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S.I.C.K. Scapula with Clavicle Fractures Case Study Presentation (2013)
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S.I.C.K. Scapula with Clavicle Fractures Case Study Presentation (2013)

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Each semester as an Athletic Training student we are required to take a clinical course. We are assigned to a clinical site and at the end of each semester we must present on an injury we encountered …

Each semester as an Athletic Training student we are required to take a clinical course. We are assigned to a clinical site and at the end of each semester we must present on an injury we encountered while working with athletes. Taking further interest into the injury we had to do research. I chose a clavicle fracture because working at a small high school I didn't see many injuries. Once evaluating my patient I realized he had S.I.C.K. Scapula (Scapular Malposition on rib cage, Inferior Medial Scapular Winging, Coracoid Tenderness, Scapular Dyskinesis). After realizing this I continued my research on this condition. I found it to be interesting because I hadn't learned about it in my classes at that point.

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  • Note: After evaluating and taking note of past hx of Grade 1 acromioclavicular ligament sprains to both shoulders, I decided to look into predisposing factors which led me to researching SICK Scapula.
  • Note: RROM could not be measured accurately because of his clavicle fracture
  • Note: patient had a Grade 1 AC sprain. This could have predisposed him to his clavicle fracture.
  • True Scapular Winging – Lesions of the nerves that innervate the surrounding muscles causing scapular winging. Paralysis of muscle. Clinical Scapular Winging – Prominence of the border because the surrounding muscles are weak (serratus anterior, trapezius, rhomboid muscles). These muscles elevate, retract, and rotate the scapula.
  • Most common complaint is anterior shoulder pain in the region of the coracoid. If not examined for tenderness this can be confused with anterior pain associated with anterior instability.
  • Note: This is the best way of detecting scapular dyskinesis. Detected by determining the position of the scapula with the patient’s arms at rest and then observing the scapular motion as the arms are elevated and lowered in the scapular plane.
  • NOTE: Kyphotic posture results in these things increasing the potential for impingementAlteration of scapular kinematics by not allowing the normal progression of the instant center of the scapular rotation from the medial scapular border to the acromioclavicular joint.
  • First objective is to improve the capability of thoracic spinal extension because these patients show abnormal stiffness, especially near the apex curve. Second Objective is to reinforce endurance capability of trunk extensor muscles to help contrast the postural trend toward a forward bending. Isometric contraction to stress resistance. Progressive education of the patient at maintenance over time of a correct posture with a correct spinal alignment, especially while sitting, the moment when the postural trend will show an increased forward flexion. Most important step of treatment.
  • The scapula must move in coordination with the moving humerus so that the instant center of rotation, the mathematical point within the humeral head that is the axis of rotation of the glenohumeral joint, is constrained wihtin a physiologic pattern throughout the full range of shoulder motion. Second role of the scapula is to provide motion along the thoracic wall. The third role of the scapula is elevation of the acromion, which occurs during the cocking and acceleration phases of throwing or arm elevation, to clear the acromion from the moving rotator cuff to decrease impingement and coracoacriomial arch compression. Treatment starts at the base of the kinetic chain. Proximal-to-distal protocol. Kibler’s clinical experience shows that achievement of scapular control decreases rotator cuff soreness and improves rotator cuff function, especially early in rehabilitation.

