exam 2 Flashcards
1
Q
elbow
A
compound synovial joint. injury to one part can affect other aspects. Two degrees of freedom (flex/ext @ulnohumeral joint, and pronation/sup @radioulnar joint)
2
Q
3 articulations at elbow
A
humeroulnar, humeroradial, and proximal radioulnar
3
Q
humeroulnar joint
A
Ginglymus jt. (Greek for hinge), trochlea of humerus articulates with ulna. Olecranon fossa accepts olecranon process of ulna during extension. Coronoid fossa accepts coronoid process of ulna during flexion.
4
Q
humeroradial joint
A
capitellum of humerus articulates with radial head. radial fossa accommodates the margin of radial head during flexion.
5
Q
proximal radioulnar joint
A
pivot joint. pronation/supination
6
Q
Medial ulnar collateral ligament
A
Resists elbow valgus deformation. Consists of anterior, posterior, and transverse bundles. Transverse contributes little or no elbow stability.
7
Q
anterior bundle of MUCL
A
THE MAJOR STABILIZING component. Origin is Inferior to axis of motion (flexion/ext), so some fibers are tight during flexion and some are taut during extension.
8
Q
Posterior bundle of MUCL
A
Origin is inferior and posterior to the axis, so fibers are tight during flexion and not during extension
9
Q
Radial collateral ligament
A
resists elbow varus deformation. Origin near axis for elbow flex/ext so fibers are right throughout ROM
10
Q
Lateral UCL
A
Primary lateral elbow stabilizer.
11
Q
Annular ligament
A
Inserts on the anterior and posterior margins of lesser (radial) semilunar notch. Maintains radial head in contact with ulna
12
Q
Olecranon bursa
A
Lies between skin and Olecranon process. Allows unrestricted movement of skin over Olecranon process. Most frequently injured bursa @ elbow. STUDENTS ELBOW
13
Q
Biceps brachii
A
Origins: Long- supraglenoid tuberosity of scap. Short- coracoid process of scap. Insertion. Radial tuberosity and fascia of forearm via bicipital aponeurosis. Elbow flex when forearm is supinated , forearm sup, shoulder flex
14
Q
Brachioradialis
A
Origin: lateral supracondylar ridge of humerus. Insertion: lateral aspect of radial styloid process. Elbow flexion with forearm in neutral position
15
Q
Brachialis
A
Insertion: ulnar tuberosity and coronoid process. Elbow flexion when forearm is pronated
16
Q
Triceps brachii
A
Origin: long head- inferior glenoid rim, lateral head- posterior gunmetal ridge, and medial head- distal 2/3 of posteromedial humerus. Insertion: Olecranon process. Extension and 2 deg shoulder extension
17
Q
Anconeous
A
Origin: lateral epicondylitis of humerus. Insertion: lateral aspect of Olecranon and posterior ulna. Assists triceps with elbow extension.
18
Q
Supinator
A
Orig: lateral epicondyle, annular ligament, radial collateral lig and supinator crest of ulna. Insertion: lateral proximal 1/3 of radius
19
Q
Pronator teres
A
Origin: common flexor tendon @medial epicondyle and medial coronoid process. Insertion: lateral surface of radial shaft.
20
Q
Flexor pronators common origin and list
A
Medial epicondyle. Pronators teres, flexor carpi radialis/ulnaris, flexor digitorum superficialis/profundus, palmaris longus
21
Q
Extensor-supinators. Common origin and list
A
Lateral epicondyle of humerus. Supinator, extensor carpi radialis longus/brevis/ulnaris, extensor digitorum.
22
Q
Brachial artery
A
Extends down arm along medial aspect of brachialis muscle. Enters anticubital fossa medial to biceps brachii tendon and lateral to median nerve. Ends at radial head, giving rise to radial and ulnar arteries.
23
Q
Radial artery
A
Originates at radial head, emerges from antecubital fossa between brachioradialis and pronators teres muscles. Continues laterally along forearm deep brachioradialis muscle
24
Q
Ulnar artery.
A
Originates at radial head continues medially down forearm.
25
Median nerve.
Enters anticubital fossa medial to brachii tendon and artery. Courses down medial forearm to hand/wrist distribution. Sensory distribution is palmar aspect thumb, index &middle finger, and 1/2 ring finger.
26
Cubical fossa
Superior border= imaginary line between medial/lateral epicondyles. Medial border= pronators teres muscle. Lateral border = brachioradialis. Contains brachial artery and median nerve
27
Ligament of Struthers
Fibrous band extending from large bony projection of humerus known as supracondylar process, to the medial epicondyle. Exists in less than 1% humans and may contribute to high median nerve entrapment. In Darwin's The Descent of Man.
28
Radial nerve
Enters anticubital fossa posterior to brachialis. Divides into superficial and deep (posterior interosseous) branches. Courses down lateral forearm to hand/wrist distribution. Sensory distribution is dorsal aspect of hand- thumb, index, middle and 1/2 ring finger.
