EF Ombro + Impacto + MR

Question 1

Quais são as estruturas primárias estabilizadoras do movimento do ombro?

Answer 1

The ligamentous constraints are the primary stabilizers at extremes of motion.

Question 2

Qual ligamento é o restritor primário da luxação umeral inferior? Qual outra função essa estrutura possui?

Answer 2

The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress in the same position.

Question 3

Qual grau de abdução de atuação do ligamento glenoumeral médio para restrição da rotação externa?

Answer 3

The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little efect when the arm is in 90 degrees of abduction.

Question 4

Como funciona o ligamento glenoumeral inferior? Qual banda está tensa em rotação externa? E em rotação interna?

Answer 4

The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch, creating a hammock-type model. With external rotation, the hammock slides anteriorly and superiorly, the anterior band tightens, and the posterior band fans out. With internal rotation, the opposite occurs.

Question 5

Qual a função do ligamento glenoumeral anteroinferior?

Answer 5

The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more.

Question 6

Quais os músculos extrínsecos da articulação do ombro?

Answer 6

The extrinsic muscles primarily control movement of the scapula and include the rhomboids, levator scapulae, trapezius, and serratus anterior.

Question 7

Quais são os músculos intrínsecos que controlam a articulação glenoumeral?

Answer 7

The intrinsic muscles control the glenohumeral joint and include the rotator cuf muscles (subscapularis, supraspinatus, infraspinatus, and teres minor), the deltoid, the pectoralis major, the teres major, the latissimus dorsi, and the biceps brachii.

Question 8

Como a ação muscular atua para estabilizar a articulação glenoumeral?

Answer 8

First, they dynamically position the scapula to place the glenoid opposite the humeral head as the shoulder moves. Rowe compared the relationship to a “ball on a seal’s nose.” As the ball (humerus) moves, the seal (scapula and glenoid) moves to maintain the balanced relationship. Second, while ligaments work in a static fashion to limit translation and rotation, their stifness and torsional rigidity are increased with concomitant muscle activity. Rotator cuf activity and biceps activity have been shown to stifen the capsule and decrease glenohumeral translation. Third, intrinsic and extrinsic muscle groups serve as fine-tuners of motion and power movers by working in “force couples.” The force couples control and direct the force through the joint, contributing to stability.

Question 9

A que distancia da inserção ossea ocorre a fusão dos tendões do supra e infraespinhal?

Answer 9

The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection.

Question 10

Em qual região ocorre a fusão do infraespinal e do redondo menor?

Answer 10

The infraspinatus and teres minor fuse near their musculotendinous junctions.

Question 11

Descreva a fusão dos tendões do subescapular e do supraespinal?

Answer 11

The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove. The roof of this sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor. This relationship is relevant to the frequent coexistence of subscapularis tendon tears with lesions of the long head of the biceps.

Question 12

Qual a posição anatomica do ligamento coracoumral?

Answer 12

The coracohumeral ligament is a thick band of ibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons. The ligament is deep to the tendinous insertion of the cuf and blends with the capsule and supraspinatus tendon to form part of the roof of the biceps sheath.

Question 13

Quantas camadas apresentam os tendões do supra e infraespinal?

Answer 13

Histological studies of the supraspinatus and infraspinatus tendons identiied five distinct layers.

Question 14

Quais são as distancias de inserções dos tendões do manguito rotador, em média?

Answer 14

The mean medial-to-lateral insertion widths of the supraspinatus, infraspinatus, teres minor, and subscapularis tendons were 12.7 mm, 13.4 mm, 11.4 mm, and 17.9 mm, respectively. The mean minimal medial-to-lateral insertion width of the entire rotator cuff insertion occurred at the midportion of the supraspinatus and was 14.7 mm.

Question 15

O que é o intervalo rotador? Quais são seus limites? Quais estruturas passam em seu interior?

