Video summary

Semiopatologia Quirúrgica UBA

Main summary

Key takeaways

Educational

Main ideas and lessons

  • Purpose of the talk: Introduce and explain a shoulder assessment form—a revised version of a form originally presented in 2005, with modifications presented in 2011.
  • Why the form was changed:
    • Updated using years of daily clinical experience (what worked, what didn’t, what needed correction).
    • Added shoulder fractures, which were missing from the original 2005 form.

Core sections captured by the form

  1. Patient introduction and referral data (anamnesis):

    • Personal information and referral source
    • Patient activities
    • Working diagnosis prompting referral
    • When the patient was seen, received, and treated
    • Injury/fracture mechanism (cause)

  2. Service demographics and epidemiology (age/sex distribution):

    • Higher prevalence of shoulder injuries in women than men
    • Peak incidence between 50–64, followed by 65+
    • These two age ranges account for over half / around 60% of patients

  3. Distribution by pathology type:

    • Majority are soft tissue injuries and fractures
    • Fractures are most common
    • Reported counts:
      • Fractures = 185
      • Soft tissue injuries = 214

  4. Resolution / treatment details (used to infer severity):

    • Surgical resolution for fractures, including:
      • Type of osteosynthesis
      • Timing
      • Immobilization duration
    • Whether there were multiple surgical interventions
    • Hospitalization details and whether traction was used
    • Whether complementary studies were performed (noted as later sections)

  5. Need for surgery in the overall population:

    • Not many patients “recovered” overall (wording is unclear), but surgery remains relatively significant within the total seen
    • Coverage includes fractures, dislocations, instabilities, and soft tissue cases

  6. Link between treatment choice and suspected injury severity:

    • Stable vs unstable fracture patterns
    • Minimal displacement vs multi-fragment fractures (e.g., surgical neck, 4-fragment classification)
    • Treatment ranges from slings/hanging braces to arthroplasty, depending on:
      • Fragment number
      • Bone/vascular deterioration

  7. Soft tissue injury solutions (non-exhaustive categories):

    • Friction syndromes
    • Tendinitis/tendinopathies (especially rotator cuff and long head of biceps)
    • Capsular issues: adhesive capsulitis
    • Osteoarthritis
    • Example interventions listed:
      • Acromioplasty
      • “Insoles” / insert-like items (term unclear in subtitles)
      • Pulley/CPM-like “pulse” (unclear)
      • Procedures “to the insertion of the cuff”
      • Mobilization under anesthesia
    • Speaker note: not a large number of surgeries for soft tissue, but some are used in specific instability cases.

  8. Instability treatment concepts:

    • Two main instability groups mentioned (subtitles garble names; likely anterior/posterior varieties)
    • Conservative care emphasizes immobilization
    • Surgical options include:
      • Arthroscopy
      • Open posterior surgery
      • Retro-axillary posterior surgery
    • The retro-axillary technique: previously used at the hospital, now not currently performed, but still considered an alternative.

Clinical risk and context emphasized (fall risk and fragility)

  • Shoulder fractures are common in older adults and often result from falls and bone alterations.
  • Highlighted factors:
    • Menopause / osteoporosis (bone quality)
    • Instability risk (fall-related comorbidities)
    • Age-related fall probability:
      • Nearly 50% of women 85+ fall at least once per year (or within 6 months), increasing with age
    • Likely fall causes:
      • Postural/gait problems
      • Muscle weakness
      • Decreased reflexes
      • Visual impairments
    • Alcohol consumption and smoking worsen bone quality and increase fracture risk
    • Many falls occur at home, relevant to shoulder fractures