29
Ulnar nerve.
Courses in cubital tunnel posterior to medial epicondyle. Superficial and susceptible to compression or entrapment. Courses down medial forearm to hand/wrist distribution. Sensory distribution is palmar and dorsal aspect of 1/2 ring finger and all of 5th finger.
30
tennis elbow
described by Runge in 1873. M & F equal incidence rates. Occurs from eccentric contraction during extension. Was known as epicondylitis, now is epicondylosis/epicondylalgia because no inflammation, thought to be microtears. Pathology likely to be angiofibroblastic degeneration of the ECRB origin, due to either normal part of aging or response to overuse/overload.
31
angiofibroblastic degeneration
hypoxic degeneration of the ECRB origin. Biopsy specimens do not contain large numbers of macrophages, lymphocytes, or neutrophils. This is symptom of incomplete healing. DUE to secondary hypoxic cell death. think of roadkill analogy. ICE is not appropriate bc slows down healing process
32
pathologic staging of tendinosis (4)
1: temporary irritation (consider biochemical inflammation)
2: Permanent tendinosis i.e. angioblastic degeneration is 50% cross section affected.
4: partial or total rupture of the tendon (note: poss from repeated cortisone injections?)
33
phases of tendinosis pain (7)
1: Mild pain after exercise 48 hrs that resolves with warm up.
3: pain with exercise that does Not alter activity
4: pain w/ exercise that Does alter activity
5: pain caused by heavy ADL
6: intermittent pain at rest that does not disturb sleep; pain caused by light ADLs.
7: constant pain at rest and pain that disturbs sleep.
34
Clinical management of tennis elbow
1. Relief of pain and control of inflammatory exudation and/or hemorrhage
2. promotion of specific tissue healing
3. promotion of general fitness
4. control of force loads through
- bracing
- improved performance tech.
- control of intensity and duration of activity
- size of racket grip inconclusive.
35
epicondylosis/algia treatment options
physical rehabilitation. soft tissue manipulation. modalities (ultrasound/laser therapy). NSAIDS. Steroid injections. Surgery with excision of pathological tissue (this is macrotrauma which the body recognizes faster)
36
Golfer's elbow
medial epicondylitis. AKA medial tennis elbow.
37
medial epicondylitis
tendinosis of the flexor pronator mass (which includes flexor carpi radialis and pronator teres). Possible but rare involvement of the median nerve (when nerve gets entrapped between 2 heads of the pronator teres; would cause numbness/tingling shooting/hot pain/fire ants)
38
DDx for medial elbow pain in throwing athlete. (source of pathology to possible diagnosis)
1. flexor pronator tendon: a. medial tendon overuse injury. b. flexor-pronator tendon disruption. c. fascial compression syndrome.
2. ulnar collateral ligament: a. ulnar collateral ligament instability. b. valgus extension overload.
3. medial elbow nerves: a. ulnar neuropathy. b. subluxating ulnar nerve. c. medial antebrachial cutaneous nerve injury.
39
OCD
osteochondritis dissecans. broken off loose bodies of bone. common with overhead activity/upper ext impact sports eg gymnastics. In younger population (CHONDROSIS) osteophytes on posteromedial olecranon common from hyperextension with valgus overload. In older population (CHONDRITIS) caused by degeneration
40
elbow's peripheral nerves
median, ulnar, radial
41
injuries associated with median nerve
(C6-8, T1) high medial nerve entrapment syndrome. Volkmann's ischemic contracture. Carpal tunnel syndrome
42
injuries associated with ulnar nerve
(C7-C8, T1) Cubital tunnel syndrome=proximal elbow. Tunnel of Guyon=at wrist
43
injuries associated with radial nerve
(C5-C8, T1) associated with radial fracture
44
common musculoskeletal injuries of elbow
dislocations, fractures, avulsions, chondral injuries, Volkmann's ischemic contracture
45
dislocations at elbow
1. posterior dislocation of ulna: -most common direction. -often fx of coronoid process accompanies this. -Ossification with brachialis is common.
2. radial head: common among children
46
supracondylar fx
- accounts for more than 60% elbow fxs in children.
- more than 95% of supracondylar fx's are hyperextension type due to FOOSH.
- elbow becomes locked in hyperextension.
- Gartland classification system 3 types.
47
Gartland Classification system for ___ fx's.
Supracondylar fx. Type 1: minimally displaced fx.
2: Displaced distal fragment (the posterior humeral cortex is intact.
3: complete displacement. @ risk for malunion and neurovascular complications.
48
among children how many growth plates are active w/in elbow joint capsule?
3 (humerus, ulna, radius)
49
humerus ossification centers
4. lateral epicondyle, medial epicondyle, capitellum &lateral part of the trochlea, medial trochlea.
50
ulnar ossification center
1. olecranon.