Answer 15

The rotator interval is defined as the triangular area in the anterior and superior shoulder where no rotator cuff tendons are present. As such, the interval is bounded by the supraspinatus superiorly, the subscapularis inferiorly, and the coracoid medially. The apex of the triangle is marked laterally by the transverse humeral ligament. The coracohumeral ligament, biceps tendon, and superior glenohumeral ligament are found in the rotator interval. The rotator interval is altered in pathological states and has been found to be contracted in patients with adhesive capsulitis and expanded in those with shoulder instability.

Question 16

Qual a posição do arco coracoacromial? Quais estruturas passam por esse arco?

Answer 16

The coracoacromial arch lies superior to the glenohumeral joint and is composed of the coracoid and the anterior acromion, which are spanned by the coracoacromial ligament. The distal clavicle usually is considered to be part of the arch as well. The rotator cuff tendons, the subacromial bursa, the biceps tendon, and the proximal humerus all pass beneath this arch.

Question 17

Qual a função secundária do arco coracoacromial?

Answer 17

The coracoacromial arch also serves as a restraint to superior proximal humeral migration, and its disruption is considered the final step in the cascade of events culminating in anterosuperior escape in advanced degenerative shoulder disorders associated with massive rotator cuff tears. In escape, the humeral head dislocates anteriorly and superiorly with attempted forward elevation of the shoulder. As a result, the humeral head comes to rest in a palpable and visible position in the subcutaneous tissues.

Question 18

Quais são as características da dor do paciente com lesões no ombro?

Answer 18

The pain, usually exacerbated by overhead activities, is worse with active rather than passive motion and may awaken the patient from sleep.

Question 19

Como é realizado o teste de impacto de Neer?

Answer 19

With the patient seated, the examiner raises the afected arm in forced forward elevation while stabilizing the scapula, causing the greater tuberosity to impinge against the acromion. Neer also described the impingement test with the use of a subacromial injection of 10 mL of 1% lidocaine (Xylocaine). Pain caused by impingement usually is significantly reduced or eliminated, but pain caused by other conditions (with the exception perhaps of calciic tendinitis) is not relieved.

Question 20

Como é realizado o teste de Hawkins-Kennedy?

Answer 20

The test is performed by forward flexing the humerus to 90 degrees and forcibly internally rotating the shoulder. This maneuver drives the greater tuberosity farther under the coracoacromial ligament, reproducing the impingement pain.

Question 21

Como é realizado o teste de Jobe? Qual músculo é testado?

Answer 21

Jobe described the “supraspinatus test” in 1983. The test is performed by placing the shoulder in 90 degrees of abduction and 30 degrees of forward flexion and internally rotated so that the thumb is pointing toward the floor. Muscle testing against resistance shows weakness or insuficiency of the supraspinatus owing to a tear or pain associated with rotator cuff impingement.

Question 22

Como é realizado o teste de estresse em rotação interna?

Answer 22

The test is performed with the patient seated and the examiner standing behind the patient. The patient’s arm is positioned in 90 degrees of abduction in the coronal plane and approximately 80 degrees of external rotation. A manual isometric muscle test is performed for external rotation and compared with one for internal rotation in the same position. If a patient with a positive impingement sign has good strength in external rotation and weakness in internal rotation, the test is positive. A positive internal rotation resistance stress test suggests internal impingement, and a negative test (more weakness in external rotation) suggests classic outlet impingement.

Question 23

Como é realizado o teste de Gerber para o subcoracoide?

Answer 23

The Gerber test is designed to identify impingement between the rotator cuf and the coracoid process. It is performed in a manner similar to the Hawkins-Kennedy impingement test. The arm is forward lexed 90 degrees and adducted 10 to 20 degrees across the body to bring the lesser tuberosity into contact with the coracoid. Pain with the maneuver indicates coracoid impingement.

Question 24

Como é realizado o teste de apreensão e recolocação de Jobe?

