2019 (Jan-Sept) Flashcards
Where does the deltoid ligament typical rupture
Off the medial malleolus side
1mm of lateral deviation of the talus = what decrease in contact
42% reduction in tibiotalar contact
What are the two things you look for on plain XRs for deltoid rupture?
> 4mm of medial clear space widening
>1mm more than superior tibiotalar space
If reduced on WB views of ankle do you still need a stress?
Yes - doesn’t maximally stress syndesmosis
Does MRI help with deltoid ruptures
No - not useful to make surgical decision
When should you repair deltoid?
Controversial
Right now algorithm:
Fix fibular +/- syndesmosis PRN
If persistent widening on ER stress and talar tilt on EVERSION stress consider it
What are you looking for on Eversion stress test of ankle
Valgus tilt of talus greater than 7 degrees
What’s the literature on deltoid repair vs. no?
Literature to support either side
- One RTC shows no difference but lacked power, short FU and lacked ability to test medial instability
- Perhaps better for preventing medial widening and better pain IF the syndemosis was also fixed
Name five diagnostic tests for ACJ pathology
- TTP over ACJ
- O’Brien test
- Paxino test
- Cross-body adduction
- AC resisted extension
ACJ TTP – best screening test to r/o ACJ pathology
O’Brien/cross-body adduction/AC resisted extension useful in confirming ACJ pathology if positive
Describe the Paxino test
Pt sitting with arm resting @ side
Create shearing force over ACJ by applying thumb pressure over PL acromial corner and counterpressure with index and middfle fingers over distal clavicle
Positive if pain occurs @ ACJ
Describe the O’Brien test as it applies to ACJ pathology
FF of arm to 90 deg with elbow extended and arm adducted 10 deg
Examiner applies downward force and patient resists first with forearm IR/pronated (thumb points down) and then with arm ER/supinated
ACJ pain exacerbated by pronated position but alleviated with supinated position
Name five diagnostic tests for LHBT pathology
- Palpation of LHBT
- Speed’s test
- Yergason test
- Upper Cut test
TTP at biceps – not reliable test for detecting or r/o biceps pathology
Speed’s/Yergason/Upper Cut tests – good confirmatory test
Upper cut test – highest clinical utility as screening and confirmatory test
Combining Speed and upper cut test significantly improves predictability of detecting biceps pathology
Describe the Upper Cut test
Pt makes fist while flexing elbow to 90 deg, and supinating forearm
Examines places hand over first and resists pt bringing their hand up and toward examiner’s chin (boxing uppercut motion)
Pain/painful pop @ anterior shoulder indicates positive test
Name nine diagnostic tests for SLAP tears
- O’Brien tetst
- Crank test
- Anterior slide test
- Biceps Load I test
- Biceps Load II test
- Modified Dynamic Labral Shear
- Labral tension
- Resisted Supination External Rotation
- Forced Shoulder Abduction and Elbow Flexion
- Only test to show consistency as screening test was modified dynamic labral shear test
- Combining anterior slide and crank tests improves ability to rule in SLAP tear
Describe the O’Brian test as it applies to SLAP tears
FF arm 90 deg with elbow extended and arm adducted 10 deg
Examiner applies downward force and patient resists first with forearm IR/pronated (thumb points down) and then with forearm ER/supinated
GHJ pain with pronated position that decreases with supinated position is positive test
Describe the Crank test for SLAP tears
Pt seated and examiner positions arm @ 160 deg FF in scapular plane
GHJ axially loaded with passive IR/ER of humerus
Positive if pain with/out a click develops
Describe the Anterior Slide test for SLAP tears
Pt places hands on hips with thumbs pointed posteriorly
Examiner places one hand across top of shoulder (index finger extends over anterior acromion)
Examiner’s other hand placed behind elbow, and applies antero-superior force to elbow while pt resists this force
Pain and/or click @ anterior shoulder is positive test
Describe the Biceps Load I test
Designed for patients with anterior instability and a SLAP tear
Pt supine, and examiner grasps pt’s wrist and elbow, and abducts arm to 90 deg
Examiner ER arm until apprehension felt and resists pt’s attempted elbow flexion
Positive test if apprehension does not change or if increased pain with resisted elbow flexion
Describe the Biceps Load II test
Designed to assess potential isolated SLAP pathology
Patient supine, and examiner places shoulder in 120 deg abduction, elbow in 90 deg flexion, forearm in supination, and then ER shoulder
Pt flexes elbow against resistance
Positive if pain with resisted elbow flexion