51
Salter-Harris classification of___.
of growth plate fxs. 5 types.
52
Salter Harris Type I
epiphysis completely separated from metaphysis (end of bone). vital parts of growth plate remain attached to epiphysis. Surgeon not usually needed to put back into place, generally just requires cast to keep in place as it heals. Unless damage to blood supply, likelihood that it will grow normallyis excellent.
53
Salter Harris Type II
Most common type of growth plate fx. Epiphysis and growth plate is partially separated from metaphysis, which is cracked. Unlike TI, they typically have to be put back into place and immobilized for normal growth to continue. Bc they usually return to normal shape during growth, sometimes Dr doesn't have to manipulate back into position.
54
Salter Harris Type III
fx occurs rarely. fx runs completely through the epiphysis and separates part of the epiphysis and growth plate from the metaphysis. Surgery sometimes necessary to restore the joint surface to normal. Outlook is good if: -blood supply to separated portion still intact, -fx is not displaced, - and if a bridge of new bone has not formed @ site of fx.
55
Salter Harris Type IV
fx runs through epiphysis, across growth plate, and into the metaphysis. Sx needed to restore joint surface to normal and to perfectly align the growth plate. Prognosis is poor unless: PERFECT alignment is achieved and maintained during healing. Occurs most commonly at end of humerus near elbow.
56
Salter Harris Type V
Uncommon, when end of bone is crushed and growth plate is compressed. it is most likely to occur at knee or ankle. Prognosis=poor since premature stunting of growth is almost inevitable.
57
Avulsion fxs
medial epicondyle (by flexors), lateral epicondyle (by extensors), biceps tuberosity on medial, posterior radius (by?). Occurs when tendons/ligaments pull pieces off.
58
chondral fxs.
radial head (compression from valgus force), Capitellum of humerus, olecranon fossa of ulna, coronoid fossa of ulna. Worst case scenario:OCD.
59
Volkmann's ischemic contracure
From an unrecognized supracondylar fx of humerus (T I Gartland fx) that was reduced as if it was an elbow dislocation. Compartment syndrome produced by obstruction of artery/vein. Flexion contracture occurs (median nerve involvement) TYPICALLY IRREVERSIBLE.
60
DDx of lateral elbow pain
Lateral epicondylitis. entrapment of radial nerve (Radial Tunnel S). Radiocapitellar joint degenerative changes. Cervical spine problems.
61
Lateral epicondylitis
"tennis" ECRB= primary muscle involved w/condition. Extensor digitorum ("communis") involved 30% of time. ECRL and ECU=lesser involvement.
62
entrapment of radial nerve
Relatively rare! Radial tunnel syndrome. r tunnel is between radiohumeral j and the supinator muscle. Symptoms: dull aching pain in proximal forearm muscle mass. No numbness typically reported, not usually shooting pain, no deformity or muscle wasting. RTS should be considered in patients with recalcitrant lateral epicondylitis.
63
radiocapitellar joint degenerative changes
dr will order elbow xrays to rule out degenerative joint changes.
64
cervical spine probs.
careful neurological exam required as cervical spine pathology may manifest as symptoms at elbow, wrist, hand. X-rays needed to R/O degenerative cervical spine conditions.
65
tennis vs little league vs golfers.
lateral epi.
valgus force causing compression of lateral side (radius and capitellum) and stress fx of medial. pain on both, dull on one, sharp on other. or pain on one side only.
medial epicondyle.
66
DDx of medial elbow pain
medial epicondylitis, ulnar nerve injury, medial collateral ligament injury, degenerative changes in medial elbow joint.
67
medial epicondylitis
pitcher's elbow/little league e/golfers e. Localized pain on medial epi. resisted wrist flexion and pronation painful. valgus stress test @ 30 deg flexion is negative. as high as 60% patients may have ulnar nerve involvement
68
ulnar nerve injury
paresthesia in 4th & 5th fingers. Tinel's sign @ elbow is positive, producing pain and/or electrical shock sensations @ elbow and down arm. Second only to CTS in frequency in terms of upper extremity compressive neuropathies. Diagnosed by neurologist using a nerve conduction velocity test. Surgery to decompress, possible transposition nerve.
69
medial UCL injury.
tenderness over UCL, anterior posterior or transverse bundle. valgus stress test at 30 degrees flexion is positive.
70
pathomechanics of medial elbow pain in pitchers
elbow torque greatest when arm Is in the max arm cocked position. From here, UCL pulls forearm forward with the rotating upper arm. TENSION produced in UCL is close to its limit. When improper mechanics used/ arm muscles become fatigued, load on UCL may be increased to more than it can withstand, causing small microtears.
71
UCL reconstructive surgery
Tommy John. in 1974 Dr Frank Jobe put chances at 1 in 100 to returning to MLB pitching. successful return after 18 months rehab. today surgery takes 1 hr, 85-90% complete recovery chance.
72
today's tommy john.