Answer 24

With the patient supine, the arm is abducted 90 degrees and externally rotated, which produces pain from impingement. Application of a posteriorly directed force to the humeral head, relocating it in the glenoid, does not change the pain in patients with primary impingement but relieves the pain in patients with instability (subluxation) and secondary impingement, who tolerate maximal external rotation with the humeral head maintained in a reduced position.

Question 25

Como é realizado o speed teste? Sua positividade indica quais patologias?

Answer 25

The Speed test is performed by having the patient forward flex the shoulder to 90 degrees with the elbow extended and the forearm supinated. Resistance is applied to the forearm, and a positive result produces pain localized to the bicipital groove. In an arthroscopic analysis that included biceps tendinitis and superior labral anterior and posterior lesions as positive findings.

Question 26

Como é realizado o teste de Yargason?

Answer 26

Yergason described the “supination sign” in 1931. The elbow is lexed to 90 degrees, and the forearm is pronated. he patient attempts to supinate the forearm actively against resistance applied by the examiner at the patient’s wrist. Pain localized to the bicipital groove indicates inlammation of the long head of the biceps. Yergason noted that this test may be negative with partial or complete rupture of the supraspinatus tendon.The elbow is flexed to 90 degrees, and the forearm is pronated. he patient attempts to supinate the forearm actively against resistance applied by the examiner at the patient’s wrist. Pain localized to the bicipital groove indicates inlammation of the long head of the biceps. Yergason noted that this test may be negative with partial or complete rupture of the supraspinatus tendon.TThe elbow is lexed to 90 degrees, and the forearm is pronated. The patient attempts to supinate the forearm actively against resistance applied by the examiner at the patient’s wrist. Pain localized to the bicipital groove indicates inlammation of the long head of the biceps. Yergason noted that this test may be negative with partial or complete rupture of the supraspinatus tendon.

Question 27

Quais são os testes que quando positivos indicam síndrome do impacto com probabilidade >95%? Quando eles são negativos, qual a probabilidade dessa sindrome ocorrer?

Answer 27

If the Hawkins-Kennedy sign, the painful arc sign, and the infraspinatus muscle (Jobe) test all were positive, the likelihood of a patient having an impingement syndrome of some degree was greater than 95%; if these three tests all were negative, the likelihood of impingement syndrome was less than 24%.

Question 28

Como é realizado o teste de lift-off?

Answer 28

In 1991, Gerber and Krushell described the lift-off test for detection of an isolated rupture of the subscapularis tendon. With the patient seated or standing, the arm is internally rotated, and the dorsum of the hand is placed against the lower back. If the patient is unable to lift the dorsum of the hand of the back, the test is positive. Electromyography has confirmed that the subscapularis muscle is maximally active with the hand in the midlumbar position and with resistance applied.

Question 29

Como é realizado o belly press test?

Answer 29

In this test, the patient presses the abdomen with the flat of the hand and attempts to keep the arm in maximal internal rotation. If active internal rotation is strong, the elbow does not drop backward, meaning it remains in front of the trunk. If the strength of the subscapularis is impaired, maximal internal rotation cannot be maintained, the patient feels weakness, and the elbow drops back behind the trunk.

Question 30

Como é realizado o teste de estresse em rotação externa?

Answer 30

he external rotation stress test is intended to test the integrity of the external rotators of the shoulder, specifically the infraspinatus and the teres minor. With the patient’s arms by his or her side in neutral flexion and abduction, the shoulders are externally rotated 45 to 60 degrees. The examiner applies force against the dorsum of the hands, attempting to rotate the shoulders internally back to neutral while the patient is asked to resist. Pain and weakness suggest inflammation or tearing of the infraspinatus or the teres minor or both.

Question 31

Como é realizado o external rotation lag test?

