient examined standing

LOSS OF LUMBAR LORDOSIS

LIST

SCOLIOSIS

Attitude:

 + PAIN   

Sciatic list. Decreased lumbar lordosis. Scoliosis.

.”bending forward test“

Active Spine movements  Forward flexion (to 90)  (Extension (20-35⁰)  side flexion (15-20⁰)  Rotation (3-20⁰)

Walking on heels (L4,5)

Walking on toes (S1)

 Hip flexion  L2  Knee extension  L3  Ankle extension  L4  Toe extension  L5  Ankle flexion  S1  Ankle eversion  S1

Supine position

Special tests  SLR  Femoral stretch test  SPINAL (PRIMITIVE REFLEXES)

ABRASIONS,CONTUSIONS KYPHUS

Dermatomes (L1 L4)  L1 back of trochanter and groin  L2  front of thigh knee, back of iliac crest  L3 upper buttock, front of thigh, & knee & medial lower leg  L4  inner buttock, outer thigh, inside of leg, dorsum of foot & great toe

Dermatomes (L5 S4)  L5  buttock, lat. Aspect of leg & dorsum of foot, inner sole & first three toes  S1  buttock, back of thigh and leg  S2  same as S1  S3  groin, inner thigh, perinium  S4 & S5  perineum genitals & lower sacrum

AUTONOMOUS SENSORY ZONES

nipple line (T4), xiphoid process (T7) Umbilicus (T10)

inguinal region (T12, L1)

perineum and perianal region S2, S3, and S4).

Dermatomal (sensory) distribution

Reflexes    

Knee  L3 Ankle  S1 Medial hamstrings L5 Lateral hamstring  S1

PRIMITIVE (spinal) REFLEXES

Anus

Glans

Babiniski test

Bulbo-cavernosus test

Palpation  Posterior: spinous processes, facets, sacrum coccyx, iliac crest, ischial tuberosity and sciatic nerve  Anterior: abdomen organs, aorta, inguinal area, iliac crest, symphysis Prone position Hip extension  S1 Knee flexion  S1 & S2

Lumber Root Syndromes Root pain Dermatome Muscle weakness Reflexes abn. Sensory examination.

Special tests  SLR  Femoral stretch test  SPINAL (PRIMITIVE REFLEXES)

Special tests Malingerer patient

PLAIN X-RAY

CT

D CT 3

MRI

BONE SCAN

THE SHOULDER

The shoulder region is made of three bones

  

Proximal humeral end. Clavicle. Scapula

THE SHOULDER   

INJURIES TUMOURS DEGENERATIVE CHANGES

Injuries of the Shoulder Region

Fractures of the clavicle

 Clavicle is a S shaped bone, with double curves

 Functions of the clavicle: 1- Power and stability of the arm. 2- Motion of the shoulder girdle. 3- Muscle attachments. 4- Protection of the neurovascular structures.

Related important structures

Fracture of the clavicle  Middle third, Most common.  Lateral third.  Medial third

Latera l

Medial

Mechanism of injury  Direct trauma.  Indirect trauma: -fall on outstretched hand(most common) - fall on the point of the shoulder.

Clinical picture  Pain, swelling.  Deformity, tenderness & crepitus at the site of fracture.  Drooping of the affected shoulder.  The patient supports the arm of the affected side to decrease the painful movements.

PATIENT SHOULD BE EXAMINED FOR:  Other skeletal injuries.  Distal pulsations.?

Investigations  Plain X-ray

Complications   

Neurovasular injury. Nonunion. Malunion.

Treatment  Conservative treatment: (main line) 1- Figure of 8 bandage: NOT RECOMMENDED. (Why?)

2- Simple arm support

 Open reduction and internal fixation: 1- patients with neurovascular injuries, 2- Lateral end fractures. 3- Nonunited fractures

Fractures of the proximal end of the humerus

Anatomy It is formed of 4 parts:

 Fractures of the proximal end may be: 1- Non displaced fracture. 2- Displaced fracture.