1 yr for pitchers 6 months for position players. pitchers usually have full ROM after 2 months and can start doing weight exercises. for next 4 months, increase weight and start doing exercises that emphasize all parts of arm. after 6 m begin throwing program.
73
degenerative changes in the medial elbow joint.
xrays to R/O bone spurs, osteochondral defects, and/or osteoarthritis. AGE=huge factor
74
bony articulations of shoulder girdle
sternoclavicular, acromioclavicular, glenohumeral. and scapulothoracic (ST, not a true bone to bone joint!)
75
sternoclavicular joint and movements
only bony articulation between shoulder girdle and trunk. motion at SC permits movement of scapula: 1. elevation/depression of clavicle, 2. protraction/retraction of clavicle, 3. rotation of clavicle.
76
Sternoclavicular disk
fibrocartilage disk (meniscus) between bony articulating surfaces. increases joint congruence and absorbs force.
77
sternoclavicular joint capsule and ligaments
1. anterior and posterior SC ligs reinforce the capsule checking ANT and POST movement of clavicle.
2. Costoclavicular ligament runs from first rib to clavicle, checks elevation of clavicle.
3. interclavicular ligament runs from clavicle to clavicle check depression of clavicle
78
Acromioclavicular joint and motions
AC= a plane of synovial joint connecting the acromion of scapula and the lateral end of clavicle. Primary functions: maintain relationship between clavicle and scapula, allow additional scapula motion on the thorax during shoulder motion. Motions: 1. scapular rotation upward or downward around an anteroposterior axis, 2. winging of scapula as acromion process rotates around vertical axis at AC joint. (vertebral border moves posteriorly and glenoid fossa moves anteriorly), 3. Tipping of scapula as acromion process rotates around a mediolateral axis (inferior angle of scapula moves posterior while anterior border moves anteriorly)
79
AC joint capsule and ligaments
Contains small fibrocartilage disk that gradually degenerates through 4th decade of life. Joint capsule is weak and provides little stability of AC joint. Superior and inferior AC ligs assist capsule to control horizontal displacement at AC joint. Coracoclavicular lig with trapezoid and conoid portions.
80
coracoclavicular lig
primary restraint that prevents superior translation of clavicle on the acromion. Trapezoid portion (anterior and lateral). Conoid portion (more medial and posterior)
81
Glenohumeral joint
ball and s. synovial joint. Head of humerus 3/4 times larger than surface of fossa. shallow glenoid fossa (when compared to socket of hip by acetabulum. Stability sacrificed for mobility. Glenoid is positioned somewhat anteriorly and superiorly relative to thorax.
82
glenoid labrum
concave fibrocartilage that surrounds periphery of glenoid fossa. provides increased depth or curvature of fossa and stabilizes joint
83
GH joint capsule
ligamentous capsule surrounds GH joint. in anatomical neutral position capsule is taut superiorly and loose anteriorly and inferiorly.
84
structures that form the roof of the GH joint
Coracoid process, acromion process, coracoacromial ligament.
85
GH major ligaments and functions.
ALL LIGAMENTS ARE thickenings of the capsule. Superior GH lig= restrains anterior translation @ 0 degrees ABD, middle GH lig= restrains anterior translation @ 45 d ABD, Inferior GH ligament complex=restrains anterior translation @90 d ABD, Posterior capsule.
86
IGHLC and functions
inferior GH ligament complex. consists of anterior band= restrains ant translation @90 ABD, supports anteroinferior humeral head, axillary pouch, and posterior band= restrains posterior translation @90 ABD, supports posteroinferior humeral head.
87
scapulothoracic articulation
not a true bone-bone joint, but rather a fibrous connection of the scapula with the thorax. the g fossa of scapula must be positioned properly in relation to head of humerus, THUS the ST and GH joints are synergistic.
88
voluntary anatomical motions of ST articulation 6
elevation/depression, retraction/protraction (add/abd) upward/downward rotation.
89
prime movers for upward rotation of ST artic.
three muscles combine to create a force couple for upward rotation: serratus anterior, upper trap, lower trap
90
ST depression, protraction and downward rotation muscle
Pectoralis minor
91
scapulohumeral rhythm
synchronous movement occurs during sagittal and frontal plane GH motions. Approx. 2:1 ratio of GH to ST motion. 120 deg GH + 60 deg ST = 180 deg total ROM
92
GH static stabilizers
=passive joint structures:
1. bony architecture.
2. glenoid labrum
3. joint capsule
4. GH ligs (rememb= functional thickenings of capsule)
5. negative joint pressure
93
GH dynamic stabilizers
=muscles of the shoulder girdle:
1. rotator cuff
2. scapular stabilizers
3. position and power muscles.
94
Rotator cuff muscles
SupraspinatusInfraspinatusTeresminorSubscapularis. eccentrically contract to slow down arm.