Answer 31

The external rotation lag sign test is designed to test the integrity of the supraspinatus and infraspinatus tendons. The patient is seated with his or her back to the examiner. The elbow is passively flexed to 90 degrees, and the shoulder is held at 20 degrees of elevation and near maximal external rotation (maximal external rotation minus 5 degrees to avoid elastic recoil in the shoulder) by the examiner. The patient is asked to maintain the position of external rotation actively as the examiner releases the wrist, while maintaining support of the arm at the elbow. The sign is positive when a lag, or angular drop, occurs. As with all tests, performance and interpretation are complicated by pathological changes in the passive range of motion.

Question 32

Como é realizado o drop sign?

Answer 32

The drop sign is intended to test the integrity of the infraspinatus. The patient is seated with his or her back to the examiner. The afected arm is held at 90 degrees of elevation in the scapular plane and at almost full external rotation with the elbow flexed at 90 degrees. The patient is asked to maintain this position actively as the examiner releases the wrist while supporting the elbow, which is mainly a function of the infraspinatus. The sign is positive if a lag or “drop” occurs.

Question 33

Como é realizado o internal rotation lag sign?

Answer 33

The internal rotation lag sign test is designed to test the integrity of the subscapularis tendon. The patient is seated with his or her back to the examiner. The afected arm is held by the examiner in almost maximal internal rotation. The elbow is flexed to 90 degrees, and the shoulder is held at 20 degrees of elevation and 20 degrees of extension. The dorsum of the hand is passively lifted away from the lumbar region until almost full internal rotation is reached. The patient is asked to maintain this position actively as the examiner releases the wrist while maintaining support at the elbow. The sign is positive when a lag occurs.

Question 34

Qual a contribuição do labrum para a articulação glenoumeral?

Answer 34

The glenoid is encircled by the labrum, composed of dense fibrocartilaginous tissue, which increases the depth of the socket by 50% around the humeral head and increases stability. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the antero-posterior direction. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally.

Question 35

Radiografia com rotação interna do ombro avalia qual lesão? E com rotação externa?

Answer 35

The internal rotation view is useful for detecting Hill-Sachs lesions, and the external rotation view provides a good view of the greater tuberosity and proximal humeral physis in skeletally immature patients.

Question 36

Como é chamada a radiografia em AP verdadeiro do ombro? Qual a sua utilidade?

Answer 36

A true anteroposterior radiograph of the glenohumeral joint (also known as the Grashey view) provides the best evaluation of the articular cartilage of the glenoid and the humeral head.

Question 37

Qual a utilidade da incidência radiografica axilar lateral?

Answer 37

The axillary lateral view has the advantage of showing the anatomy of the glenoid rim, the acromion, the coracoid, and the proximal humerus.

Question 38

Qual incidência radiografica é utilizada para classificar o acromio segundo Morrison e Bigliani?

Answer 38

An outlet view assists in the evaluation of patients with rotator cuff disease. This view is a lateral view of the scapula with the tube angled 10 degrees caudad. On this radiograph, the acromion can be classified into one of three types (flat, curved, or hooked).

Question 39

Qual tamanho do espaço acromioumeral sugere lesão do manguito rotador? E lesão massiva?

Answer 39

Superior migration of the humeral head with narrowing of the acromiohumeral space to less than 7 mm suggests a rotator cuff tear, and a space less than 5 mm suggests a massive tear.

Question 40

Lesões de Hill-Sachs são melhor avaliadas com qual incidência radiológica? E as lesões tipo Bankar ósseo?

Answer 40

A Stryker notch view is helpful to evaluate for Hill-Sachs lesions, and a West Point view is used to evaluate bony Bankart lesions.

Question 41

O que indica o extravasamento de contraste na artrografia da articulação glenoumeral?

Answer 41

Leakage of contrast material into the subacromial and subdeltoid spaces ater injection into the glenohumeral joint indicates a fullthickness tear.

Question 42

Qual melhor ponderação da RNM para avaliar lesões do manguito rotador?

Answer 42

T2

Question 43

Qual músculo do manguito é melhor avaliado no corte coronal da RNM? Qual o sinal de lesão crônica desse músculo?