Transcript

  • 1. S.I.C.K. SCAPULA IN A HIGH SCHOOL ATHLETE By Chelsey Toney
  • 2. BONY/ SOFT TISSUE ANATOMY
  • 3. SOAP NOTE 3/26/2013 S: C/C: 16 year old male Hockey and Lacrosse player came in with right clavicle fracture. MOI: Was going into corner at rink and kid put him in a head lock, kicked him, and landed on top of his right shoulder and then kid landed on top of his left shoulder. Immediate sharp pain in right shoulder, couldn’t move extremity, and knew his clavicle was fractured. Was given ice and sent to the hospital. Took x-rays, put him in a sling, and gave him pain medicine. Pain scale 10/10 at rest and with movements. Medical Hx: Type 1 diabetes. Past Hx: 2nd degree tear to AC Joint right and left. Right scaphoid fracture 6 months ago. O: Obvious deformity, right arm held down to side. When palpating, obvious deformity near AC joint, pushed back. A/PROM: compared bilaterally no ROM because of pain level. Strength Tests/ MME: N/A. Special Tests: N/A. A: Fracture to right clavicle P: Leave in sling. 1 or 2 days daily take out to stretch elbow. Ice as needed (20 min on 20 min off). Will be going to doctor. Possible surgery with plate to realign and heal correctly. Ibuprofen or Tylenol when needed. If no surgery 4-6 weeks in sling to heal. PICO P: Athlete, 16 year old male, Hockey and Lacrosse, Clavicle fracture I: Sling 4-6 weeks O: Healing long-term
  • 4. Patient X-Ray Patient’s Clavicle
  • 5. ROM MEASUREMENTS JOINT MOTION OF SHOULDER NORMAL ACTION FLEXION DEGREES 180° EXTENSION ADDUCTION 40° ABDUCTION 180° MEDIAL ROTATION 90° LATERAL ROTATION AROM 50° 90° PROM ACTION RIGHT LEFT ACTION RIGHT LEFT FLEXION 155° 180° FLEXION 173° 180° EXTENSION 31° 43° EXTENSION 44° 57° ADDUCTION ------------------- ------------------- ADDUCTION ------------------- ---------------- ABDUCTION 150° 180° ABDUCTION 180° 180° MEDIAL ROTATION 62° 105° MEDIAL ROTATION 60° 78° LATERAL ROTATION 55° 96° LATERAL ROTATION 107° 107°
  • 6. Thoracic Kyphotic Curve of Spine Prominence of Inferomedial border of Scapula
  • 7. AC JOINT/ LIGAMENT The AC joint stabilizes the scapula in relation to the clavicle by three ligaments. - Coracoacromial ligament - Coracoclavicular ligament - Acromioclavicular ligament
  • 8. S.I.C.K. SCAPULA DEFINED S: Scapular Malposition on rib cage I: Inferior Medial Scapular Winging C: Coracoid Tenderness K: Scapular Dyskinesis
  • 9. SCAPULAR MALPOSITION Asymmetric malposition of the scapula that will appear as if one shoulder is lower than the other.
  • 10. INFERIOR MEDIAL SCAPULAR WINGING Contributes to loss of power and limited flexion and abduction of the upper extremity. It is usually due to weak Serratus anterior, Trapezius, and Rhomboid muscles.
  • 11. CORACOID TENDERNESS The Pectoralis minor tightens as the coracoid tilts inferiorly and shifts laterally away from the midline, and its insertion at the coracoid becomes very tender.
  • 12. SCAPULAR DYSKINESIS Alteration of the normal position or motion of the scapula during coupled scapulohumeral movements. Dyskinetic patterns fall into 3 categories characterized by: Type 1 – Prominence of the inferomedial border of the scapula http://www.yout ube.com/watch? v=HRalJc5T_5g Type 2 – Prominence of the entire medial border Type 3 – Prominence of the superomedial border
  • 13. RESULTS FOUND According to W. Ben Kibler, MD… • A resting posture of thoracic kyphosis and increased cervical lordosis , results in: - Excessive scapular protraction - Acromial depression in all phases of athletic activity • Fractures of the clavicle can: - Shorten or angulate the strut, which helps maintain proper scapular position. • Acromioclavicular joint injuries, instabilities, or arthrosis also: - Interfere with clavicular strut function - Can alter scapular kinematics • Bony abnormalities such as malunion of a clavicular fracture or an acriomioclavicular joint separation may be the cause of dyskinesis.
  • 14. REHABILITATIVE APPROACH - Targeting kyphotic posture Treatment objectives: 1. Increase mobility and elasticity of the thoracic spine in the direction of extension 2. Reinforcement of the endurance capability of trunk extensor muscles 3. Recover of muscular retractions when present 4. Learning of correct posture to be adopted in everyday life activities
  • 15. REHABILITATIVE APPROACH - Targeting S.I.C.K. Scapula, specifically Scapular Dyskinesis Emphasizes to achieve full and appropriate scapular motion and coordinating that motion with complementary trunk and hip movements 1. Correcting any strength or flexibility deficits in the low back and thoracic levels – Flexibility exercises, strengthening trunk, and correction of postural abnormalities 2. Scapular retraction and massage can increase the tightness of the coracoid-based muscles. 3. As scapular control increases, scapular exercises can progress by decreasing the emphasis on proximal facilitation to distal.
  • 16. WORKS CITED Acromioclavicular Joint Separation. Methodist Orthopedic’s and Sports Medicine Web site. 2001. Available at: http://www.methodistorthopedics.com. Accessed April 16, 2013. Bronfort, G, Evans, R, Anderson, A, Svendsen, K, Bracha. Y, Grimm, R. Spinal Manipulation, Medication, or Home Exercise with advice for Acute and Subacute Neck Pain. Ann Intern Med. 2012;156(1_Part_1):1-10. Burkhart, S, Morgan, C, Kibler, B. The Disabled Throwing Shoulder: Spectrum of Pathology Part 3: the SICK Scapula, Scapular Dyskinesis, the Kinetic Chain, and Rehabilitation. The Journal of Artroscopic and Related Surgery. 2003 July-August;19(6):641-661. Published 2003. doi: 10.1016/S0749-8063(03)00389-X Fish, D, Martin, R. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008 March; 1(1):1–11. Published online 2007 November 2. doi: 10.1007/s12178-007-9000-5 Gumino, A, Carbone, S, Postacchini, F. Scapular Dyskinesis and SICK Scapula Syndrome in Patients with Chronic Type III Acromioclavicular Dislocation. The Journal of Arthroscopic and Related Surgery. 2009;25(1):40-45. Kibler, B, McMullen, J. Scapular Dyskinesis and Its Relation to Shoulder Pain. Journal of the American Academy of Orthopaedic Surgeons. 2003;11(2):142-151. Smith, L. Posture – Let’s Set Things Straight...Just How Important Is Posture? Dr. Larry’s Newsletter. 2005. Available at: http://www.drlarrysmith.com/june2005.htm. Accessed April 17, 2013. Zaina, F, Atanasio, S, Ferraro, C, Fusco, C, Negrini, A, Romano, M, Negrini, S. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. European Journal of Physical and Rehabilitaton Medicine. 2009;45:595-603.