95
SITS function
supraspinatus: initiates abduction, humeral head compression
infraspinatus: external rotator
teres minor: external rotator
subscapularis: role in internal rotation and poss some extension
96
rotator cuff and ___ form force couple
deltoid. collectively, four cuff muscles exert downward and inward force on the humeral head (stabilizing thru compression). The 3 segments of the deltoid muscle exert an upward (impingement causing) net force during ABduction and flexion. This Force Couple facilitates motion without superior translation of humeral head
97
scapular stabilizers
levator scapula, rhomboids, traps (upper, middle, and lower), serratus anterior, and pectoralis minor
98
position and power muscles of shoulder
deltoid, pectoralis major, and latissimus dorsi
99
deltoid position and power role
gross positioning of arm in space. 3 functional components: anterior= flexion, ABduction, horizontal flexion. Middle= ABduction. Posterior= extension, ABduction, horizontal extension.
100
pectoralis major and latissimus dorsi position and power roles
provide power during overhead activities. primary internal rotators of humerus
101
long thoracic motor deficits (C5,6,7)
winged scap (serratus anterior)
102
suprascapular motor deficits (C5, 6)
difficulty initiating ABduction (supraspinatus)
103
Axillary motor and sensory deficits C5,6
difficulty with ABduction (deltoid).
| sensory d: Lateral side of arm below point of shoulder
104
musculocutaneous C5,6,7 motor and sensory deficits
motor d: very weak elbow flexion (biceps and brachialis)
| sensory d: lateral forearm.
105
Radial C5-T1 motor and sensory deficits
motor d: drop wrist (ECRL, ECRB, ECU)
| sensory d: posterolateral arm; dorsum of hand
106
median C5-T1 motor and sensory deficits
motor:weak pronation and wrist flexion (pronators and FCR)
Sensory: radial portion of forearm.
107
ulnar C7,8, T1
motor: clawing of fingers (interossei, lumbricals)
sensory: ulnar 1/2 of ring finger + little finger
108
SC joint
least commonly injured joint of shoulder girdle. dislocation= exceedingly rare=1-3% of all dislocations at shoulder.
109
of SC joint dislocations
anterior SC are 3 times more common than posterior. Posterior SC= potentially catastrophic and can lead to compromise of trachea, esophagus, and large blood vessels.
110
SC joint sprains and treatment
Grade I and II always treated nonoperatively for a few days. Persistent pain with GII may indicate need for surgery. Grade III anterior injuries are quite unstable- treat with benign neglect (sling for 4-6 wks to let it scar back down). G III posterior injuries are potentially more problematic and may require closed reduction under anesthesia
111
SC joint injuries surgical treatment
mediastinal compression from a posterior SC dislocations is one of the few indications for surgical intervention.
112
SC joint degenerative disorders
osteoarthritis, septic arthritis, rheumatoid arthritis, sternoclavicular hyperstosis
113
AC injuries MOI
most common cause of AC joint injury ("shoulder separation") is falling on point of shoulder.
As shoulder strikes ground, force from fall pushes scap down. Clavicle cannot move enough to follow the motion of the scapula, ligaments around AC j begin to tear, dislocating the joint.
114
AC joint ligamentous injuries classification system
Rockwood's 6,
115
Rockwood's classification of __ joint ligamentous injuries.
AC. type I: sprain of AC ligs. type II: complete disruption of AC joint, with slight widening of AC joint and sprain of coracoclavicular ligs.
Type III: complete disruption of AC and CC ligs, coracoclavicular interspace increased 25-100% more than normal shoulder.
type IV: complete disruption of AC and CC ligs displaced posteriorly into/through the trap muscle.
Type V: Complete disruption of AC and CC ligs with gross displacement of the AC joint.
Type VI: comp disrupt of AC and CC ligs w/gross displacement of joint; reconstructed with deltoid or trap muscle.
116
AC joint non op treatment
- adhesive strapping
- sling/bandage
- Kenny Howard Brace and harness
- figure 8 bandage
- sling and pressure dressing
- abduction traction and suspension in bed
- casting
117
AC joint op treatment
sx involves relocating the joint and repairing torn ligaments. screw may be used to hold clavicle in place while ligaments heal, which is usually removed 6-8 wks after surgery.
118
Fxs of clavicle
one of the most frequent traumatic injuries affecting the shoulder (approx. 50% of all shoulder girdle injuries.) It is most common fx in childhood but represents only 5% of all adult fxs. most clavicular fx's occur in diaphysis or middle third, while medial third fx are exceedingly rare.
119
Allman fx classification scheme of ____
group 1=middle 1/3rd of clavicle; most common. Group II= distal (lateral 1/3rd) Group III= medial 1/3rd.
120
Neer fx classification of ___
distal 1/3rd clavicular fxs. Type I: interligamentous fx with minimal displacement. Type II: fx displaced secondary to a fx medial to the coracoclavicular ligaments. Type III: lateral clavicle fx that involves the articular surface of the AC joint alone.