Answer 43

Coronal oblique MR images assist in evaluating the supraspinatus tendon and muscle, delineating the extent of retraction and the size and quality of the supraspinatus muscle. Fatty replacement of the supraspinatus muscle and the supraspinatus fossa indicates chronic pathology.

Question 44

O que pode ser avaliado no corte sagital da RNM?

Answer 44

The sagittal oblique images show the anterior and posterior extent of supraspinatus tearing and the quality of all of the rotator cuff muscles.

Question 45

O que se avalia nos cortes axiais da RNM?

Answer 45

Axial images are used to show the condition of the biceps tendon and of the subscapularis and infraspinatus tendons and muscles.

Question 46

Quando solicitar RNM para um paciente com síndrome do impacto no ombro?

Answer 46

Patients with an insidious onset of shoulder pain and dysfunction do not require MRI evaluation until appropriate nonoperative treatment has failed. Patients for whom surgery is not a consideration do not need MRI unless there are concerns about another pathological entity, such as an infection or neoplasm.

Question 47

Como Neer definiu a síndrome do impacto?

Answer 47

In 1972, Neer described impingement syndrome characterized by a ridge of proliferative spurs and excrescences on the undersurface of the anterior process of the acromion, apparently caused by repeated impingement of the rotator cuf and the humeral head with traction of the coracoacromial ligament.

Question 48

Qual estrutura anatômica é susceptivel ao impacto na flexão do ombro?

Answer 48

The supraspinatus insertion into the greater tuberosity that passes beneath the coracoacromial arch during forward flexion of the shoulder is susceptible to impingement.

Question 49

Quais são os tipos de impactos da síndrome do impacto?

Answer 49

(1) primary impingement, (2) secondary impingement, (3) subcoracoid impingement, and (4) internal impingement. Primary impingement is subcategorized further into intrinsic and extrinsic types.

Question 50

Quando um impacto primário é considerado intrínseco?

Answer 50

When the structures passing beneath the coracoacromial arch become enlarged resulting in abutment against the arch, the cause of the impingement is considered to be intrinsic. Examples of this condition include thickening of the rotator cuff, calcium deposits within the rotator cuff, and thickening of the subacromial bursa.

Question 51

Quando um impacto primário é considerado extrínseco?

Answer 51

Extrinsic impingement occurs when the space available for the rotator cuff is diminished; examples include subacromial spurring, acromial fracture or pathological os acromiale, osteophytes of the undersurface of the acromioclavicular joint, and exostoses at the greater tuberosity.

Question 52

Qual subtipo de acromio, de acordo com a classificação de Morrison e Bigliani, está mais relacionada à síndrome do impacto?

Answer 52

Tipo III (ganchoso)

Question 53

Qual evento é responsável pela síndrome do impacto secundário?

Answer 53

Secondary impingement occurs when there is instability of the glenohumeral joint allowing translation of the humeral head, typically anteriorly, resulting in contact of the rotator cuff against the coracoacromial arch.

Question 54

Quais são os estágios de desenvolvimento da síndrome do impacto e suas idades típicas de aparecimento?

Answer 54

Stage 1: Edema and Hemorrhage
Typical age of patient: 40 years old
Differential diagnosis: subluxation, acromioclavicular joint arthritis Clinical course: reversible
Treatment: conservative

Stage 2: Fibrosis and Tendinitis
Typical age of patient: 25 to 40 years old
Differential diagnosis: frozen shoulder, calcium deposits
Clinical course: recurrent pain with activity
Treatment: consider bursectomy or division of coracoacromial ligament

Stage 3: Bone Spurs and Tendon Rupture Typical
age of patient: >40 years old
Differential diagnosis: cervical radiculitis, neoplasm
Clinical course: progressive disability
Treatment: anterior or acromioplasty, rotator cuff repair

Question 55

Qual é a forma mais comum de síndrome do impacto subcoracoide?