Mode of trauma  Fall on outstretched hand.  Minor trauma to old osteoporotic patients.  Major trauma to young patients.

Clinical picture  Pain, swelling & inability to move the shoulder.  Ecchymosis & crepitus over the affected shoulder.  Deformity due to fracture or to associated dislocation.  Neurological and vascular examination: axillary nerve

Plain X ray

C.T scan

Complications  Axillary nerve injury

Deltoid wasting

 Malunion

Treatment  Non operative treatment: Non or minimally displaced fracrtures

 Open reduction and internal fixation. Big fragments, mild comminution

 Arthroplasty. Comminuted fractures, fractures involving the head

Fractures of the glenoid (Very rare)  Extra-articular: not involving the articular surface.  Intra-articular: extends to the articular surface.

Shoulder Dislocation

Shoulder dislocations are divided into:  Acute dislocation.  Chronic (negelected) dislocation.  Recurrent dislocation.

Direction of dislocation Described according to the relation of the head to the glenoid  Anterior: most common type.  Posterior.  Inferior.

Mechanism of injury  Indirect force: combined abduction, extension and external rotation.  Direct force: blow directed to the proximal humerus.

Clinical picture  Pain & inability to move the shoulder.  Deformity of the shoulder joint, the humeral head is palpable in the dislocated position.  The arm is held in abduction and slight external rotation (anterior dislocation).  Associated axillary nerve injury.  Vascular injury.

X ray

Complications  Vascular injury: Axillary artery injury, at the time of dislocation and at the time of relocation.  Neural injury: to the brachial plexus. Neural injury may be Neurapraxia, Axonotmesis, or Neurotmesis. Most common injury involves the axillary nerve.  Recurrence of dislocation.

Recurrence of dislocation  This is the most common complication.  Causes of recurrence: 1- Patient age: High incidence below the age of 40 years. 2- Inadequate immobilization: less than 3 weeks. 3- associated head fractures: (Hill-Sachs lesion) increase the incidence of recurrence. 4- Glenoid labral injury (Bankart lesion)

Mechanism of Hill Sachs lesion

Treatment

Acute dislocation  Closed reduction under general anesthesia as urgent as possible. Neurovascular examination is mandatory after closed reduction.  Open reduction is rarely needed in cases of locked dislocations

Closed reduction

Traction & counter traction

Recurrent dislocation  Operative treatment: for soft tissue balance, repair ,or blocking the dislocation mechanism.  Physiotherapy program.

TUMOURS IN THE SHOULDER REGION

A- BENGIN OSTEOCHONDROMA

TUMOURS IN THE SHOULDER REGION A- BENGIN CHONDROBLASTOMA

TUMOURS IN THE SHOULDER REGION B-MALIGNANT CHONDROSARCOMA

TUMOURS IN THE SHOULDER REGION B-MALIGNANT CHONDROSARCOMA

TUMOURS IN THE SHOULDER REGION

B-MALIGNANT SECONDARIES

PATHOLOGICALFRACTURES IN THE SHOULDER REGION

DEGENERATIVE ARTHROSIS

SUMMERY

 Fractures of the middle third of the clavicle is the most common fracture site.  Axillary artery may be injured in fractures of the clavicle.  Conservative treatment is the main line of treatment.  Minor trauma to the upper limb should not be neglected in old persons.  Axillary nerve is the most commonly affected nerve in fractures and dislocations of the proximal end of the humerus.

 Open reduction or arthroplasty are the main line of treatment in cases of displaced fractures of the proximal humeral end.  Anterior shoulder dislocation is the most common type of shoulder dislocations.  In anterior shoulder dislocation, the arm is held in abduction and slight external rotation.  Shoulder immobilization for three weeks is needed after closed reduction of shoulder dislocation.  Recurrent shoulder dislocation is the most common complication of acute dislocation.