Describe the Modified Dynamic Labral Shear test for SLAP tears
Examiner flexes elbow to 90 deg and abducts arm to 120 deg while maximally ER arm
Examiner lowers arm to 60 deg abduction
Positive test with pain/painful click along posterior joint line bw 120-90 deg abduction
Name the Beighton criteria for joint hyper mobility
- Passive DF for fifth finger > 90 deg
- Passive flexion of thumb to forearm
- Hyperflexion of elbows > 10 deg
- Hyperflexion of knees > 10 deg
- Forward flexion of trunk with knees fully extended and palms resting on floor
Score greater than or equal to 5 indicates joint hyper mobility
Name four tests for anterior instability of the GHJ
- Anterior apprehension
- Jobe relocation and surprise
- Anterior drawer test
- Anterior load and shift
Name four tests for posterior instability of GHJ
- Jerk test
- Kim test
- Posterior drawer
- Posterior load and shift
Describe the Jerk test for posterior instability of GHJ
Pt sitting, examiner holds scapula with one hand while pt’s arm abducted to 90 deg and IR to 90 deg
Pts arm is axially loaded at elbow while applying horizontal adduction force
Positive if pain with/out clunk
Describe the Kim test for posterior instability of GHJ
Pt sitting with arm in 90 deg abduction, examiner holds elbow and applies axial force/45 deg of upward diagonal elevation while pushing postero-inferiorly on upper arm
Positive if pain with/out clunk
Name two tests for inferior instability of GHJ
- Sulcus sign
2. Gagey test
Describe the Gagey test
Examiner’s forearm pushing down on shoulder girdle, examiner lifts pt’s relaxed upper limb into abduction with other hand
Abduction > 105 deg or apprehension limiting passive abduction positive for interior laxity
Sulcus sign grading scheme
Sulcus Grading
I – Acromiohumeral interval < 1cm
II – Acromiohumeral interval 1-2 cm
III – Acromiohumeral interval > 2cm
Hawkin’s Scale for GHJ translation
0 – Little or no translation (<25% of humeral head diameter)
1 – Humeral head moves onto glenoid rim
2 – Humeral head can be dislocated by spontaneously reduces
3 – Humeral head does not relocate when pressure removed
Pathology of internal impingement in overhead throwing athletes
o Late cocking phase of throwing can translate GT/articular RC surface to impinge against posterosuperior glenoid
Partial-/full-thickness RC tears, posterosuperior labral tears
oSecondary to subtle anterior shoulder instability and posterior capsule/posterior band IGHL contracture
Increased ER at expense of decreased IR
Name six diagnostic tests for the cervical spine
- Spurling test
- Axial Manual Traction Test
- Shoulder Abduction Test
- Valsalva Test
- Upper Limb Tension Test
Upper limb tension test
• Only useful screening test
Spurlilng/axial manual traction/shoulder abduction/Valsalva tests
• Useful in confirming cervical spine pathology
Describe the Upper Limb Tension Test
Pt supine
Examiner sequentially depresses scapula, abducts shoulder, supinates forearm, extends wrist and fingers, ER shoulder, extend elbow, and laterally flex neck away and then over to affected side
Positive if
• Radicular sxs reproduced
• Side-to-side difference >10 deg observed in elbow extension upon test completion
• Sxs increased with CL lateral flexion of neck or decreased with ipsilateral lateral flexion
Name four diagnostic tests for scapular dyskinesia
- Kibler Assessment
- Scrapula Retraction Test
- Lateral Scapular Slide Test
- Scapular Assistance Test
Interpret these tests with caution secondary to
• Challenges with assessing scapulothoracic motion beneath overlying muscles and SC tissues,
• Three rotational movements and two translations of scapula
• Their weak association with clinically relevant shoulder pathology
Describe the Kibler Assessment Scapular Dyskinesis
Visual assessment by inspecting bilateral scapular motion during shoulder elevation and lowering in scapular and sagittal planes for any asymmetry in position or motion
I – Prominent inferior medial scapular border
II – Prominent entire medial scapular border
III – Excessive superior migration of superior medial scapular border
IV – Normal and symmetric scapular motion (posterior tilting, ER, upward motion of scapula during arm elevation)
Name three tests for subacromial impingement
- Neer test
- Neer sign
- Hawkin’s test
- When evaluating for subacromial bursitis or RC tears, all three tests are useful screening tests for r/o these pathologies if negative
- If positive, possibility of other shoulder pathologies still exists
- Neer test only test to reliably predict subacromial bursitis alone or partial thickness rotator cuff tear (RCT)
Describe the Neer sign and test
Neer Sign
Performed by preventing scapular motion with one hand while other hand of examiner passively forward flexes arm