Answer 55

The iatrogenic form was most common in their series, and it was found in patients who had undergone a Trillat osteotomy of the coracoid for the treatment of anterior instability.

Question 56

Quais são os achados de exame físico na síndrome do impacto subcoracóide?

Answer 56

Physical findings attributed to this condition include tenderness over the coracoid and a positive coracoid impingement test. An injection of lidocaine into the subcoracoid region similar to the Neer impingement test has been used to evaluate patients for coracoid impingement. Relief of pain suggests the diagnosis, but the proximity of multiple structures in the subcoracoid region, including the glenohumeral joint itself, makes the accuracy of these injections questionable.

Question 57

Qual a distancia sugerida na TC para a síndrome do impacto subacromial? Qual o tratamento de escolha para essa síndrome?

Answer 57

CT has been used in the diagnosis of coracoid impingement; a suggested distance of 6.8 mm between the coracoid tip and the closest portion of the proximal humerus indicates impingement. For suspected impingement, open or arthroscopic coracoplasty has been recommended.

Question 58

Qual a posição do braço na síndrome do impacto interno? Em qual região o manguito impacta?

Answer 58

Internal contact of the rotator cuff occurs with the posterosuperior aspect of the glenoid when the arm is abducted, extended, and externally rotated as in the cocked position of the throwing motion.

Question 59

Como guiar o tratamento para pacientes com síndrome do impacto primária extrínseca?

Answer 59

The initial treatment of a patient with tendinopathy caused by classic primary extrinsic impingement is a well-planned and well-executed nonoperative regimen including antiinflammatory medications, one or at most two subacromial cortisone injections, and a physical therapy program focusing on stretching for full shoulder motion and strengthening the rotator cuff. If the patient fails to respond ater 3 to 4 months of conservative therapy, operative intervention may be indicated and should be directed to the specific lesion.

Question 60

Quais são os princípios mais importantes postulados por Neer para a realização da acromioplastia?

Answer 60

Main principles of the original procedure as described by Neer are kept in mind, as follows:
■ Release (but not resection) of the coracoacromial ligament;
■ Removal of the anterior lip and lateral edge of the acromion;
■ Removal of part of the acromion anterior to the anterior border of the clavicle;
■ Removal of the distal 1 to 1.5 cm of clavicle if significant degenerative changes are found;

Question 61

Qual a pior complicação mais comum do tratamento cirúrgico da síndrome do impacto?

Answer 61

The worst common complication is loss of anterior deltoid function, which is caused by either axillary nerve injury or detachment of the deltoid from the acromion.

Question 62

Como é caracterizada a dor na lesão do manguito rotador?

Answer 62

Pain usually is present at night and may be referred to the area of the deltoid insertion.

Question 63

Lesão completa do manguito rotador é compatível com função completa?

Answer 63

Sim

Question 64

Qual a taxa de resolução das lesões do manguito com o tratamento não cirúrgico?

Answer 64

Resolution of symptoms has been reported in 33% to 90% of patients treated nonoperatively, and we recommend nonoperative treatment initially for elderly patients or patients with low activity with suspected rotator cuf tears.

Question 65

Qual o fator prognóstico mais relacionado com o sucesso do tratamento não cirúrgico das lesões do manguito?

Answer 65

The duration of symptoms seems to correlate inversely with the long-term success of nonsurgical management because patients with symptoms for longer than 6 months had poorer outcomes.

Question 66

Após os 66 anos, qual a chance de lesão bilateral do manguito rotador?

Answer 66

The presence of rotator cuff disease has been shown to correlate with age; after the age of 66 years there is a 50% likelihood of bilateral tears.

Question 67

Qual a relação da duração com a severidade da doença?

Answer 67

Duration of symptoms also has been correlated with severity the longer the symptoms, the more extensive the fatty degeneration of the torn rotator cuff muscle (moderate supraspinatus fatty infiltration appeared an average of 3 years ater the onset of symptoms and that severe fatty infiltration appeared at an average of 5 years ater the onset of symptoms).