Functional testing and complication awareness

  • Get Up and Go test:
    • Selected for simplicity, speed, and ease of administration
  • The team links certain shoulder/soft-tissue issues to risks of:
    • Reflex Sympathetic Dystrophy (RSD) / similar syndrome (terminology varies)
    • Adhesive capsulitis
  • Awareness is needed for patients at risk after:
    • Trauma
    • Fractures
    • Immobilization
  • Conditions/disorders associated with the RSD-like syndrome include:
    • Limb trauma
    • Vascular surgery trauma
    • Diabetes
    • Alcoholism
    • Systemic nervous system diseases
    • Medications or other triggers

Assessment details (pain, movement, and rehabilitation logic)

Pain and movement assessment (reverse side of the form)

  • Pain is recorded using a 0–10 Visual Analog Scale, including:
    • Pain during anterior elevation
    • Nocturnal pain
    • Pain when lying on the affected side
  • Pain patterns are evaluated as:
    • Concentric vs eccentric elevation (differences explained by which structures are being assessed)
  • Key methodological concept:
    • Different movement types probe different tissue types
      • Active mobility: evaluates both contractile and non-contractile structures
      • Passive mobilization pain: primarily indicates capsular/joint implications (speaker distinguishes passive pain as more capsular/joint)
      • Isometric concentric / non-concentric / eccentric: evaluates mainly musculotendinous (contractile) structures
  • Range of motion measurement:
    • Elevation in degrees using specific reference gestures (gesture landmarks 1/2)
    • Passive range of motion plus comparison (passive vs dynamic)
  • Scapulohumeral rhythm:
    • Alterations relate to dyskinesias seen in shoulder pathology and fractures

Shoulder capsular pattern and rehabilitation philosophy

  • Capsular pattern described:
    • Limitation order: external rotation → reduction (abduction?) → internal rotation
    • As mobility returns, recovery order reverses:
      • internal rotation → reduction → external rotation
  • “Minimum degrees needed” for daily independence:
    • Wash face: ~60° anterior elevation, some elbow flexion, ~20° external rotation
    • Comb hair: ~90° elevation reduction, elbow flexion, ~90° external rotation
    • Personal hygiene: ~20° internal rotation, elbow flexion, ~20° extension
  • Rehabilitation guidance:
    • Don’t obsess over perfect degrees—focus on functionality/independence

Outcome measurement and testing

Scoring tools included (UCLA vs Constant)

  • UCLA and Constant scales are used.
  • UCLA:
    • More emphasized by the speaker who focuses on fractures
    • Pain matters, but not the only factor
    • Patient satisfaction contributes +5 points
    • Subjectivity acknowledged (described as stronger “patient affinity” than “professional affinity,” unclear wording in subtitles)
  • Constant:
    • Includes pain, ADLs, range/strength
    • Reliability and reproducibility noted
    • Age appropriateness issues exist (age dependence)

Evidence-based test selection criteria embedded in the form

  • Tests are selected and grouped by pathology.
  • Evidence cues in formatting:
    • Bold: very good evidence; maximum probability ratio ≥ 5
    • Normal font: moderate evidence (score < 5 but still considered)
    • Italics: no evidence described in 2011; mainly experience-based

Imaging interpretation guidance

X-ray (fracture-focused)

Includes extraction of:

  • Number of fragments and their relationships
  • Callus evolution
  • Deviations and soft-tissue-related concerns
  • Presence/absence of arthritic processes
  • Subchondral geodes
  • Shape of anatomical regions (subtitle unclear)
  • Subacromial space

Cervical-level checks (radiculopathy context)

  • Cervical curvature and straightening/closure changes
  • Arthritic processes
  • Intervertebral foramina to assess nerve/plexus emergence

MRI (soft tissue and instability)

  • Limited fracture-specific utility (as described)
  • More about associated soft tissue injury:
    • Necrotic processes
    • Musculotendinous structure status
    • Degree of injury per structure
    • Synovial fluid: increased vs normal
  • Instability context:
    • Presence/absence of Bankart and Hill lesions

Cervical radiculopathy screening (to avoid confusing it with shoulder pathology)