Positive if pain at anterior edge of acromion
Neer Test
Diagnosis confirmed when pain relieved with injection of 1% Xylocaine beneath anterior acromion
Name four tests for supraspinatus assessment
- Jobe test
- Full can test
- Drop arm test
- Painful arc
- Jobe test useful as both screening and confirmatory test but only for massive/large RCT
- Full can test has similar utility when finding is weakness
- Drop-arm test is specific for detecting partial- and full-thickness RCT
- Painful arc test is a valuable screening test
Name three tests for infraspinatus/teres minor assessment
- Resisted ER
- Hornblower test
- ER Lag sign (dropping sign)
Infraspinatus
• Weakness in ER is good screening test for infraspinatus tears
• ER lag sign is good confirmatory test for full-thickness infraspinatus tears
Teres Minor
• Pattie/Hornblower useful as both screening and confirmatory test for teres minor tear
• ER lag sign > 40 deg highly specific and sensitive for teres minor tear
Name six tests for subscapularis assessment
- Belly press
- Belly-off
- Lift-off
- Bear hug
- IR lag sign
- IR resistance at abduction and ER
- Belly-off test is excellent screening and confirmatory test
- Belly press, liftoff, and bear hug tests all useful confirmatory tests
- Bear hug more sensitive than belly press for partial SSC tears
- Lift-off test difficult to complete in setting of pain or restricted ROM
When does rotator cuff rehears normally occur post op
Retears occur early.
( often by 3 months, rates drop off after 6 mo )
Tendon healing is prolonged ( 6 mo to a year) therefore repairs need to be strong enough to last this long.
Where do rotator cuff tenders typically retear?
weak link = suture tendon interface caused by poor tissue quality of the tendon
Which of the following factors of mechanical augmentation creates the biggest increase in load to failure in rotator cuff tendon repair?
A) stitch configuration
B) size of instrument throwing suture
C) shape of instrument throwing suture
D ) size of tissue bite
A) stitch configuration
Ponce et al – compared stitch configuration, size and shape of instrument, size of tissue bite and stich configuration had the biggest increase in load to failure
But still have weakness in tendon suture interface – therefore strategies to improve RCR integrity with mechanical or biological means
Do dermal autografts (Acellular Dermal Matrices) improve outcomes after RCR?
Consensus
RCR augmented with ADM appear to have higher rate of structural integrity on post op imaging
Effect of Marrow Venting Procedures (Microfracture) on RCR ?
Consensus
Beneficial in improving healing rates on large and massive tears but may not make a different for small-medium size tears
Effect of PRP on RCR?
No true consensus
Mixed results – some show benefit some don’t
? cause for inconsistency as not all PRP is the same.
Large table in paper with no overt consensus.
Effect of Bone Marrow Aspirate on RCR?
2 studies available – poor scientific rigor ( no control ) There was some positive effects in the studies but consensus was not strong enough evidence for a conclusion supporting.
Effect of Adipose – Derived Stem Cells on RCR ?
Only one study – authors found no real difference clinically however struc integ higher on post op MRI
Need more evidence before any recommendations can be made
Patient factor indications to augment rotator cuff repair (predictors of failure to heal)
age > 65 multiple tendon involvement > 1 large tear > 2 cm retraction > 2 cm high grade fatty infiltration (Goutallier > 2)
What is the primary restraint to talus ER and lateral displacement
Deltoid ligament
Who is at highest risk for false positive for measuring medial clear space evaluation on standard XR
Tall males (on ave 1mm more)
What is cutoff for medial clear space (MCS)
> 5mm
Three ways to judge instability in lateral malleolus fractures
Manual stress XR
Gravity stress XR
Weight bearing XR
What did Sanders et al. study show on unstable weber B fractures?
81 patients with unstable weber B, randomized to op vs non op
Good: No functional differences @ 1 years
Bad: 20% nonop group showed signs of mal alignment at 1 year and had delayed union
1 advantage and 1 disadvantage of PL plating of fibula for weber B fractures
Pro: biomechanically most stable
Con: Peroneal irritation
- usually from distal oblique screw in plate
- Suggest placing plate 1cm from tip of mal +/- using 2.0 or 2.4mm screw below plate
IM fixation for Weber B indications
Poor soft tissue
High risk for wound complications
Advantage of IM fixation of Weber B fixation
- Soft tissue friendly
- Greater torque resistance than 1/3 tubular + lag