Question 68

Quais os fatores de bom prognostico no tratamento cirurgico do manguito?

Answer 68

Early operative intervention, when most tears are small and less degeneration of the muscle has occurred, improves outcomes.

Question 69

Como é a classificação de lesão do manguito rotador de espessura total (Cofield)?

Answer 69

Small tear:

Question 70

Como é a classificação de Goutallier para degeneração gordurosa do manguito rotador?

Answer 70

Grau 0: Normal
Grau I: Pequenas estrias de gordura
Grau II: Proporção menor de gordura em relação ao músculo
Grau III: Proporção de gordura e músculo se equivalem
Grau IV: Proporção de gordura maior que de músculo

Question 71

Quais são os tipos de lesões parciais do manguito rotador? Qual a mais comum na poupulação geral? Qual a mais comum em jovens?

Answer 71

Partial-thickness tears may be articular sided, bursal sided, or intratendinous. Among partial-thickness tears, cadaver studies indicate that intratendinous tears are more common than articular-sided or bursal-sided tears, whereas a clinical study found that articular-sided tears constituted 91% of all partial-thickness tears in a popu-lation of young athletes.

Question 72

Como são diferenciados as síndromes de impacto do ombro?

Answer 72

• Primária
  
  • Intrínseca (espessamento das estruturas que passam pelo arco coracoacromial - MR, depósito de cálcio no MR, bursa subacromial)
  • Extrínseca (diminuição do espaço subacromial - fratura do acromio, os acromiale, osteofito subacromial, spurring subacromial, exostose da tuberosidade maior)
• Secundária (luxação glenoumeral)
• Subcoracóide
  
  • Iatrogênico (após osteotomia de Trillat para instabilidade anterior)
  • Idiopático
• Interno

Question 73

Como é avaliado tomograficamente o impacto subcoracóide?

Answer 73

CT has been used in the diagnosis of coracoid impingement; a suggested distance of 6.8 mm between the coracoid tip and the closest portion of the proximal humerus indicates impingement. For suspected impingement, open or arthroscopic coracoplasty has been recommended.

Question 74

Quais modalidade cirúrgicas para o tratamento da síndrome do impacto?

Answer 74

Arthroscopic or open acromioplasty when indicated is the surgical treatment of choice for impingement syndrome.

Question 75

No tratamento cirúrgico da síndrome do impacto, o que deve ser feito como o ligamento coracoacromial?

Answer 75

Original technical descriptions called for resecting and removing a portion of the coracoacromial ligament to prevent the cut edge from scarring back to the acromion. Our current practice is to release the ligament.

Question 76

Como deve ser manejada a lesão de espessura parcial do MR?

Answer 76

For partial-thickness rotator cuff tears, a nonoperative program that includes activity modification, stretching and strengthening exercises, and antiinflammatory medication is appropriate as initial treatment. Operative management is indicated if conservative management fails. Débridement or repair of partial-thickness rotator cuff tears depends on the degree of the tear and the activity level and age of the patient.

Question 77

O que fazer no tratamento cirurgico de uma lesão parcial do MR com 50%?

Answer 77

If a lesion involves less than 50% of cuff thickness, acromioplasty and débridement are suficient treatment. If a tear is longer or thicker, elliptical excision of the diseased tendon and repair are indicated.

Question 78

Qual o objetivo principal da cirurgia para LMR?

Answer 78

The primary goal of operative management of rotator cuff tears is pain relief, and this is accomplished with predictable results. Improvement of function is a secondary but important consideration.

Question 79

Em quais casos a cirurgia para LRM é apropriada?

Answer 79

Surgery is appropriate for an acute rotator cuff injury in a young patient or in an older patient (60 to 70 years old) with a defined injury who suddenly is unable to rotate the arm externally against resistance.

Question 80

Qual contraindicação para a cirurgia de LMR?