  • Rationale: symptoms in shoulder/upper limb may originate from cervical problems (radiculopathy), not the shoulder.
  • Four tests considered together:
    1. Spurling test
    2. Distraction test
    3. Upper limb tension test (neurodynamic test)
    4. Cervical rotation < 60° toward the symptomatic side

Presence-based interpretation logic (as stated)

  • If 4 of 4 present → high probability (score 30)
  • If score >10 with present tests → very good indication
  • If 2 of 4 present → score ~0.88 (little confidence)
  • If 3 of 4 present → intermediate suspicion (score ~61; subtitle formatting inconsistent)

Treatment duration tracking section change

  • Prior form: 10 sessions
  • Revised form: 20 sessions
  • Justification:
    • Shoulder fractures: treatment averages around 4 months, implying ~3–4 milestone lines
    • Soft tissue may not require 20 sessions, but the form provides enough structure for follow-up/evolution

Methodology / instruction-style details (as presented)

A) Shoulder form construction approach (update strategy)

  • Start from the 2005 shoulder assessment form.
  • Modify the 2011 version using:
    • Practical feedback from daily use:
      • what was useful
      • what was incorrect or needed correction
    • Structural changes to better fit clinical needs
  • Add a new content category:
    • shoulder fractures (not previously included)

B) Evaluation flow in the form

  • Record anamnesis:
    • personal data and referral origin
    • patient activity profile
    • diagnosis prompting referral and medical timeline
    • cause/mechanism of injury or fracture
  • Record epidemiology snapshot:
    • age/sex distribution and pathology distribution
  • Record pathology resolution / treatment details:
    • If fracture:
      • resolution (surgical/medical)
      • osteosynthesis type
      • timing and immobilization duration
      • interventions count/type
      • hospitalization and traction use
      • complementary studies (noted later)
    • If soft tissue injury:
      • diagnosis category and applicable treatment options
    • If instability:
      • conservative vs surgical pathway
      • surgical procedure type (arthroscopy/open; retro-axillary alternative if applicable)

C) Pain attribution methodology (movement type → likely structure)

  • Use pain + movement/test type to infer tissue involvement:
    • Passive pain → more capsular/joint (non-contractile)
    • Active/selected isometric patterns → better for musculotendinous (contractile)
  • Record:
    • VAS 0–10 intensity
    • pain location/behavior during specific movements/positions
    • concentric vs eccentric differences

D) Imaging interpretation methodology

  • X-ray: radiographic fracture characteristics for treatment selection
  • MRI: associated soft tissue and instability lesions (including Bankart/Hill)

E) Cervical radiculopathy screening methodology (4-test rule)

  • Apply the combined four-test logic and the score thresholds described above.

F) Outcome measurement methodology

  • Choose between UCLA and Constant.
  • Apply scale-specific emphasis:
    • UCLA: pain and satisfaction (satisfaction contributes +5)
    • Constant: function/ADLs/strength + pain (noting age dependence)

G) Evidence rating methodology for test selection

  • Use formatting cues:
    • Bold = strong evidence (max probability ratio ≥ 5)
    • Normal = moderate evidence
    • Italics = no evidence described (experience-based)

Speakers / sources featured

  • Speaker 1: main presenter of the shoulder assessment form (name not fully legible)
  • Jose: referenced for slide navigation
  • Marcelo: co-author/colleague; repeatedly mentioned; associated with soft tissue pathology
  • Sandra: presented a clinical case of shoulder instability earlier
  • Daniel: discussed vestibular issues; associated with Get Up and Go test
  • Silvina: discussed optimal movement degrees for daily performance
  • Graciela: named in course closing
  • Unnamed closing speaker: course closing (name not captured)

Referenced scales / authors / tests

  • UCLA scale
  • Constant scale
  • Tests:
    • Spurling test
    • Distraction test
    • Upper limb tension test (neurodynamic test)
    • Cervical rotation < 60°
  • MRI lesions:
    • Bankart lesion
    • Hill lesion

Original video