121
brachial plexus stingers/burners
formally called transient brachial plexopathy or neuropraxia. symptoms are unilateral and usually subside within seconds/mins. weakness usually resolves after 24 hrs but can last for weeks.
122
Seddon Nerve injury classification
neuropraxia: MOI=stretch/tension injury. Local demyelination but axons and epineurium are not disrupted.
axonotmesis: internal disruption of axons results in Wallerian degeneration. Recovery requires regeneration of a nerve.
neurotmesis: Complete disruption of neural tubes. Surgical repair or grafting procedures required.
123
nerve injuries in the upper extremity
1. spinal accessory nerve- trapezius or sternocleidomastoid weakness. Commonly injured in wrestling and ice hockey.
2. Long thoracic nerve-serratus anterior weakness->scapular winging.
3. suprascapular nerve-supraspinatus and/or infraspinatus weakness. NOTE this nerve has no sensory function.
4. musculocutaneous nerve- biceps brachii and/or brachialis weakness, uncommon in absence of an open wound.
5. axillary nerve- subscapularis and/or deltoid weakness, anterior GH dislocation commonly affects this nerve.
124
natural incidence of rotator cuff tears ranges from
5-26.5%. PTRCTs are more frequent. incidence of rotator cuff injury is age dependent, with FTRCTs rare in patients under 40.
125
Pathoanatomy of RCTs
Outlet impingement- type 1 acromion= "flat". 2=curved. 3= hooked.
Secondary impingement
126
Special tests for RCT
Full/empty can test.
127
Full can test
75% accurate for supra spinsters tears. Less painful to patient than empty can
128
Empty can test
70% accurate for supraspinatus tears.
129
Is shoulder pain location useful in locating the site of the RCT?
NO. pain is poorly correlated with actual location of tear.
130
In patients with RC tendinopathy:
Motion pain more common than rest/night pain. Lateral and anterior portions of shoulder=most common locations of pain, regardless of RCT site.
131
Supraspinatus test (can tests) most accurate when interpreted as
+ with MMT less than grade 5.
132
External rotation strength (infraspinatus) is most accurate with
with MMT less than grade 4+.
133
Lift off test is most accurate for subscapularis tears with
MMT less than grade 3
134
MRI or MRA for RCTs?
MRA. magnetic resonance angiography
135
Diagnostic classification system for RCTs based on___. And categories
Tear size. Small tear= 3-5 cm.
| massive tear = >5 cm.
136
Surgical techniques for RC repair.
Excellent results reported with use of arthroscopic or combined (mini open) in the treatment of small and medium years. Large and massive years are more appropriately managed with open surgical techniques.
137
Overhead athlete
Large ROM. Repetitive microtrauma. Muscular fatigue leads to altered kinematics which leads to injury.
138
Shoulder impingement syndrome
Impingement type pain in shoulder can be put into 2 different categories. Pain that tends to occur in people over 35 and pain that tends to occur in people 35 yrs and younger.
139
Neer's outlet impingement.
Encroachment of rotator cuff by the coroacromial arch. Diminished subacromial space results in compressive wear and degeneration of RC muscles. Caused by abnormal morphology of acromion and/or AC joint arthritis.
140
Type 1 acromion process
Flat. Normal subacromial space. Minimal impingement risk. 6%
141
Type II acromion process.
Curved. Slightly decreased subacromial space, increased risk of impingement. 42%
142
Type III acromion process.
Significantly decreased subacromial space. Highest risk of impingement. 51%
143
Type IV
Hooked with spurs.
144
GH non-outlet impingement
Rotator cuff pathology in presence of normal supraspinatus outlet. ABNORMAL SCAP MOTION. Decreased RC control (depression and compression) of humeral head. Thickened bursa. Calcific depositis. Subtle GH instability.
145
Primary impingement.
Older athletes. Degeneration of RC musculature. No GH jt instability. AC joint arthritis. Calcific deposits. Classic surgery addresses the corachromial arch and a curved/hooked acromion process.
146
Secondary impingement.
Younger, typically overhead athletes. Subtle GH instability. Decreased humeral head control. Surgery addresses excessive GH laxity.
147
Primary GH impingement surgical options
Traditional view: partial acromioplasty (anterior aspect of acromion). release of coracoacromial ligament. efficacy widely questioned now.
Current view: acromioplasty and release of the coracoacromial ligament are not necessary for successful surgical repair of classic RC impingement. The coracoacromial ligament cannot be sacrificed without possibly creating anterior-superior shoulder instability.
148
secondary GH impingement surgical options
in the presence of "subtle instability" ->anterior capsular shift. This sx addresses the anatomical cause of the GH dysfunction. No "impingement" surgery, e.g., acromioplasty w/ decompression of subacromial arch.