Answer 80

Surgery is contraindicated in patients with rotator cuff tears and concomitant stiffness (secondary to adhesive capsulitis). Any significant preoperative stiffness must be corrected before rotator cuff repair to avoid severe postoperative stiffness.

Question 81

Qual a taxa de reruptura do MR?

Answer 81

Rerupture of the cuff occurs in 20% to 65%.

Question 82

Quais são as vantagens do reparo artroscópico para LMR?

Answer 82

Proposed advantages of arthroscopic repair include access for glenohumeral inspection and treatment of intraarticular lesions, no deltoid detachment, less soft tissue dissection, and smaller incisions.

Question 83

Quais são os 5 fatores que melhoram os resultados do tratamento cirurgico das lesões maciças do MR?

Answer 83

Cordasco and Bigliani identified five factors that improved results of operative treatment of large and massive rotator cuff tears:

1. Adequate subacromial decompression
2. Maintaining the integrity of the deltoid origin
3. Mobilizing torn tendons and performing an interval slide when indicated
4. Repairing tendons to bone
5. Carefully supervising and staging postoperative rehabilitation

Question 84

Como é a técnica não anatomica de McLaughlin para reparo do MR?

Answer 84

McLaughlin described suturing the tendon to a trough in bone at whatever point it could be advanced onto the humeral head. This may be more proximal (approximately 2 cm) through the anterior neck area.

Question 85

Qual o melhor tratamento para lesões maciças do MR em que o reparo anatomico não é viável?

Answer 85

Partial repair has been shown to be superior to débridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuf tears.

Question 86

Como é a técnica de Cofield para transposição do subscapular nas lesões do supraespinhal? Qual complicação pode ocorrer com essa técnica?

Answer 86

Cofield described subscapularis tendon transposition to fill large gaps in the supraspinatus insertion. The flap is created by separating the outer portion of the subscapularis from the inner capsular portion. It is detached from the lesser tuberosity and mobilized superiorly to cover the humeral head. Transposition of the upper portion of the subscapularis tendon can result in anterior instability and weakness of internal rotation.

Question 87

Qual a tecnica preconizada para lesões maciças do subescapular e supraespinhal?

Answer 87

For anterosuperior tears involving the subscapularis and the supraspinatus, transfer of the pectoralis major has been described.

Question 88

Para lesões maciças do supra e infraespinal, qual técnica é preconizada?

Answer 88

For posterosuperior tears involving the infraspinatus and supraspinatus, the latissimus dorsi has been transferred.

Question 89

Qual complicação operatória pode ocorrer no reparo da LMR?

Answer 89

An unsolved complication of rotator cuff surgery involves coracoacromial arch deficiency with anterosuperior cuff tears resulting in subluxation of the humeral head, for which there is no efective treatment. Preservation of the coracoacromial arch is the best method to prevent this complication.

Question 90

Como ocorre a artropatia do MR?

Answer 90

Due to a massive rotator cuff tear, normal humeral head depression of the supraspinatus is lost and the unopposed deltoid pull leads to superior subluxation and shearing forces across the glenoid.

Question 91

Quais são os sinais radiográficos de artropatia do MR?

Answer 91

Sourcil sign (erosion of the inferior acromial surface as the humeral head “articulates” against the undersurface of the acromion), inferior humeral head osteophytes, and loss of glenohumeral joint space.

Question 92

Qual é a contra-indicação para realização da artroplastia total convencional do ombro? Qual método de artroplastia é realizada nesses casos?

Answer 92

LMR irraparável. Artroplastia total reversa.

Question 93

Classificação de Ellman para LMR

Answer 93

1 - Crescent
2 - Reverse L
3 - L shaped
4 - Trapezoidal
5 - Massive tear Full thickness rotator cuff tears

Question 94

A que distancia o nervo subescapular passa medialmente em relação ao colo da glenoide?

Answer 94

1,8 cm