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glenohumeral laxity vs instability
laxity, in nonpathological states, is the normal degree of passive joint translation. instability is the giving way or subluxation of a joint during functional activity that causes pain and inability to complete that activity, it may or may not cause pain
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directions of GH instability
Anterior (most common), often a combined anteroinferior instability.
Inferior, results in multidirectional instability bc of the involvement of the anterior and posterior bands of the IGHLC.
Posterior, stressed during flexion w/ resistance, i.e. planks, pushups.
Multidirectional, with primary pain in ant/post/infer direction
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multidirectional GH instability
primary anterior= pain when arm abducted + ER position
primary posterior=pain w/ pushing heavy objects
primary inferior= pain w/carrying heavy objects @side
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LigMaster Arthrometer
permits measurement of anterior, posterior, and inferior GH joint laxity/stability to the nearest .1 mm, current cost $20 k
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Masten's classification
AMBRI or TUBS
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AMBRI
Atraumatic, Multidirectional, Bilateral, Rehabilitation (responds well to), Inferior capsular shift
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TUBS
Traumatic, Unidirectional instability (ant. most common), Bankart lesion usually occurs, Surgery usually required, usually anterior capsular shift technique + Bankart repair= >90% success rate.
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TUBS lesion
pathomechanics: dislocation/sublux (usually ant!), contact/collision sports, forceful abduction and external rotation, associated bony and labral pathology.
Clinical treatment: Reduction of dislocation, immobilization 4-6 wks in sling, Sx commonly indicated to: repair GH lig damage w/ capsular shift, repair Bankart lesion, Hill-Sachs lesion
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Bankart lesion and reverse
torn anterior labrum. Reverse=torn posterior labrum.
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Hill-Sachs lesion and reverse
with anter. dislocation->postero-superior humeral head (ARE PRESENT IN 80% PX W/ ANT SHOULDER DISLOCATIONS).
reverse Hill-Sachs w/ posterior dislocation -> anteroinferior humeral head.
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circle concept of stability
injurt to structures on one side of jt leading to instability can, at the same time, cause injury to structures on the other side or to other parts of the jt. Clinician must be aware, especially with macrot, even if patients sx are predominantly on one side.
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History of Posterior shoulder dislocations.
Hx: rare, 2% all shoulder dislocations. 50% are missed initially. delay in diagnosis avgs =about 3 months. MOI: fall or blow on forward flexed, adducted + internally-rotated arm, or repetitive microtrauma
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pathologies caused by posterior shoulder dislocations
posterior capsular instability
reverse Bankart lesion
Avulsion fx of lesser tuberosity of humerus
Reverse Hill-Sachs lesion
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treatment of recurrent posterior shoulder instability
First line of Tx: non-op (strengthening of musculature)Failure of surgical stabilization ranges from 12-50% (commonly dislocates again). Best results occur with surgical repair of a traumatic capsulolabral avulsion without posterior capsule instability.
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MDI
multidirectional instability. definition=symptomatic GH inst. in more than 1 direction. while definition is straightforward, diagnosis and clinical management of MDI are not.
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Wynne-Davis hypermobility criteria
passive apposition of thumb to volar forearm.
passive hyperextension of fingers parallel to dorsal forearm.
active elbow hyperextension >10 deg
active knee hyperextension >10 deg
passive ankle dorsiflexion >50 deg
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MDI typical px history
age-10-30 yrs. bilateral in 11-13% patients. on clinical exam, px dislocate in ant, inf, and post directions. chief complaint= pain
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MDI pathology
excessively lax inferior capsular pouch. weakness of rotator cuff, scapular stabilizer muscles. proprioceptive deficit(s) (upper weight bearing and balancing)? general ligamentous laxity
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clinical management of AMBRI and MDI patients
TRY REHAB 1st: pain free ROM to re-est neuromuscular controls (focus on deltoid and RCM w/ arm below 90 deg ABduction. Strengthen scapular stabilizers (serratus anterior, rhomboids, traps).
Sx indicated for compliant patients who remain symptomatic after 6 months supervised rehab. success rate >90% for both arthro and open
Sx contraindicated for voluntary dislocators and px with emotional disorders.
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freq of GH dislocations in USA; and percent of direction.
19 k first time traumatic injuries per yr. 25 k total first time and recurrent dislocations per yr.
98%anterior! 2 %posterior
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key ligaments of GH joint
superior GH lig, middle GH lig, Inferior GH lig complex.
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pathoanatomy of Bankart lesion.
the detachment of the GH capsule from the anterior capsule and labrum of the glenoid rim of the GH joint. this lesion is the MOST COMMON REASON for recurrent anterior GH dislocations. In surgical repair there are various anchoring techniques used to reattach the labrum to the glenoid rim.
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Atraumatic (aka "subtle") GH instability
Pathomechanics: -repetitive microt, -gradual breakdown of GH ligs and joint capsule results in MDI, -poor neuromuscular control, -muscular imbalance
Treatment: -Cessation of offending activity, -Rehab program
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subtle instability:capsular and ligamentous creep deformation
- present in younger overhead athletes.
- stretching of ant band of IGHLC caused by repetitive microtrauma
- result=humeral head subluxation.
- can also result in stretching of dynamic stabilizers (serratus anterior, posterior rotator cuff muscles).
- associated labral pathology is often present
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key clinical GH laxity tests
Apprehension test
Relocation test (JOBE)
Anterior release ("Surprise") test
patient complains of pain and often has no sense of apprehension. If all 3 are +, then the positive predictive value for anter GH instability is 94%. Surprise test is single most accurate test
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BC micro-instability is so subtle, your clinical exam
may be more sensitive than radiographs/MRI.
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clinical laxity tests for subtle GH instability
Load and Shift (anterior/post drawer), Sulcus sign, Feagin test.
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key anatomical features of glenoid labrum
site of attachment for GH ligs and long head of biceps
| blood supply to peripheral region closest to bone; inner rim is relatively avascular
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SLAP lesion
superior labrum tear, anterior to posterior.
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glenoid anterior labrum injury epidemiology
anterior labral injury and anterior shoulder instability are closely linked clinical entities (labral tears present in about 85% of acute traumatic shoulder dislocations). incidence rate of ant GH disloc in gen pop is 1.7%, w/ 90%recurrence rate in patients under 20. obviously can easily affect anterior labrum
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glenoid posterior labrum injury epidem.
Injuries to posterior labrum are almost exclusively found in contact sport athletes, and may not be associated with GH instability (can be caused by repetitive shear stress in sports, not just post dislocation)
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SLAP epid.
as many as 17% of SLAP lesions are caused by acute trauma. commonly caused by traction e.g. water skiing, or compression e.g. FOOSH. classification system: Snyder, 4 types
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Snyder classification system
I: superior labral fraying and degenerative change without detachment of the labrum from the glenoid and w/o bicep tendon involvement.
II: T I w/ stripping of superior labrum with its attached biceps tendon from the superior rim of the glenoid.
III: bucket handle tear of sup labrum w/ displacement of inferior portion of tear into the joint while the labrum and biceps tendon remain attached to the glenoid superiorly.
IV: bucket handle tear of labrum w/ associated tear of the biceps tendon. Inferior displaced portion of tear includes a portion of injured biceps tendon and there is also partial tear of biceps tendon attached to the superior glenoid.
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Special tests for SLAP lesions
active compression (O'Brien's test), Anterior slide test, Compression-rotation (grind test)
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scapular stabilizers and rotators
traps (3), rhomboid major, rhomboid minor, levator scapulae, serratus anterior,
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scapular extrinsic musculature
deltoid (3), biceps brachii, triceps brachii. EXTRINSIC: while these muscles originate/insert on the scapula, they move the arm and/.or forearm, but not the scapula.
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roles of scapula during overhead movements (5)
1. stable part of GH articulation as it positions the glenoid for articulation with the humeral head to maintain the instant center of rotation ICR w/in a physiologically tolerable range.
2. retraction and protraction of the scapula along the thoracic wall
3. elevation of the acromion
4. serves as a stable base for attachment of rotator cuff muscles
5. a link in the proximal to distal sequencing of velocity, forces, and energy that allows for the efficient shoulder functioning.
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pathomechanics associated with scapular dyskinesis (3)
muscular imbalance sequelae, excessive scapular protraction sequelae, and loss of stable scapular base sequelae.
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muscular imbalance sequelae
- strong and short ant chest wall muscles.
- stretch weakness of scapular retractors (rhomboids, middle trap)
- weak serratus anterior, possibly lower trap too with scaplar winging.
- excessive scapular protraction
- loss of stable base for rotator cuff muscles
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excessive scapular protraction sequelae
Creates glenoid fossa anteversion (ante-tilting).
Loss of bony restraint to anterior humeral translation.
Chronic strain of the anterior stabilizing structures.
Greater tuberosity of humerus now under the coracoacromial ligament.
Stretch weakness of scapular retractors.
Tight posterior GH joint capsule.
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loss of stable scapular base sequelae
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No stable origin for muscle actions.
Decreased dynamic stabilization by the rotator cuff muscles.
Exacerbates scapular protraction.
Associated secondary impingement.
Associated labral pathology.
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cascade of events associated with scapular dyskinesis
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Serratus anterior = the first muscle to fail
Loss of proper rotation of glenoid fossa
Subtle scapular winging occurs
Depressed acromion
Secondary impingement
Dropped elbow during pitching/swimming
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objective measurements of scapular dyskinesia
lateral scapular slide test: measures inferior angle of scapula to adjacent spinous process @0,45, and 90 deg abduction. ABNORMAL = >1.5 cm asymmetry @ any elev.
Scapular winging: usually too subtle to appreciate at rest. best demonstrated with resisted activity such as wall push up. Serratus ant weakness with winging, lower trap weakness with tilting.
